Management of snake bite
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Transcript Management of snake bite
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
5
DANGEROUSLY POISONOUS SNAKES
KING COBRA
COMMON COBRA
COMMON KRAIT
RUSSELL’S VIPER
SAWSCALED VIPER
MOST COMMON POISONOUS SNAKE IS
COMMON KRAIT
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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
Universal
fear - a state of shock
Bite site -multiple teeth impressions
significant local pain or swelling -ABSENT
Adequate reassurance and symptomatic
treatment .
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•
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 3048 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
Rx
-
SWELLING
methyl prednisolone
(10mg/kgQ8H) x 3days
cardiogenic
hypovolemic
neurogenic
If renal function is normal
Start with volume expanders(20ml/kg of isotonic
soln)
Corrected?
hypovolemic shock
Symptoms of other
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
uremia
anuria
Peritoneal
dialysis
hyperkalemia
Flluid
overload
Treat
cardigenic shock
Treat ccf
Avoid fluid overload
Oxygen inhalation
Tacypnea
Hypoxemia
Unexplained
Mild
drowsiness
acidosis
treatment-o2inhalation
cpap
ventillation
Correct
coagulation failure
FFP-10ml/kg
Correct platelet deficiency
Whole blood– frank bleeding