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Snake bite protocol
- 1. PROTOCOL-SNAKE BITE PRESENTER: Dr.Shivaraja A MODERATOR: Dr.Jaidev M.D 18 January 2017 1
- 2. OVERVIEW • INTRODUCTION • HISTORY • DIAGNOSIS • TREATMENT • SUMMARY 18 January 2017 2
- 3. INTRODUCTION • Neglected tropical disease • Highest burden in south east asia • Under reported • Occupational, climatic hazard • 2/3 of snake bite have no signs of envenomation • Costly treatment and limited resources 18 January 2017 3
- 4. HISTORY • Duration: >24hr, no symptoms= unlikely to develop envenomation, >24hr with signs and symptoms= difficult to treat • Identify snake: venomous/nonvenomous • Treatment received: allopathic/alternative, First aid 18 January 2017 4
- 5. • Victim activities during bite: grass cutting, animal feeding=attract rat= attract snake • Day/night: krait is nocturnal. Repairing shed, edge of rice field=disturbed sleeping krait in morning • Past history of snakebites • Allergy to egg, sera 18 January 2017 5
- 6. COBRA SEA SNAKE HUMP NOSED VIPER18 January 2017 6
- 7. RUSSELS VIPER KRAIT SAW SCALED VIPER 18 January 2017 7
- 8. CLINICAL FEATURES 18 January 2017 8
- 9. VISIBLE SIMPLE DIAGNOSTIC TECHNICAL DIAGNOSTIC BLEEDING GINGIVAL BLEEDING HEMOPTYSIS HEMATURIA ECCHYMOSIES LATERALNEUROLOGICALSIGNS 20 MINUTE WHOLE BLOOD CLOTTING TEST RENAL IMPAIRMENT- UREA, CREATININE, POTASSIUM OCCULT BLEEDING- Hb, PCV,PLATELET PROGRESSIVE WEAKNESS DESCENDING PARALYSIS- PTOSIS, OPTHALMOPLEGIA, NUMBNESS OF LIPS, DYSARTHRIA, DYSPHAGIA, POOLING OF SECRETIONS WEAKNESS OF NECK MUSCLE DIFFICULTY IN BREATHING, FASCICULATIONS SINGLE BREATH COUNT BASIC GRIP TEST LENGTH OF TIME OF UPWARD GAZE MAINTENANCE SPIROMETRY - FEV GRIP TEST WITH EQUIPMENT PAINFUL PROGRESSIVE SWELLING RAPIDLY DEVELOPING SWELLING AND EDEMA CROSSING JOINTS BLISTERING OF LIMB COMMENCING AT BITE SITE SEVERE PAIN IN LIMB COMMENCING AT BITE SITE LIMB CIRCUMFERENCE AT FIXED TIME INTERVALS EXTENT OF SWELLING AND NECROSIS AT FIXED TIME INTERVALS SALINE MANOMETER OR STRYKER MEASUREMENT OF INTRACOMPARTMENT AL PRESSURE 18 January 2017 9
- 10. Syndromic approach • Syndrome 1 • Local envenomation with bleeding/clotting disturbance- Viperidae(all species). • Syndrome 2 • Local envenomation with bleeding/clotting disturbance,shock, acute kidney injury- Russels viper, humpnosed viper, Srilanka, South-west India. • With conjuctival edema, acute kidney injury- Russels viper,Myanmar. • With ptosis, external ophthalmoplegia,facial paralysis, dark brown urine- Russels viper, Srilanka, South-west India. 18 January 2017 10
- 11. • Syndrome 3 • Local envenomation with paralysis- King cobra or cobra • Syndrome 4 • Paralysis with minimal/no Local envenoming Bitten on land while sleeping on ground-krait Bitten in sea, estuary, fresh water lakes- sea snake 18 January 2017 11
- 12. • Syndrome 5 • Paralysis with dark brown urine, acute kidney injury- Bitten on land with bleeding or clotting disturbance- Russels viper, humpnosed viper, Srilanka, South India. Bitten on land while sleeping indoors-Krait Bitten in sea, estuary, fresh water lakes(with no bleeding or clotting disturbance)- sea snake 18 January 2017 12
