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Animal And Insect Bites

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    • 1. ANIMAL & INSECT BITES James Taclin C. Banez, MD, FPCS, FPSGS, DPBS, DPSA
    • 2. RABIES
      • In any mammalian animal
      • Rhabdovirus:
        • Rabies – meningoencephalitis
        • - worldwide
        • Ebola – hemorrhagic fever
        • Marburg – hemorrhagic fever Africa
    • 3. RABIES
      • Developed countries ---> raccoons,
      • skunks, bats, etc
      • Developing and under developed
        • Dogs (90%-Phil.)
      • Cats, cattle, horse, sheep, bats and exotic animals (5-10%)
      • Small rodents, birds and reptiles does not serve as reservoir of infection
    • 4. Epidemiology (Rabies)
      • Incidence rate:
        • 5–7/million
        • Average cases: 450 annually (Phil.)
        • Philippine is 3 rd worldwide
        • San Lazaro Hospital:
          • Pet dogs – 88% of cases
          • Stray dogs – 10% of cases
          • Cats – 2% of cases
    • 5. Prevention
      • Avoidance of said animals
      • Vaccination of pets (dogs, cats)
      • Exotic animals:
        • Quarantine for 90 days then vaccinate after another 30 days
        • Pet bitten by rabid animals:
          • No previous vaccine ---> isolate for 6 months, vaccinate 1 month---->release
          • w/ vaccine ----> give vaccine again and isolated for 90 days
    • 6. Transmission
      • Bites of rabid animals
      • Licking of the mucosa or open wound
      • Period of communicability :
        • Dogs & cats = 3-5 days before the onset of the symptoms until the entire course of the illness.
    • 7. Transmission
      • Incubation periods (Human):
        • 1 days to 5 yrs. (average 8wks )
        • Variations:
          • Severity of the bite
          • Site of bite in relation to nerve supply and distance from CNS
          • Size of innoculum, protection offered by clothing and other factors
          • Age and immune status of the host
    • 8. Transmission
      • Virus stays in :
        • CNS
        • Liver
        • Salivary gland
      • Travels thru the nerve
      • Incubation periods:
        • 1 days to 5 yrs. (average 8wks)
    • 9. Diagnosis
      • Circumstances of bite:
        • Provokes/unprovoked (domestic)
        • Vaccination of dogs ----> 90% effective
        • Wild animal ----> considered rabid
      • Extent & location of bite:
        • Severe:
          • multiple or deep puncture wound
          • Head, face, neck hands or fingers
        • Mild:
          • Superficial laceration, scratches
          • Bites on other sites mentioned
    • 10. Diagnosis
      • Laboratory diagnosis:
        • Pre-mortem (human):
          • Fluorescent microscopy of skin biopsies from nape of the neck.
          • Isolation of virus from saliva and CSF
          • Detection of antibody in serum and CSF in unvaccinated person
        • Postmortem (human):
          • Fluorescent microscopy of brain and salivary gland
        • Animal brain :
          • Histology = negri bodies
            • Demonstration of virus in brain tissue
    • 11. Natural History of Clinical Rabies in Man
      • Infected pts. usually go through 4 stages:
      • Exposure:
      • Incubation Period 20-90 days:
        • >95% present s/sx w/in 6 months of exposure
        • >98% w/in 1 yr.
      • First Symptoms (Prodrome) 2-10 days
        • Virus reaches the spinal cord
        • Nonspecific s/sx:
          • Fever, Anorexia, N/V, Headache, Malaise, lethargy
        • 1 st rabies specific symptom:
          • Pain , itching or paresthesias at site of bite
    • 12. Natural History of Clinical Rabies in Man
      • First Neurological Signs/Acute Neurological Phase: 2-7 days
        • Virus reaches the brain, multiplies and disseminates rapidly to the rest of the body organs notably the salivary glands
        • Pt may die at this stage
    • 13. Natural History of Clinical Rabies in Man
      • First Neurological Signs/Acute Neurological Phase: 2-7 days
        • May present in 2 ways:
        • Encephalitic or Furious rabies (80%):
          • Hyperactive episodes:
            • Combative, presents bizarre behavior, may be very agitated or apprehensive
            • Alternating w/ lucid moments where pt appears well
          • Hydrophobia – elicited by giving pt glass of water; positive rxn. – agitation, caused by painful contraction of laryngeal muscles upon drinking
          • Aerophobia – elicited by fanning the pt
    • 14. Natural History of Clinical Rabies in Man
      • First Neurological Signs/Acute Neurological Phase: 2-7 days
        • May present in 2 ways:
        • Paralytic or “dumb” rabies (20%)
          • Starts as paralysis of the bitten area w/c spreads to involve all limbs and eventually ends in respiratory paralysis
          • Most often missed due to absent hydrophobia and aerophobia
          • High index of suspicion who came in w/ paralysis or encephalitis of undetermined etiology.
