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Management	  of	  Rural	  Snakebites:	  	                   Lessons	  from	  Papua	  New	  Guinea	                        ...
PAPUA NEW GUINEA                                            Port Moresby                 AUSTRALIA18/11/2012	             ...
Charles	  Campbell	  Toxinology	  Centre	  •  Mul*-­‐focal	   applied	   research	   with	   strong	   focus	   on	     im...
18/11/2012	     9	  
Photo: Dr Wolfgang Wüster
Photo: Dr Wolfgang Wüster
Photo: Dr Wolfgang Wüster
Photo: Dr Wolfgang Wüster
Snakebite	  in	  remote	  areas	  •  Many	  rural	  health	  facili*es	  are	  not	  in	  a	  posi*on	  to	       manage	 ...
Successful	  early	  snakebite	  management	  •  Excellent	  outcomes	  can	  be	  achieved	  in	  even	  the	  most	     ...
Be	  prepared	  for	  snakebite	  •  Having	  a	  protocol	  in	  place	  that	  is	  known	  to	  all	     personnel.	  •...
Have	  a	  protocol	  in	  place	  	  •    Systema*c	  and	  sequen*al	  inves*ga*ons.	  •    Immediate	  assessment	  of	...
Treatment	  or	  Referral	  •  Need	  to	  decide	  as	  quickly	  as	  possible	  if	  it	  is	  possible	  to	     treat...
Key	  consideraHons	  •  There	  should	  always	  be	  a	  clear	  reason	  for	  pa*ent	     referral,	  and	  this	  sh...
Timing	  of	  medical	  referrals	  •  A	  pa*ent	  who	  needs	  referral	  should	  be	  send	  onward	  as	     soon	  ...
Types	  of	  transport	                                •  Carried	  by	  stretcher	                                •  Priv...
Criteria	  for	  referral	  (1)	  •  Does	  the	  health	  facility	  have	  the	  resources	  to	  treat	  the	     pa*en...
Criteria	  for	  referral	  (2)	  •  Will	  referral	  of	  the	  pa*ent	  result	  in	  a	  significant	     improvement	 ...
PaHent	  safety	  (1)	  •  Will	  the	  safety	  of	  the	  pa*ent	  be	  compromised	  by	     a^emp*ng	  to	  transport	...
PaHent	  safety	  (2)	  •  A	  clinically	  unstable	  pa*ent	  should	  not	  be	  moved	  un*l	     the	  immediate	  ri...
Stabilising	  shocked	  or	  bleeding	  paHents	  •  Pa*ents	  bi^en	  by	  some	  species	  of	  viper	  may	  present	  ...
Stabilising	  shocked	  or	  bleeding	  paHents	  •  If	  an*venom	  is	  available	  it	  should	  be	  given	  without	 ...
Treatment	  of	  Shock	  (1)	   •  Specific	  treatments	           –  Assess	  for	  &	  treat	  Airway	  or	  Breathing	 ...
Treatment	  of	  Shock	  (2)	    •  Specific	  Treatments	            –  Treat	  obvious	  cause	                   •  If	 ...
Treatment	  of	  Shock	  (3)	    •  Intravenous	  access	            –  Try	  to	  be	  successful	  as	  soon	  as	  poss...
PaHents	  with	  airway/breathing	  problems	                               • Protect	  the	  airway!	                    ...
15 mm connectorBroad	  	  end	  	  fits	  	  under	  	    pa*ent’s	  	  mouth	                   	  Pointed	  	  end	  	  o...
PosiHoning	  	  of	  	  the	  	  Mask	  Watch the position of the mask regarding the eyes
1.	  	  Place	  	  mask	  	  onto	  	  face	  	  &	  	  spread	  	  your	  	  fingers	  	  as	  	  shown	  
2.	  	  Place	  	  your	  	  fingers	  	  under	  the	  jaw	  	  grasping	  	  mandibular	                 margins-­‐	  don...
3.	  	  Double	  	  handed	  approach	  
ComplicaHons	  	  of	  	  BMV	  •    Ineffec*ve	  	  oxygena*on:	  	  hypoxia	  •    Gastric	  	  infla*on	  •    Aspira*on	...
Laryngeal	  Masks	  LMA Supreme   	       Elliptical airway tube                                  prevents kinking        ...
Gastric drainage tube                                         Securing bar, should be at lips                             ...
Reinforced tip                                                        prevents fold over        Epiglottic fins prevent ep...
