Dr Arya Jith

Best way to a manage

Is to prevent a snake bite…..!

A WORLD WITHOUT SNAKES

NEARLY A QUARTER OF US WOULD GO HUNGRY

THEY ARE IMPORTANT ELEMENTS IN FOOD CHAIN THAT CONTROL RODENT POPULATION

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5 DANGEROUSLY POISONOUS SNAKES KING COBRA COMMON COBRA COMMON KRAIT RUSSELL’S VIPER SAWSCALED VIPERMOST COMMON POISONOUS SNAKE IS

COMMON KRAIT

TO IDENTIFY WHETHER IT WAS A POISONOUS SNAKE.

216 SPECIES- 52 VENOMOUS IF THE PAIN NUMBNESS AND OEDEMA

IS SPREADING THEN IT IS A VENOMOUS SNAKE.

SUSPECTED SNAKE BITE

OBSERVATION 24 HOURS

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Universal fear - a state of shock Bite site -multiple teeth impressions significant local pain or swelling -

ABSENT Adequate reassurance and symptomatic

treatment .

• To rule out ptosis

Evidence of early external ophthalmoplegia .

• size and reaction of the pupils.

• Early paralysis of pterygoid muscles.

• “broken neck sign

Oedema petechiae bullae oozing from the wound should be noted

Extent of swelling circumference of the bitten limb should be

noted every 15 minutes- spreading

CT> 10 MINUTES Bleeding manifestations Oliguria /haematuria Hypotension Ptosis Circumoral paraesthesia Aphonia/Dysarthria

GRADE0 – NO ENVENOMATION GRADE 1- MINIMAL ENVENOMATION (local pain and swelling) GRADE2-MODERATE ENVENOMATION (Pain ,swelling,ecchymosis spreading +mild systemic/ lab manifestations) GRADE 3-SEVERE ENVENOMATION (Marked local response+severe

systemic findings+significant lab findings)

Blood grouping Hb, elevated PCV TC-leucocytosis Platelet count- thrombocytopenia Peripheral smear – Haemolysis BT,CT(20 min) prolonged PT ,aPTT Urea Serum Electrolytes- hyperkalemia Urine Routine-haematuria Metabolic /resp acidosis

Level of consiousness Pulse, BP, Resp rate,Capillary refill time Clotting time 1/2hr -1hourly Urine output Muscle weakness

GRADE 0-NO ENVENOMATION

Local wound care Injn TT Observation -24 hrs

MINIMAL ENVENOMATION Injn TT Antibiotics (inj CP/Ampicillin) Observe for 24 hours

Moderate and Severe Envenomation Injn TT Antibiotics(Ampicillin /CP/ 3 rd genertn cephalosporins+ metronidazole) local anti oedema measures

NEVER APPLY A TOURNIQUET ABOVE THE SITE

IF THE PATIENT COMES WITH A TOURNIQUET always CHECK FOR VASCULARITY

Do not suck out venom Do not incise the bite wound nor

apply any chemicals

Antivenom is immunoglobulin (usually the enzyme refined F(ab)2 fragment of IgG) purified from the serum or plasma of a horse or sheep that has been immunized with the venoms of one or more species of snake.

Monovalent or monospecific antivenom Polyvalent India –polyvalent is available which act

against the venom of commonly found snakes in india

Neurotoxicity Bleeding/coagulopathy Myoglobinuria/haemoglobinuria Cardiac toxicity Local swelling involving more than half of

the bitten limb Rapid extension of swelling Development of an enlarged tender Lymph node draining the bitten limb ARF

10 vials polyvalent asv(irrespective of body weight and age)

2nd dose - overt bleeding is present 10 vials

OR Do 20 minute clotting time and

give 2 vials Q6H till the coagulation parameters are normal

No test dose is required

One vial is added with 100 ml of normal saline. After 10 -15 minutes 9 vials can be added in the same fluid over one hour

Urticaria ,itching ,fever , shaking chills ,nausea ,vomiting ,diarrhoea abdominal cramps ,tachycardia hypotension , bronchospasm and angioedema

ASV is discontinued

0.01mg/kg of Adrenaline is given (1:1000)as IM should be given

100mg of Hydocortisone(2mg/kg) and

10mg of H1 antihistamine (children- 0.2mg/kg) IV

2nd dose of Adrenaline 0.5 mg (1:1000) IM can be repeated

Patient is recovered ASV can be restarted slowly within 10 – 15 minutes

Best effect – used within 4 hours Can be administered upto 48 hours Efficacy is seen upto 6- 7 days

Normalization of BP Bleeding stops within 15 – 30 mts Normalization of coagulation

parameters within 6 hours Neurological sign will be resolving within

30-48 hours

Neostigmine -0.05mg to 0.1mg/kg every 4 hours

Atropine 0.02mg/kg (5minutes prior to neostigmine)

Watch for ptosis

Shock Renal failure Myocardial failure Shock lung Bleeding

PUFFINESS CHEMOSIS PAROTID SWELLING Rx - methyl prednisolone (10mg/kgQ8H) x 3days

If renal function is normal

Start with volume expanders(20ml/kg of isotonic soln)

Corrected? Symptoms of other shock

hypovolemic shock

Raised JVP Oedema Signs of pulmonary oedema Feeble heart sounds Changes in ecg Start Dobutamine Drip (5-10microg/min)

Uncorrected-Neurogenic shock

Dopamine drip(10-12microg /min)

BP is coming up

Nor adrenaline (0.1- 0.5 microgram/kg)

Early dialysis

Treat cardigenic shock Treat ccf Avoid fluid overload Oxygen inhalation

Tacypnea Hypoxemia Unexplained drowsiness Mild acidosis treatment-o2inhalation cpap ventillation

Correct coagulation failure FFP-10ml/kg Correct platelet deficiency Whole blood– frank bleeding