          • Hx of prior exposure (bite or non-bite)
    • 15. Natural History of Clinical Rabies in Man
      • Onset of Coma 0-14d
        • Pituitary dysfunction
        • Hypoventilation, apnea
        • Hypotension
        • Cardiac arrhythmia, cardiac arrest
        • Coma
      • Death:
        • Secondary infection, nutritional deficiency and respiratory problem
    • 16. Management
      • Biting animals:
        • Domestic = observe for 10 days
        • Wild = vaccine shd. be given
      • Patients management:
        • Immediate local care:
          • Thorough irrigation w/ copious water/soap
          • Debridement / antibiotic / tetanus toxoid
          • Immediate suturing of wound (not advisable)
    • 17. Management
      • Patients management:
        • Immediate local care :
          • Head & neck bites:
            • Healing by secondary intention produces an unacceptable scar.
            • Primary closure has best outcome w/ less risk of infection
            • Severe human bite and avulsion injuries of the face requires flaps to close the wound
    • 18. Management
      • Patients management:
        • Immediate local care:
          • Hand Injuries:
            • 1/3 of dog bites in the hand becomes infected even w/ adequate therapy
            • Healing by secondary intention is recommended for most hand laceration.
            • All tendons and nerve injuries should be managed by delayed repair
            • After thorough exploration, irrigation and debridement, the hand shd. be immobilized, wrapped in a bulky dressing
    • 19. Management
      • Patients management:
        • Immediate local care:
          • Other parts of the body:
    • 20. Management
      • Patients management:
        • Prophylaxis:
        • Post-exposure prophylaxis:
          • Incubation period 10 days to 1 year (20-90d)
          • Incubation of <30 days (head & neck, upper extremities)
    • 21. Management
      • Prophylaxis:
        • Immunization:
        • Passive:
          • Human Rabies Immune Globulin (HRIG)
            • 20 I.U./KgBW
          • Equine Rabies Immune Globulin
            • 40 I.U./KgBW
        • A portion is infiltrated into the wound
        • Given with in 8 days
    • 22. Management
      • Prophylaxis:
        • Immunization:
        • Active:
          • Human Diploid Cell Vaccine (HDCV)
            • 5 dose IM (1ml) ----> 0, 3 rd , 7 th ,14 th and 28 th days WHO - 90 th day
            • Booster:
              • HDCV – 2 dose (0 and 3 rd day)
              • Antibodies levels checked every 6 months
    • 23. Management WHO GUIDE FOR POST-EXPOSURE TREATMENT: Assess Nature of Contact or Injury and the Biting Animals TYPE OF EXPOSURE TREATMENT HEALTHY SICK/RABID Category I: Touching or feeding, licking of healthy skin w/ no open wound, no documented contact of saliva w/ mucous membrane, reliable history No treatment No treatment Category II: Nibbling of uncovered skin, superficial scratch that doesn’t break skin, licking over broken skin or healing wounds. Category I w/ unrealiable history Vaccine + observe Vaccine (full course) Category III: Single or multiple transdermal bite or scratch which penetrates skin at any location; licking of mucous membrane Vaccine + RIG + observe Vaccine + RIG + (Full course)
    • 24. Management
      • Side effects of Vaccine (HBCV):
        • Sickness, pain and swelling of injection site
        • Fever, N/V, diarrhea, lymphadenopathy
        • Headache and dizziness
      • Contraindications:
        • Immuno-suppressive agents (measure antibody titer)
        • Allergies (antihistamine and epinephrine)
        • Pregnancy (not accepted nor documented)
    • 25. Management
      • Treatment for symptomatic patients:
      • Supportive:
        • Sedation
        • Respiratory support
        • Management heart arrhythmia and seizures
        • Nursing care
        • INTERFERON (not effective)
    • 26. SNAKE BITE
    • 27. SNAKE BITES Characteristic Poisonous Nonpoisonous a. Shape of head triangular round b. Pit (+) (-) c. Pupils elliptical Round d. Bite marks Fang marks 2 rows of teeth e. Caudal plates Single row Double row f. Color body Red ring next to yellow (coral snakes) Alternating color
    • 28. Venom Snakes
      • Toxicology:
        • Peptides:
          • Damages the endothelium:
            • Increase vascular permeability
              • Edema and hypovolemic
        • Enzymes:
          • Proteases & L-amino acid oxidase :
            • Cause tissue necrosis
          • Hyaluronidase:
            • Facilitate spread of venom through tissue
          • Phospholipase A2:
            • Damages erythrocytes and muscle cells.