Laryngeal	  Masks	  •  Advantages:	     –  Easy	  to	  insert,	  and	  it	  technique	  can	  easily	  be	  taught	  to	  ...
Why	  and	  when	  to	  insert	  LMA	  •  Pa*ents	  who	  can	  tolerate	  a	  Guedel	  airway	  will	  tolerate	     an	 ...
Excessive	  oral	  secreHons	  •  Oaen	  a	  serious,	  life-­‐threatening	  complica*on	  of	     neurotoxic	  snake	  bi...
PreparaHon	  for	  paHent	  referral	  (1)	  •  Organise	  transport:	          –  What	  type	  of	  transport	  is	  nec...
PreparaHon	  for	  paHent	  referral	  (2)	  •  Ensure	  staff	  are	  ready:	      –  Adequately	  trained	  &	  experienc...
PreparaHon	  for	  paHent	  referral	  (3)	  •  Communica*on	  complete:	          –  Consult	  the	  referral	  hospital	...
Referral	  leXers	  •  In	  addi*on	  to	  clinical	  notes	  that	  are	  sent	  with	  pa*ent,	     send	  a	  referral	...
PaHent	  care	  during	  transport	  •  Posi*on	  the	  pa*ent	  in	  a	  sifng	  posi*on	  if	  they	  have	  no	     air...
Summary	  (1)	  •  Have	  a	  clear	  reason	  for	  referral	  of	  the	  pa*ent	  (i.e.:	  to	     obtain	  an*venom	  t...
Summary	  (2)	  •  Do	  not	  refer	  the	  pa*ent	  un*l	  they	  are	  clinically	  stable	     in	  terms	  of	  airway...
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
Management of Rural Snakebite
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Management of Rural Snakebite

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Management of Rural Snakebite: Lessons from Papua New Guinea by David Williams - CEO Global Snakebite Initiative

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Transcript of "Management of Rural Snakebite"

  1. 1. Management  of  Rural  Snakebites:     Lessons  from  Papua  New  Guinea   David  Williams   Charles  Campbell  Toxinology  Centre   School  of  Medicine  &  Health  Sciences   University  of  Papua  New  Guinea     CEO,  Global  Snakebite  IniGaGve  18/11/2012   1  
  2. 2. PAPUA NEW GUINEA Port Moresby AUSTRALIA18/11/2012   2  
  3. 3. Charles  Campbell  Toxinology  Centre  •  Mul*-­‐focal   applied   research   with   strong   focus   on   improving  the  clinical  management  of  snakebite  in  a   resource-­‐relevant  manner.  •  Combines   clinical   research   with   applied   field   and   laboratory   studies,   health   worker   training   and   community  educa*on.  •  Developing  capacity  for  local  an*venom  produc*on  •  Developing   na*onal   treatment   protocols   and   clinical  guidelines.  
  4. 4. 18/11/2012   9  
  5. 5. Photo: Dr Wolfgang Wüster
  6. 6. Photo: Dr Wolfgang Wüster
  7. 7. Photo: Dr Wolfgang Wüster
  8. 8. Photo: Dr Wolfgang Wüster
  9. 9. Snakebite  in  remote  areas  •  Many  rural  health  facili*es  are  not  in  a  posi*on  to   manage  snake  bite  pa*ents  because  of  a  lack  of  drugs,   equipment,  skills  and  specific  knowledge  •  They  can  poten*ally  apply  good  first  aid,  provide   emergency  treatment  for  shock,  and  if  necessary   provide  suppor*ve  care  and  non-­‐invasive  airway   management  •  In  these  situa*ons  pa*ents  will  need  to  be  sent  to   another  hospital  for  defini*ve  treatment  •  All  health  centres  should  develop  and  maintain  a  clear,   pre-­‐exis*ng  plan  for  how  pa*ents  will  be  transported,   and  to  which  hospital  they  will  be  sent    18/11/2012   17  
  10. 10. Successful  early  snakebite  management  •  Excellent  outcomes  can  be  achieved  in  even  the  most   basic  care  environments.  •  Snakebite  can  treated  in  remote  loca*ons  by  nurse   prac**oners.  •  Medical  evacua*on  should  not  need  to  be  an   automa*c  process.  •  Intensive  care  admission  is  avoidable.  •  Training,  educa*on  and  appropriate  basic  resources   are  the  basic  requirements.  
