Snake BiteSanjaya Gihan Weerasinghe

Snakes Bites in Sri Lanka

• 65000 snake bites annually• 800 deaths• Fatality- 5 in 100000 population• Dramatic increase in Hospital admissions• Acceptance of Western Medical

therapy• Case fatality rate has been reduced

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96 species of snakes in Sri Lanka.

Only 5 of the land snakes are considered potentially deadly.

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Highly Venomous Snakes

• Cobra (Naja naja)• Common krait (Bungarus caeruleus) • Sri Lanka krait (Bungarus ceylonicus) • Russells's viper (Daboia russelii) • Saw scaled viper (Echis carinatus)

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Moderately Venomous Snakes

• Hump nosed viper (Hypnale hypnale)• Green pit viper (Trimeresurus trigonocephalus)

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A 10 years old boy is presented with a swelling in the R/S ankle complaining of a snake bite

12.15 pm•While the boy was playing in an abandoned paddy field, he felt a sharp pain in the R/S ankle. •When he checked there was bleeding from the site of pain and there were bite marks.•Boy didn’t see the snake.

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• He was taken home immediately by his brother lifting on arms.

• They didn’t do anything with the wound- washing, tying tourniquet,etc.

• By the time he reached home, the boy was, drowsy vomited (food particles and few drops of fresh blood) burning type of abdominal pain.

• Taken to ayurvedic prationer nearby.Sanjaya Gihan

• After 1 ½ hours after the incident,he was brought to hospital in three wheeler.

On admission,• Bite site - Swelling ,Color change,Painful• No Bleeding nor Bruising.• No blister formation.

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Bite Marks Bleeding from the Site

Necrosis

Blistering Sanjaya Gihan

• By then he had neurological involvement .

Ptosis External Opthalmoplegia Drowsiness

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Neurological

• Drowsiness• Paraesthesiae• abnormalities of taste and smell• “heavy” eyelids• ptosis• external ophthalmoplegia • paralysis of facial muscles• difficulty in swallowing• respiratory and generalised flaccid paralysis

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In the Ward..• A catheter was inserted.• Haematuria was noticed.

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Gum Bleeding

Subconjunctival Haemorrhage Sanjaya Gihan

Management of A Snake Bite

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First Aids

Dos

•Reassure.•Remove all rings, Bracelets from bitten parts of the body.•Wash the bitten area with soap and water.•Keep the stricken limb below the heart.•Immobilize the bitten limb with splint or slings.•Get medical help as quick as possible.

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Do Nots

•Don’t panic•Don’t make any cut, scratch or incision•Don’t suck at the wound•Don’t apply ice packs to the bitten area.•Don’t use tight bands or tourniquet.•Don’t drink alcohol, take herbal medicine or Aspirin.

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Transport to hospital

• Quickly, but safely and Comfortably• Minimal Movements avoid systemic absorption

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In the ETU

• Rapid Clinical Assessment & Resuscitation. (ABC)

• Bite site was cleaned with soap and water.• IV canulae was inserted.• Blood was taken for 20WBCT (20 minute whole blood clotting test)• O.Paracetamol 500mg• IV Ranitidine 25mg• Patient was sent to the ward.

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Detailed Clinical Assessment

History• 3 Preliminary Qs– In which part of the body?– How long ago?– Brought the snake? Can describe it?

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Snake Identification

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Cobra නයා�

•“Spectacle” like marking in Dorsum of the Hood.

•When excited this fold expands into a hood .

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Common/Indian Kraitතෙ�ල් කරවලා�

• Oily,shiny,Bluish black appearance• Paired white bands on the dorsal surface

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Sri Lankan Kraitදුනු කරවලා�

• Blackish brown snake with white bands on the body

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Russell’s Viperතිත් තෙ��ළඟා�

• Highly poisonous 40% of deaths is due to this snake in Sri Lanka

• Largest & most widely distributed viper in Sri Lanka.

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• “V” shaped white marking in the head.

• Has 3 rows of black elliptical markings running alone the length.

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Saw Scaled Viperව�ලි තෙ��ළඟා�

• Sandy brown in colour

• birds foot mark over the head

• When disturbed, it rubs the coils against each other producing a hissing noise (characteristic)

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Hump Nosed Viperකුන කටුව�/ තෙ��තෙලා�න්

තෙ�ලිස්සා�• Brown in colour with dark brown & black markings.• Upturned hump.

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Green Pit Viper�ලා� තෙ��ළඟා�

• Bright green in colour with black markings

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If the snake is identified as non venomous , patient can be discharged after a booster dose of Tetanus toxoid.

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Investigations

• 20 WBCT• FBC• SC & BU• SE• SGOT/SGPT• Blood Grouping• IP OP chart

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20 mins Whole Blood Clotting Test

Incoagulable blood is diagnostic of a viper biteand rules out an elapid bite Sanjaya Gihan

Snake Venom Antiserum

• Only specific antidote to snake venom• most important decision in the management • IV Immunoglobulin (IgG)

• “polyvalent anti-snake venom serum” • Covers Cobra, Krait, Russell’s viper, Saw-

scaled viper.• Not against Hump nosed viper.

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Indications for Antivenom

• Signs of systemic envenomation (ARF,Dark color urine,Generalized Rhabdomyolysis)

• Haemostatic abnormalities (20WBCT)• Spontaneus Bleeding• Neurotoxic signs

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Administration of antivenom Serum• 3 IV lines • Keep adrenaline ready in a

syringe 0.5mg (1:1000)• 10 ampoules of AVS• Each dissolved in 10ml of

water• 100ml AVS into 200ml of

Normal Saline• Slow IV infusion for 1 hour

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• Watch for any reaction such as,– Fever ,Chills– Itching,Urticaria– Bronchospasms

• If a Early Anaphylactoid reaction occurs ???

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• Stop AVS infusion• Give adrenaline 0.5mg (1:1000) IM• IV Chlorpheniramine 5mg• IV Hydrocortisone 200mg

• Restart AVS after the reaction settled• In Shock ----> Sub lingual Adrenaline

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More Antivenom??

• Persistant or Recurrent Incoagulability by 20WBCT after 6 hours

• Further Deterioration

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Supportive/ancillary treatment

• In severely envenomed patients – Assisted ventilation. – renal dialysis.– Wound Debridement.– Fasciotomy.

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Treatment of the bitten part

• The bitten limb is nursed in the most• comfortable position, slightly elevated • Bullae aspirated only if likely to rupture

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Rehabilitation

• Restoration of normal function in the bitten part.

• Conventional physiotherapy.

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Long Term Complications

• Chronic Ulceration• Osteomyelitis• Chronic Renal Failure• Chronic Neurological deficit

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Thank You…!!

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