Snake Bite Management for the ED Nurse

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Presentation on managing the snake bite victim for the emergency nurse in Australia.

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Snake Bite Management for the ED Nurse

  1. 1. Snake Bite Managementfor the ED NurseBy Kane Guthrie FCENA
  2. 2. Snake Bites in Australia• Definitive or suspected bites are common• Severe envenoming rare– Potentially fatal!• Each snake has characteristic clinicalsyndrome• Limited clinicians with limited knowledge
  3. 3. Quiz• How many poisonous snakesdo we have in Australia?
  4. 4. Risk Assessment• Geographic area• Anatomic site of bite• Number of strikes• Use of PIB• Pre-hospital course & treatment• Previous snakebites• Systemic features• Investigations
  5. 5. Physical Exam• Vital Signs• Mental Status• Evidence of bite• Lymphadenopathy• Evidence of abnormal bleeding• Signs of paralysis• Respiratory Function
  6. 6. Investigations• Whole blood clotting (resource limited)• FBC• Coagulation profile• Fribrinogen, D-Dimer• U & E, CK
  7. 7. Snake Venom Detection Kit• Dose not determine if envenomed or not!• Useful test to:– Confirm which one 5 groups responsible forenvenoming.– Helps determine which antivenom is required.– Best done in laboratory.– Use bite site swabs or urine.• Use geographic area & clinical examalongside!
  8. 8. SVDK
  9. 9. Clinical EffectsNon Specific:• Nausea & vomiting• Headache• Abdominal Pain• Diarrhoea• Dizziness• Collapse
  10. 10. Specific Envenoming Syndromes• Coagulopathy• Neurotoxicity• Myotoxicity• Rhabdomyolysis
  11. 11. Pre-Hospital CareFirst Aid:– PIBTransport:– ASAP –> hospital capable of:– Dr able to Mx snakebite– Laboratory open 24/7– Stocks adequate supplies antivenom
  12. 12. Pressure Immobilisation BandageCanale, E. Isbister, G. Currie, B. (2009). EMA. 21, 184-190.
  13. 13. Pressure Immobilisation Bandage
  14. 14. In-Hospital• Resus Bay• Get help – consider PIC 131126• Determine if envenomed:– History– Physical exam– Laboratory investigations/SVDK• Determine if antivenom required• Supportive care and treatment (ADT)
  15. 15. AntivenomTwo types:1. Monovalent:– More specific, cheaper, safer less serum sickness.2. Polyvalent:– Contains equivalent of 1 vial of each monovalent.• Give 1 vial 500mls N/saline over 20mins!• Risks: anaphylaxis, serum sickness!
  16. 16. Major Types: by Clinical Syndromes5 major groups:1. Brown Snakes2. Tiger Snakes3. Mulga/black snakes4. Taipans5. Death Adders
  17. 17. Brown Snakes• Eastern/western brown snake, Dugite• Found all throughout Aust! (except Tasmania)• Most common cause of death from snakebite!
  18. 18. Brown SnakeEnvenoming:• VICC- bleeding gums, cannula site, ICH.• Renal failure & oliguria infrequent.• Rare – diplopia, ptosis & MAHA.
  19. 19. Brown SnakeManagement:1. PIB- Resus bay2. Check Coag’s FBC and U&ESigns of Envenomation:• 1 vial of CSL brown snake antivenom• Serial coag test to check if safe for D/C• New recommendation only 1 vial!• White, I. Buckley, N. (2012) Antivenom Update. Australian Prescriber (35, 5).
  20. 20. Tiger Snakes• 9 types of tiger snakes.• Found along coastal regions southern/easternAustralia.• Fast moving, easily alarmed that strike readily.• Have high rate of dry bites!
  21. 21. Tiger SnakeSimilar to brown snake but cause paralysis!Envenoming:• VICC• Neurotoxicity – progressive flaccid paralysis– Diplopia, ptosis, Resp failure• Rhabdomyolysis– Significant pain, muscle breakdown
  22. 22. Tiger SnakeManagement:1. PIB-Resus bay2. Bloods, Coag’s, FBC, U&E,3. Serial peak flow, neuro exam!Envenomed:• 1 vial Tiger snake antivenom• Consider intubation for resp failure
  23. 23. Mulga/Black Snakes• Mulga, king brown, Red-bellied or black snake• Found around Australia• Large, aggressive with painful bite
  24. 24. Mulga/Black SnakeEnvenomation:• Severe rhabdomyolysis• Anticoagulation abnormalities– Increased INR and aPTT.• Non specific symptoms:– Headache, nausea & vomiting
  25. 25. Mulga/Black SnakeManagement:1. PIB-Resus bay2. Bloods, Coag’s, FBC, U&E, UrineEnvenomed:• IDC – fluids, monitor CK• 1 vial black snake antivenom
  26. 26. Taipans• Coastal & Inland Taipans• Found northern Aust (NT & QLD)• Envenoming rare, but lethal without AV!
  27. 27. TaipansEnvenoming:• VICC• Neurotoxicity– Venom causes paralysis, seizures• Rhabdomyolysis• Systemic envenoming can causes rapid onsetcollapse within minutes!
  28. 28. TaipansManagement:1. PIB-Resus bay2. Bloods, Coag’s, FBC, U&E, UrineEnvenomed:• IDC – fluids, monitor CK• Prepare for resp failure – intubation• Give 1-2 vials taipan antivenom• Supportive care & monitoring
  29. 29. Death Adder• Common, desert, northern, pilbra- deathadder.• Found mainland Australia.• Characterised viper like appearance, short, fatwith diamond shaped head!
  30. 30. Death AdderEnvenomation:• Neurotoxicity- descending flaccid paralysis• Manifest with 6 hoursEarly signs:• Diplopia, ptosis, difficulty swallowing.
  31. 31. Death AdderManagement:1. PIB-Resus bay2. Bloods, Coag’s, FBC, U&E,3. PEFR- neuro assessmentEnvenomed:• Intubation for respiratory failure.• 1 vial death adder antivenom• Sx resolve 1-2 days
  32. 32. Questions
  33. 33. Take Home Points• PIB always!• Envenomation is rare!• 1 vial of antivenom is usually suffice!• Make use of the experts!
  34. 34. Thank-you

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