- 13. HISTORY OF SNAKE BITE- NO DEAD SNAKE OR DISCRIPTION OR SNAKE INCOAGULABLE BLOOD OR SPONTANEOUS SYSTEMIC BLEEDING NEUROTOXIC SIGNS MARKED LOCAL SWELLING NEUROTOXIC SIGNS INCOAGULABLE BLOOD OR SPONTANEOUS SYSTEMIC BLEEDING NEUROTOXIC SIGNS ACUTE RENAL FAILURE ACUTE RENAL FAILURE BITTEN IN SEA HUMP NOSED VIPER BITE EARLY BLISTERING/ NECROSIS BITTEN IN LAND, SLEEPING ON FLOOR OF HOUSE SAW SCALED VIPER BITE COBRA BITE KRAIT BITE SEA SNAKE BITE RUSSELS VIPER BITE YES NO YES NO YES YES YES NO NO YES YES 18 January 2017 13
- 14. 20 MIN WBCT • 2ml of freshly sampled venous blood in small, new or heat cleaned, glass vessel. • Leave undisturbed for 20 minutes at ambient temperature. • Tip the blood once, if blood is still liquid and runs out, indicates hypofibrinogenemia due to venom induced consumption coagulopathy. 18 January 2017 14
- 15. TREATMENT • First aid • Antisnake venom • Neostigmine • Non specific treatment • Summary 18 January 2017 15
- 16. FIRST AID- RIGHT • Reassure the patient • Immobilise the limbs • Get To Hospital immediately • Tell the doctor of any systemic symptoms 18 January 2017 16
- 17. ANTISNAKE VENOM • Equine hyperimmune response, purified by papain/pepsin. • Lyophilised or liquid • Monovalent or polyvalent • Binds and neutralises circulating venom 18 January 2017 17
- 18. ANTISNAKE VENOM • Each vial neutralises a given amount of venom from the species against which it is effective • Same dosing schedule in repeated snake bite or repeat dose • Same dose in children and adults • Cannot reverse renal failure, coagulopathy, necrosis, swelling,presynaptic envenoming 18 January 2017 18
- 19. ANTISNAKE VENOM • Lyophilised vials to be reconstituted with 10ml of distilled water • Each ml after reconstitution, neutralises • 0.6mg of Cobra(Naja naja) venom • 0.6mg of Russel’s viper(Vipera russeli) venom • 0.45mg of Sawscaled viper(Echis carinatus) venom • 0.45mg of Krait (Bungareus caeruleus) venom 18 January 2017 19
- 20. AVAILABLE PRODUCTS PRODUCED BY COUNTRIES SPECIES INITIAL DOSE MAXIMUM DOSE 18 January 2017 20
- 21. CRITERIA FOR ASV ADMINISTRATION BLEEDING PROGRESSIVE WEAKNESS PAINFUL PROGRESSIVE SWELLING •INCOAGULABLE BLOOD(WBCT) •SYSTEMIC BLEEDING, NO LOCAL BRUISING •LAB EVIDENCE OF COAGULOPATHY •HEMATURIA- MYOGLOBINURIA •PTOSIS •OPTHALMOPLEGIA •EXCESSIVE SALIVATION •BULBAR PARALYSIS •DYSPHAGIA • METALLIC TASTE • RESPIRATORY DISTRESS •SWELLING REACHING >15cm FOR 1 HOUR •SWELLING AFTER BITES TO EXTREMITIES REACHING KNEE OR ELBOW BY 4 HRS, WHOLE LIMB WITHIN 8 HRS, EXTENDING INTO TRUNK •AIRWAY COMPROMISE OR RESPIRATORY DISTRESS •COMPARTMENT SYNDROME OR MAJOR VESSEL ENTRAPMENT REQUIRED ASV= VENOM INJECTED-BOUND VENOM 18 January 2017 21
- 22. REPEAT ASV BLEEDING PROGRESSIVE WEAKNESS PAINFUL PROGRESSIVE SWELLING CHECK WBCT- 6HOUR AFTER LAST DOSE OF ASV. CONTINUE ASV TILL RESTORING COAGULATION, OR MAXIMUM VIALS REACHED. REASSESS EVERY 1 HOUR. IF WORSENING, GIVE SECOND DOSE-SAME AMOUNT. IF NO WORSENING- ASSESS AFTER ANOTHER 1 HOUR. ONLY 2 DOSES OF ASV- NO CIRULATING VENOM AFTERWARDS, GIVE SUPPORTIVE TREATMENT INDIVIDUALISED (NO CIRCULATING VENOM, CANNOT CROSS BLOOD TISSUE BARRIER) REQUIRED ASV= VENOM INJECTED-BOUND VENOM 18 January 2017 22
- 23. ADMINISTRATION OF ASV • No test dose • Prophylactic adrenaline and antihistaminics. • IV injection- slow iv injection-2ml/min • Infusion- liquid or reconstituted ASV is diluted in 5-10ml/kg of body weight of isotonic saline or glucose. Infused at a constant rate over 1 hour. 18 January 2017 23