  11. 11. Be  prepared  for  snakebite  •  Having  a  protocol  in  place  that  is  known  to  all   personnel.  •  Stocking  adequate  appropriate  an*venom  if  possible.  •  Have  an  organised  emergency  room.  •  If  you  are  going  to  seek  advice  from  an  external   consultant,  have  their  details  in  a  place  where   anyone  can  find  them.  •  Plan  early:  if  evacua*on  is  necessary  you  should   organise  it  sooner  rather  than  later  
  12. 12. Have  a  protocol  in  place    •  Systema*c  and  sequen*al  inves*ga*ons.  •  Immediate  assessment  of  ABC.  •  Thorough  history.  •  Good  clinical  examina*on  to  demonstrate  specific  life-­‐ threatening  deficits:   –  Threats  to  airway  and  breathing  (neurotoxic  signs)   –  Bleeding  (seen  and  unseen)   –  Other  defects  (severe  cytotoxicity,  shock)  •  20WBCT  •  Be  realis*c  about  who  to  treat  and  who  to  refer.  
  13. 13. Treatment  or  Referral  •  Need  to  decide  as  quickly  as  possible  if  it  is  possible  to   treat  the  pa*ent  locally,  or  if  they  will  require  referral   to  hospital  elsewhere:   –  Bites  with  no  signs,  or  minimal  local  swelling  and  no  other   signs  may  not  need  referral   –  Bites  with  extensive  local  swelling  (>50%  limb)  or  very  severe   localised  swelling  (e.g.:  fingers/hands/toes/feet),  or  with   bleeding,  paralysis  should  be  referred  to  hospital  without   delay  •  Referrals  need  to  be  well  planned  and  consequences   carefully  considered.  18/11/2012   31  
  14. 14. Key  consideraHons  •  There  should  always  be  a  clear  reason  for  pa*ent   referral,  and  this  should  be  recorded  in  both  the   pa*ent’s  notes,  and  in  the  referral  le^er.  •  Pa*ent  transport  should  not  put  the  pa*ent  at   addi*onal  risk  or  reduce  the  level  of  pa*ent  safety  •  Referral  should  be  to  a  facility  that  provides  a  higher   level  of  care  •  Pa*ents  at  risk  of  life-­‐threatening  problems  such  as   bleeding,  neurotoxicity,  shock  or  renal  failure  should   always  be  accompanied  by  medical  staff  trained  in   basic  emergency  life  support  18/11/2012   32  
  15. 15. Timing  of  medical  referrals  •  A  pa*ent  who  needs  referral  should  be  send  onward  as   soon  as  possible  •  Don’t  wait  for  complica*ons  to  occur!  •  Specific  *ming:   –  aaer  first  aid  (immobilisa*on  or  PIB)  applied   –  once  you  have  resuscitated  Airway,  Breathing  and  Circula*on,   in  that  order,  to  the  best  of  your  ability  &  resources  •  Do  not  wait  un*l  the  pa*ent  has  deteriorated  before   ini*a*ng  referral  or  they  may  die  enroute  •  Early  referral  saves  limbs  and  saves  lives!  18/11/2012   33  
  16. 16. Types  of  transport   •  Carried  by  stretcher   •  Private  vehicles:   –  Motorcycles   –  Ca^le-­‐drawn  carts   –  Tractors   –  Cars  and  trucks   •  Ambulances   •  Government  vehicles   •  Boats   •  Aerial  retrieval  in  rare  situa*ons   (i.e.:  military)  18/11/2012   34  
  17. 17. Criteria  for  referral  (1)  •  Does  the  health  facility  have  the  resources  to  treat  the   pa*ent?:   –  Essen*al  drugs  and  medical  supplies   –  Equipment  (diagnos*c,  treatment  delivery  and  life  support)   –  Staff  with  the  necessary  knowledge  and  experience  to   provide  treatment  and  make  informed  decisions  •  If  the  answer  to  any  of  these  points  is  no,  then  early   referral  to  a  be^er  facility  should  be  a  priority  once  the   pa*ent  is  stabilised  18/11/2012   35  
  18. 18. Criteria  for  referral  (2)  •  Will  referral  of  the  pa*ent  result  in  a  significant   improvement  in  pa*ent  care,  or  provide  access  to  an   essen*al,  but  locally  unavailable  medical  service?   –  If  the  answer  is  yes,  then  referral  is  appropriate   –  If  the  answer  is  no,  reconsider  referral  of  this  pa*ent  18/11/2012   36  
