Envenomation evaluation and treatment
Envenomation is the process by which venom is injected by the bite or sting of a venomous animal. Many kinds of animals, including mammals, reptiles, spiders, insects and fish employ venom for hunting and for self-defense.
Mechanism of action
Some venom is applied externally, especially to sensitive tissues such as the eyes, but most venom is administered by piercing the skin of the victim. Venom in the saliva of the Gila monster and some other reptiles enters prey through bites of grooved teeth. More commonly animals have specialized organs such as hollow teeth (fangs) and tubular stingers that penetrate the prey's skin, whereupon muscles attached to the attacker's venom reservoir squirt venom deep within the victim's body tissue. For example, the fangs of venomous snakes are connected to a venom gland by means of a duct. Death may occur as a result of bites or stings. The rate of envenoming is described as the likelihood of venom successfully entering a system upon bite or sting.
Snake envenomation is a major cause of death and disability in the developing countries, particularly India and Southeast Asia. Species variation in venom components, yield, and lethality leads to quite different clinical presentations and mortality. Venomous snakes are divided into 5 families. Bites of the Viperidae, Crotalidae and Colubridae usually cause primarily local effects and bleeding; the Elapidae most commonly cause neurological symptoms, particularly paralysis; while the Hydrophidae cause paralysis and myolysis. Venoms are complex mixtures of enzymes, peptides and metalloproteins. 26 enzymes have been identified, and 10 of those are found in most venom.
Components have been identified that act as procoagulants, anticoagulants, hyaluronidases, RNases, DNases, postsynaptic toxins and presynaptic toxins. Other peptides induce capillary leak syndrome, haemolysis and shock. The clinical results of envenomation vary widely, and there may be no envenomation with a bite. Syndromes reported include oedema, haemolysis, shock, bleeding, pituitary failure, renal failure, myonecrosis, and combinations of the above. First aid measures that have been proposed include tourniquets, constricting bands, tight crepe bandages, incision and suction, cryotherapy, and high voltage electric shock. None of these has been shown to be effective except usage of a crepe bandage for Australian elapid bite.
Tourniquets or cryotherapy, if used for extended periods may lead to gangrene. The most important first aid measure is rapid transport to comprehensive medical care. There is some controversy about medical treatment in the United States, but less in other countries. Supportive measures routinely required include intravenous fluids, tetanus prophylaxis and antibiotics. Anticholinergics may be useful in elapid bite. Intubation and ventilation may be necessary. Unproven surgical approaches include excision of envenomated tissues and fasciotomy.
The former is disfiguring, the latter should be reserved for those patients with demonstrated increased intracompartmental pressure. More than 100 antivenins are produced by about 36 laboratories worldwide. The products are effective, but carry a high risk of serum sickness and a lesser risk of anaphylaxis. A more effective and less reactive product is under development.
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Clinical Pharmacology and Toxicology Research