Transcript Get hurt while hiking

HKCEM College Tutorial
Get hurt
while hiking
AUTHOR
DR. TOMMY LAM SHING KIT
NOV., 2013
Triage (Category II)
▪ Female 40 year old
▪ Hiking with friends weekend
▪ Get hurt over left ankle in grass
▪ ? Bitten
▪ BP 158/94
▪ Pulse 100/min
▪ Temp 37.2 °C
2
Assessment
▪ Assess and stabilize ABC if necessary
3
Physical Exam
▪ Is it a snake bite ?
▪ Is it a dry bite/ non venomous snake bite ?
▪ Is there envenomation ?
▪ Local sign and symptom?
▪ Systemic sign and symptom ?
4
Left ankle
5
Physical Exam
▪ Fang mark , Number of fang mark ?
▪ Swelling ? Longitudinal and involved joint
▪ Progression ? Mark by “marker” at different time or taking photo
▪ Clinical compartment syndrome?
▪ Ecchymosis ?
▪ Blisters?
▪ Necrosis?
6
4 hours later
7
Snake identification
▪ History taking
▪ Any snake specimen available ?
▪ What we can do if in doubt on the snake
specimen ?
▪ Consult snake identification from Kadoorie
Farm & Botanic Garden (KFBG)
8
Poisonous snake in HK
▪Viperidae
▪Colubridae
▪Elapidae
▪Hydrophidae
9
Local features
▪Pain
▪Bruising
▪Blister
▪Necrosis
10
Systemic features
▪Bleeding tendency
▪Oozing from the wound
11
Neuromuscular
▪Breathing difficulty
▪Paresthesia
▪Ptosis, diplopia
▪Dysphagia
▪Muscle weakness
12
Clinical Feature
Snake
Feature
Cobras
Severe local pain and swelling,
blister, and necrosis (neurotoxic
symptoms if king cobra)
Severe local pain with incoagulable
blood
Absent or mild local symptom with
neurotoxic symptoms
Vipers or pit viper
Krait
13
Investigation
▪ Complete blood picture (especially Platelet count)
▪ Renal and liver function test
▪ Clotting profile
▪ Fibrinogen
▪ ECG
▪ Urine for RBC
 Need serial blood tests if present too early
14
Treatment
▪ Remove constricting object from injured part or limbs (e.g. remove
ring if bitten finger)
▪ Dressing
▪ ATT
▪ Analgesic
▪ Antibiotic for infected wound or significant local reaction
▪ Antivenom
15
Some Poisonous Snake in HK
▪ Green Pit Viper/ Bamboo Snake/Cryptelytrops albolabris/青竹蛇
16
Some Poisonous Snake in HK
▪ Chinese Cobra/Naja atra/眼鏡蛇/飯鏟頭
17
Some Poisonous Snake in HK
▪ King Cobra/Ophiophagus hannah/眼鏡王蛇, 過山烏
18
Some Poisonous Snake in HK
▪ Many-banded Krait/Bungarus multicinctus/銀腳帶
19
Some Poisonous Snake in HK
▪ Banded Krait/Bungarus fasciatus/金腳帶
20
Some Poisonous Snake in HK
▪ Red-necked Keelback/ Rhabdophis subminiatus/紅脖游蛇
21
Common envenomation syndrome
Family
Viperidae
Elapidae
Hydrophidae
Colubridae
Clinical Feature
Cytotoxic, vasculolytic and
haemotoxic
Neurotoxic and local tissue
necrosis
Rhabdomyolysis , hyperkalaemia
and renal failure
Localized pain, swelling,
haemolysis and coagulopathy
22
Antivenom for
common snake bite in HK
Antivenom
Viperidae
Bamboo Snake
Mountain Pit Viper
Elapidae
Chinese Cobra
King Cobra
Banded Krait
Many-banded Krait
青竹蛇
山烙鐵頭
Green Pit Viper/
Agkistrodon halys
Agkistrodon halys
眼鏡蛇, 飯鏟頭
眼鏡王蛇, 過山烏
Naja naja
King Cobra
金腳帶
銀腳帶
Banded Krait
Bungarus
multicinctus
23
Pretreatment
▪ Antihistamine -- Piriton (Chlorpheniramine)
▪ Hydrocortisone
▪ Watch out for anaphylaxis or anaphylactoid
reaction
24
Our patient
▪ Present with mild wound pain and snake specimen
confirmed Green Pit Viper
▪ Observation after 24 hours
▪ Pain controlled by analgesics
▪ Serial blood tests revealed no systemic involvement
▪ Discharge uneventfully
25
Thank you
26