  19. 19. PaHent  safety  (1)  •  Will  the  safety  of  the  pa*ent  be  compromised  by   a^emp*ng  to  transport  them  to  another  facility?:   –  Is  the  pa*ent  clinically  unstable?   •  Is  there  severe  bleeding?   •  Is  the  pa*ent  shocked?   •  Does  the  pa*ent  has  airway  and  breathing  problems?   –  Will  it  be  possible  to  provide  emergency  treatment  to  the   pa*ent  in  the  type  of  transport  that  is  available?   •  If  not,  are  there  any  alterna*ves  available?   –  Are  the  road  condi*ons  suitable  to  ensure  that  the  pa*ent   can  reach  the  referral  hospital?   •  Is  there  a  risk  of  the  vehicle  gefng  bogged  or  stopped  by  floods  18/11/2012   37  
  20. 20. PaHent  safety  (2)  •  A  clinically  unstable  pa*ent  should  not  be  moved  un*l   the  immediate  risk  has  reduced:   –  Shocked  pa*ents  or  those  with  severe  bleeding  require   adequate  fluid  resuscita*on  to  maintain  cerebral  perfusion   (i.e:  a  minimum  BP  of  80/60)   –  Airway  and/or  breathing  support  for  paralysed  pa*ents  •  Obtain  qualified  medical  advice  from  an  expert   –  Consider  the  need  to  have  the  pa*ent  retrieved  by   ambulance  and  a  medical  team  •  Is  it  safer  to  delay  referral  un*l  the  pa*ent  is  more   stable,  or  is  it  a  case  of  ‘now  or  never’?  18/11/2012   38  
  21. 21. Stabilising  shocked  or  bleeding  paHents  •  Pa*ents  bi^en  by  some  species  of  viper  may  present   with  hypovolaemia  and  vasodilata*on  leading  to   hypotension  and  shock  •  This  may  be  due  to  migra*on  of  circula*ng  fluid  into   the  swollen  limb,  or  may  be  the  result  of  external  or   internal  haemorrhage  •  Emergency  resuscita*on  with  crystalloid  or  colloid   should  be  carried  out.  •  Endeavour  to  maintain  a  minimum  blood  pressure  of   80/60  mmHg  18/11/2012   39  
  22. 22. Stabilising  shocked  or  bleeding  paHents  •  If  an*venom  is  available  it  should  be  given  without   delay  to  neutralise  circula*ng  toxins  that  contribute  to   coagulopathy  •  Be  careful  not  to  overload  the  pa*ent  with  fluids  as  this   may  lead  to  addi*onal  complica*ons    •  Pa*ents  in  whom  increased  capillary  permeability  is   suspected  may  benefit  from  administra*on  of    i.v.i.   dopamine  (2.5-­‐5.0  μg/kg/min)  •  When  stable  transport  the  pa*ent  while  con*nuing  to   monitor  bleeding  and  blood  pressure,  and  with   adequate  intravenous  fluid  to  con*nue  treatment  18/11/2012   40  
  23. 23. Treatment  of  Shock  (1)   •  Specific  treatments   –  Assess  for  &  treat  Airway  or  Breathing  problem   –  Obtain  good,  large-­‐bore  IV  access,  if  not  available   –  20ml/kg  crystalloid,  saline  or  Ringer’s,  as  fast  as  possible   –  eg.  a  50kg  person  should  be  given  20x50=1000ml   –  eg.  a  15kg  child  should  be  given  20x15=300ml   –  Repeat  the  vital  signs  frequently,  e.g.  every  10  minutes   –  Give  high  flow  oxygen  (6-­‐15l/min)   –  Repeat  the  infusion  if  the  pa*ent  is  s*ll  unstable   –  Give  an*venom,  if  available   •  Consider  whole  blood  replacement  aaer  40ml/kg  of  crystalloid,  if  there  is   heavy  bleeding  &  no  an*venom  is  available  18/11/2012   41  
  24. 24. Treatment  of  Shock  (2)   •  Specific  Treatments   –  Treat  obvious  cause   •  If  cause  is  an*venom  reac*on  (adrenaline,  promethazine,   hydrocor*sone)   •  If  sep*c  shock,  give  broad  spectrum  IV  an*bio*cs   –  Atropine  5-­‐20  mcg/kg  for  bradycardia   –  Consider  dopamine  (5-­‐20mcg/kg/min)  18/11/2012   42  
  25. 25. Treatment  of  Shock  (3)   •  Intravenous  access   –  Try  to  be  successful  as  soon  as  possible   –  As  large  an  IV  cannula  as  possible   –  Ideally  2  lines   –  Use  femoral,  long  saphenous  or  external  jugular  if  necessary   –  Avoid  causing  another  site  of  bleeding   –  Intraosseus,  especially  in  child,  if  no  IV  access  in  first  few   minutes  18/11/2012   43  