    • 29. Venom Snakes
        • Neurotoxin:
          • Blocks neuromuscular junction
        • Others:
          • Endonuclease, alkaline and acid phosphatase, cholinesterase
      • Other deleterious effect:
        • Affects cardiovascular, pulmonary, renal and neurologic systems
        • Affects coagulation, fibrinolysis, platelet function and vascular integrity causing hemorrhagic or thrombotic sequelae
    • 30. Clinical Manifestations
      • Local:
        • 20% of pit vipers do not cause envenomation
        • Venom causes burning pain w/in minutes, followed by edema and erythema ----> edema progresses over the next few hrs w/ development of ecchymoses and hemorrhagic bullae
    • 31. Clinical Manifestations
      • Systemic:
        • Pt usually complain of weakness, N/V, perioral paresthesias, metallic taste and fasiculations.
        • Continuing capillary leak leads to hypotension ---> shock, pulmonary edema
        • Coagulopathy can develop w/in an hour and manifest:
          • Bleeding (gingiva, bite site, venipuncture site and recent wounds
          • Leads to DIC (disseminated intravascular coagulopathy)
    • 32. Clinical Manifestations
      • Systemic:
        • Acute renal failure due to:
          • Direct nephrotoxin
          • Circulatory collapse
          • Consumption coagulopathy
        • Neurotoxic venom (black mamba/coral snake/sea snake):
          • Local injury is minimal or absent
          • Cranial nerve dysfunction and loss of deep tendon reflexes
          • Progress to respiratory depression and paralysis after several hours.
    • 33. Laboratory Examination
        • CBC
        • DIC panel
        • Serum electrolyte
        • BUN, Creatinine
        • Urinalysis
        • ECG
    • 34. Management
      • Field Therapy:
        • Calm the pt. / cleansed / immobilized below the level of the heart.
        • Tourniquet , to occlude the vein; removed when:
          • as soon as IVF is started
          • Antivenom is ready for administration
          • Patient is not in shock
    • 35. Management
      • Field Therapy:
        • Incision & Suction:
          • Effective if done w/in 5 mins and continued for at least 30 minutes.
          • If done > 5mins ----> loss 50% 0f it’s value
          • If delayed > 30mins ----> loss 100% value
        • Excision of the bite wound:
          • In severe bites
          • Pt allergic to horse serum
          • Those pt. seen w/in 1 hr. following the bit
        • Cryotherapy – not recommended
    • 36. Management
      • Hospital Management:
        • History:
          • Hx. Of incident
          • Type of snake
          • Field management and prior antivenin tx.
        • PE:
          • Vital signs
          • Size and wound appearance (degree of envenomation / neurological examination for coral snake)
    • 37. Management
      • Hospital Management:
      • Wound care:
        • Cleansed thoroughly and extremity splinted
        • Debridement if necessary
        • Tetanus toxoid and tetanus immune globulin
        • Broad spectrum antibiotic (3-5days)
      • Fasciotomy:
        • Done only if compartment pressure are over 30mmhg.
        • Routine fasciotomies to prevent compartment syndrome have not proved to be beneficial.
    • 38. Management
      • Hospital Management:
      • Degree of Envenomation:
      • Grade 0: No envenomation
        • Minimal pain in wound, <1 inch of edema & erythema, no systemic symptoms
      • Grade I: Minimal
        • Moderate to severe pain
        • 1-5inches edema & erythema at 12hrs.
        • No systemic symptoms
    • 39. Management
      • Hospital Management:
      • Degree of Envenomation:
      • Grade II: Moderate
        • Severe pain
        • 6-12inches of edema & erythema at 12hrs.
        • N/V, shock or neurotoxic symptoms
      • Grade III: Severe
        • Severe pain, >12 inches edema/erythema at 12hrs
        • Grade II plus generalized petechia and ecchymosis
    • 40. Management
      • Hospital Management:
      • Degree of Envenomation:
      • Grade IV: Very Severe
        • Renal failure/blood tinged secretions
        • Coma and death
        • Local edema extend beyond involved extremity
    • 41. Antivenin Therapy
      • Most important tx
      • Horse serum; skin testing (0.02ml of 1:10 dilution of antivenum w/ 0.9% NaCl intradermally).