- 24. COMPLICATIONS OF ASV • Urticaria • Itching • Fever • Nausea, vomiting • Diarrhea • Abdominal cramps • Tachycardia, hypotension • Bronchospasm • Angioedema 18 January 2017 24
- 25. • Indian ASV- average time of onset of reactions is 20min. • Stop ASV at first sign of reaction. • Give im adrenaline 0.01ml/kg (Reaches peak effect by 8min), if no response/worsening, repeat im adrenaline. 18 January 2017 25
- 26. MANAGEMENT OF ASV REACTIONS • Discontinue ASV • Inj Adrenaline 0.01mg/kg IM • Inj Pheniramine maleate 0.5mg/kg/d iv • Inj Promethazine 0.3-0.5mg/kg IM • Inj Chlorpheniramine maleate 0.2mg/kg iv • Inj Hydrocortisone 2mg/kg IV 18 January 2017 26
- 27. NEOSTIGMINE • 0.6mg of atropine sulphate IV (0.05mg/kg)(0.6mg/ml) • 1.5-2mg of neostigmine IM(0.04mg/kg) (0.5mg/ml,2.5mg/ml) • INDICATIONS • DESCENDING PARALYSIS- PTOSIS, OPTHALMOPLEGIA, NUMBNESS OF LIPS, DYSARTHRIA, DYSPHAGIA, POOLING OF SECRETIONS • WEAKNESS OF NECK MUSCLE • DIFFICULTY IN BREATHING, FASCICULATIONS 18 January 2017 27
- 28. • Observe for 20min- o Single breath count o Amount of iris uncovered(mm) o Interincisor distance o Length of time upward gaze can be maintained o Spirometry • If improvement present, repeat atropine and neostigmine every 30 minutes, till recovery or upto 8 hours. 18 January 2017 28
- 29. NONSPECIFIC TREATMENT • ANALGESIA- Paracetamol 10mg/kg/dose 4-6 hr, Tramadol. Avoid Aspirin. • ANTIBIOTICS- if local tissue necrosis. • ANXIETY- Reassurance. • COMPLICATIONS- supportive therapies- dialysis, ventilatory care, blood and blood product transfusion. 18 January 2017 29
- 30. SNAKE BITE NON SPECIFIC HISTORY TIME AFTER BITE VICTIM ACTIVITIES DURING BITE TIME OF BITE DAY/NIGHT SITE/NUMBER OF BITE PAST HISTORY OF SNAKE BITE TREATMENT RECEIVED- ALLOPATHY/ALTERNATIVE NON LIFE THREATENING SPECIFIC •ANALGESIA- PARACETAMOL. (avoid aspirin) •ANTIBIOTICS- if local tissue necrosis •SUPPORTIVE- Dialysis, ventilation, blood product transfusion LIFE THREATENING AIRWAY, BREATHING, CIRCULATION,DISABILITY/ DRUGS 18 January 2017 30
- 31. BLEEDING NON LIFE THREATENING CHECK WBCT 6 HR AFTER COMPLETING ASV PROGRESSIVE WEAKNESS PAINFUL PROGRESSIVE SWELLING REPEAT ASV INDIVIDUALISED ASV 8-10VIALS COAGULABLE BLOOD REPEAT ASV(MAX.30VIALS) INCOAGULABLE BLOOD FFP IF INCOAGULABLE AFTER 6 HR WORSENING NO WORSENING SUPPORTIVE MEASURES IF WORSENING REPEAT ASV(MAX.20VIA LS ASSESS EVERY HOUR WBCT EVERY 6 HR, WATCH FOR BLEEDING NEOSTIGMINE 18 January 2017 31
- 32. SUMMARY • No test dose • Give Prophylactic adrenaline and antihistaminics • Slow iv injection-2ml/min • Infusion- liquid/reconstituted ASV diluted in 5-10ml/kg of isotonic saline or glucose infused at constant rate over 1 hour. DRUG DOSE ROUTE ADRENALINE(1mg/ ml) 0.01mg/kg im PHENIRAMINE MALEATE (22. 75mg/ml) 0.5mg/kg iv PROMETHAZINE(2 5mg/ml) 0.3-0.5 mg/kg im HYDROCORTISONE (100mg/ml) 2mg/kg iv DRUGS FOR ASV REACTIONSASV administration 18 January 2017 32
- 33. REFERENCES • Government of India.National Snake bite protocol. Newdelhi: Helath and Family Welfare department: 2007 • Warrel D.A: WHO/SEARO Guidelines for the management of snakebites,2010 • Simpson I.D: A2 Snakebite management in Asia and Africa. Available from http://www.pmrc.org.pk/A2%20Snakebite/20Ma nagementin%20Asia%20and%20Africa.pdf.pdf 18 January 2017 33
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- 39. DIAGNOSIS 18 January 2017 39
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