  26. 26. PaHents  with  airway/breathing  problems   • Protect  the  airway!   –  Posture,  chin  lia  or  head  *lt  to   improve  air  entry   –  Guedel’s  airway  devices   –  Oropharyngeal  airways   –  Laryngeal  masks   –  Endotracheal  intuba*on   • Support  breathing   –  Supplementary  oxygen   –  Ambu  Bag  ven*la*on   –  Mechanical  ven*la*on   • Transport  only  if  the  airway  is   secure  and  breathing  can  be   supported  by  trained  staff  18/11/2012   44  
  27. 27. 15 mm connectorBroad    end    fits    under     pa*ent’s    mouth    Pointed    end    over    the     pa*ent’s    nose   Inflatable cushion
  28. 28. PosiHoning    of    the    Mask  Watch the position of the mask regarding the eyes
  29. 29. 1.    Place    mask    onto    face    &    spread    your    fingers    as    shown  
  30. 30. 2.    Place    your    fingers    under  the  jaw    grasping    mandibular   margins-­‐  don’t    push    into    the    soT    Hssues  
  31. 31. 3.    Double    handed  approach  
  32. 32. ComplicaHons    of    BMV  •  Ineffec*ve    oxygena*on:    hypoxia  •  Gastric    infla*on  •  Aspira*on  •  Compression    of  eyeballs   –  re*nal    detachment  •  Compression    of    facial    and    infraorbital    nerves  •  Complica*ons    related    to    oro-­‐pharyngeal      or     nasopharyngeal  airways    used  
  33. 33. Laryngeal  Masks  LMA Supreme   Elliptical airway tube prevents kinking Tougher tip prevents folding during insertion.
  34. 34. Gastric drainage tube Securing bar, should be at lips Bite block Ventilating tube18/11/2012   54  
  35. 35. Reinforced tip prevents fold over Epiglottic fins prevent epiglottis from entering airway Gastric drainage tube Cuff must be fully deflated to prevent bulging here during insertion18/11/2012   55  
  36. 36. Laryngeal  Masks  •  Advantages:   –  Easy  to  insert,  and  it  technique  can  easily  be  taught  to  non-­‐ doctors.   –  Be^er  oxygena*on  than  with  use  of  bag/mask  alone.   –  Rescue  airway  •  Disadvantages:   –  Gastric  infla*on  if  not  correctly  posi*oned   –  Aspira*on  risk  not  100%  removed   –  Cuff  pressure  need  to  be  monitored   –  Risk  of  pharyngeal  trauma  is  forcefully  inserted  including  risk   of  hypoglossal  nerve  injury  
  37. 37. Why  and  when  to  insert  LMA  •  Pa*ents  who  can  tolerate  a  Guedel  airway  will  tolerate   an  LMA  equally  well  •  LMA  may  not  protect  against  aspira*on  but  very  few   cases  of  aspira*on  have  been  recorded   –  but  be^er  protec*on  than  BMV  alone   –  increasing  use  in  first  aid  trauma    •  Easier  to  insert  than  endotracheal  tube   –  Don’t  need  laryngoscope  •  Can  insert  while  ECM  being  conducted   –  Difficult  to  intubate  in  these  condi*ons  
  38. 38. Excessive  oral  secreHons  •  Oaen  a  serious,  life-­‐threatening  complica*on  of   neurotoxic  snake  bites  (e.g.:  mamba  bites)  •  Careful,  regular  suc*oning  of  the  airways  is  essen*al:   –  Hand-­‐held  or  foot-­‐operated  suc*on  pumps  available   –  Ignored,  death  from  airway  obstruc*on  may  be  very  rapid  •  Ancillary  drug  treatment  with  atropine  (0.6  mg/kg)   every  3-­‐4  hours  can  help  to  reduce  secre*on  levels  •  Posi*on  the  pa*ent  appropriately:   –  Recovery  posi*on  on  their  side   –  NEVER  transport  a  neurotoxic  pa*ent  in  supine  posi*on  18/11/2012   59  
  39. 39. PreparaHon  for  paHent  referral  (1)  •  Organise  transport:   –  What  type  of  transport  is  necessary?  Is  it  available?     –  If  not,  what  are  the  alterna*ves?   –  Basics:  vehicle  with  fuel,  driver,  spare  tyre,  mobile  phone   –  Check  that  road  condi*ons  &  weather  appropriate   –  Who  will  accompany  the  pa*ent?  •  Prepare  the  pa*ent:   –  First  aid  measures  in  place  and  pa*ent  stable  as  possible   –  If  an*venom  is  available,  administer  before  departure   –  airway  &  breathing  managed  appropriately   –  circula*on:  nil  by  mouth,  IV  line  secured  well,  IV  fluids  18/11/2012   60  
