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Management of Rural Snakebite

Management of Rural Snakebite



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

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



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    Management of Rural Snakebite Management of Rural Snakebite Presentation Transcript

    • 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  
    • PAPUA NEW GUINEA Port Moresby AUSTRALIA18/11/2012   2  
    • 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.  
    • 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  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  
    • 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.  
    • 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  
    • 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.  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 15 mm connectorBroad    end    fits    under     pa*ent’s    mouth    Pointed    end    over    the     pa*ent’s    nose   Inflatable cushion
    • 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’t    push    into    the    soT    Hssues  
    • 3.    Double    handed  approach  
    • 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  
    • Laryngeal  Masks  LMA Supreme   Elliptical airway tube prevents kinking Tougher tip prevents folding during insertion.
    • Gastric drainage tube Securing bar, should be at lips Bite block Ventilating tube18/11/2012   54  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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  
    • 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