  40. 40. PreparaHon  for  paHent  referral  (2)  •  Ensure  staff  are  ready:   –  Adequately  trained  &  experienced  to  manage  circula*on   problems,  airway  and  breathing  enroute   –  Do  they  have  personal  items  &  money  ready   –  Are  their  shias  covered   –  Have  arrangements  been  made  for  their  return   –  if  you  absolutely  cannot  send  a  staff  member  with  the   pa*ent,  reconsider  the  need  to    refer  the  pa*ent,  or  consider   wai*ng  un*l  you  can  send  a  staff  member  •  Drugs  &  equipment  ready  in  box/bag   –  Adequate  i.v.  fluids,  sphygmanomometer,  stethoscope   –  Airway  equipment,  oxygen,  suc*on  pump  &  a^achments  18/11/2012  Flashlight  or  lantern  (for  night  transfers)   –  61  
  41. 41. PreparaHon  for  paHent  referral  (3)  •  Communica*on  complete:   –  Consult  the  referral  hospital  for  advice  before  you  send  the   pa*ent  onwards   –  Ensure  that  they  have  the  capacity  and  resources  to  be  able   to  accept  the  pa*ent   –  Once  referral  is  confirmed,  prepare  documenta*on  •  Documenta*on:   –  referral  le^er   –  copy  of  notes,  snakebite  admission  sheet  or  snakebite   observa*on  sheet   –  Chest  X-­‐Ray  if  available,  especially  for  intubated  pa*ents  18/11/2012   62  
  42. 42. Referral  leXers  •  In  addi*on  to  clinical  notes  that  are  sent  with  pa*ent,   send  a  referral  le^er  that  includes:   –  Date  &  *me   –  Name  of  referring  person,  referring  facility   –  Name  of  the  doctor  the  pa*ent  is  being  referred  to   –  Telephone  call  details,  telephone  number  for  feedback   –  Name  and  details  of  pa*ent   –  Summary  of  history  (bite  history,  symptoms  and  signs),   examina*on,  results  and  *mes  of  inves*ga*ons   –  Any  informa*on  about  type  of  snake  suspected   –  Summary  of  treatments  given,  *ming  &  response   –  Details  of  improvement  or  deteriora*on       –  Reasons  for  referral  18/11/2012   63  
  43. 43. PaHent  care  during  transport  •  Posi*on  the  pa*ent  in  a  sifng  posi*on  if  they  have  no   airway  or  breathing  problems  •  If  the  airway  is  compromised,  lay  them  on  their  side,   with  the  head  supported  and  *lted  slightly  downwards   to  prevent  aspira*on  of  mucus/saliva  •  Hang  the  I.V.  fluid  bag  and  monitor  it    •  Staff  member  should  remain  with  the  pa*ent  so  that   emergency  treatment  can  be  given  if  needed  •  If  no  staff  member  accompanies  the  pa*ent,  and  the   referral  is  urgent,  then  a  family  member  must  be   taught  to  provide  basic  life  support.    18/11/2012   64  
  44. 44. Summary  (1)  •  Have  a  clear  reason  for  referral  of  the  pa*ent  (i.e.:  to   obtain  an*venom  treatment,  or  gain  access  to  a   ven*lator)  •  Be  sure  that  referral  will  result  in  an  improvement  in   care  for  the  pa*ent,  and  that  the  transport  of  the   pa*ent  does  not  place  them  at  greater  risk  •  If  referral  is  necessary,  do  it  as  soon  as  possible  •  Choose  appropriate  transport  •  Ensure  that  the  pa*ent  meets  the  criteria  for  referral  to   another  hospital  18/11/2012   65  
  45. 45. Summary  (2)  •  Do  not  refer  the  pa*ent  un*l  they  are  clinically  stable   in  terms  of  airway,  breathing  and  circula*on  •  Be  well  prepared:   –  Organise  transport   –  Prepare  the  pa*ent   –  Ensure  staff  are  ready  to  travel  with  pa*ent   –  Assemble  necessary  drugs  and  equipment   –  Communicate  with  the  referral  hospital  and  prepare  the   documenta*on  •  Care  for  the  pa*ent  during  transport  18/11/2012   66  

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