        • (+) allergy ----> premedication w/ diphenhydramine HCL 25-50ug IV and an epinephrine drip (2-20ug/min) during antivenin administration.
    • 42. Antivenin Therapy
      • Antivenin dose depends on the severity of envenomation and administered over 2-4hrs.
        • Grade I = No antivenin
        • Grade II = 3-4 amp. in 500ml NSS
        • Grade III = 5-15amp. in 500ml NSS
      • Pt re-evaluated every 2hrs and if necessary a repeat dose of ativenin shld be evaluated and given.
    • 43. Antivenin Therapy
      • Children: antivenin be increased by 50% bec. of higher rate of venom to body mass.
      • Pregnancy is not contraindicated
      • Antivenin for coral snake bite should be initiated even if envenomation is only suspected for there are frequently no local manifestation
    • 44. Antivenin Therapy
      • King cobra & Black mamba snake bites (Quick acting venom)
        • The initial dose of antivenin is part of it’s first aid tx.
    • 45. Other form of Management
      • Need for respirator ---> for respiratory failure
      • Dialysis ----> for renal failure
      • CNS Decompression
      • Transfusion of blood and its derivatives
      • Nutrition
    • 46. ARTHROPOD BITE
    • 47. Hymenoptera
      • BEES (Honeybee/bumble bee/ black hornet),
        • Venom: drop by drop similar to rattle snake
        • Bees has a barb-shaped stinger
        • Venom:
          • H istamine/serotonin (local rxn & pain)
            • Causes tissue necrosis
          • Phospholipase/hyaluronidase
            • Destroy collagen
            • Allergen – can elicit IgE mediated response
    • 48. Manifestation
      • Local rxn:
        • Sting produced localize pain,
        • wheal --> pustule
        • 20% produced large local rxn as erythematous, edematous, painful and pruritic areas larger than 10cm. For 2-5 days
          • Represents combination of IgE mediated, cell mediated
    • 49. Manifestation
      • Systemic rxn:
        • Multiple stings can produced toxic rxns.
          • Vomiting, diarrhea, generalized edema
          • Cardiovascular collapse
          • Hemolysis
        • 3% causes death due to anaphylaxis w/in 1 hr.
          • Starts as urticaria ----> angioedema , respiratory arrest 2 nd to airway edema and cardiovascular collapse
    • 50. Treatment
      • Local therapy:
        • Removal of sting (gentle scraping)
        • Clean the site
        • Pain: - apply ice
        • - vinegar
        • - topical or injected lidocaine
        • Pruritus: - antihistamine
        • Larger area: – elevate the site
        • - analgesia
        • - prednisone (1mg/k/day)
    • 51. Treatment
      • Systemic therapy:
      • Mild anaphylaxis :
        • 0.3 ml of 1:1000 epinephrine subQ (children – 0.01ml/kg)
        • Oral or IV antihistamine
      • Severe anaphylaxis:
        • IVF - endotracheal intubation
        • Vasopressor - steroid
        • Bronchodilator - ICU monitoring
    • 52. Spiders
      • Lactrodectus spiders (Black Widow)
        • Worldwide
        • female: black color w/ a distinctive red ventral marking w/ hourglass shape
        • Nocturnal spider; bites defensively
        • Has neurotoxic venom
          • Act at presynaptic terminal
          • Enhance neurotransmitter release
            • Acetylcholine = neuromuscular junction (muscle spasm)
            • Norepinephrine = produces adrenergic stimulation
    • 53. Spiders
      • Lactrodectus spiders ( Black Widow)
        • Manifestation:
          • Erythema & pain at bite site
          • Neuromuscular symptoms (30mins)
            • Severe pain & spasm of large muscle grp
              • Abdominal cramps (like acute abd)
              • Dyspnea (chest tightness)
            • Adrenergic stimulation:
              • HPN / diaphoresis / tachycardia
              • Fasciculation / Nausea/vomiting
              • Headache / paresthesia / fatigue / salivation
            • Acute symptoms peak several hours & resolve in 1-2 days
            • Death unusual
    • 54. Spiders
      • Lactrodectus spiders (Black Widow)
        • Treatment:
        • Mild envenomation
          • Local wound care:
            • Clean the site
            • Apply ice – to alleviate pain
            • tetanus prophylaxis
        • Severe envenomation
          • IV calcium gluconate (transient effect)
          • Narcotic & benzodiazepine - relieve muscle pain
          • Antivenin (horse serum) – reserve for severe envenomation due to anaphylaxis & serum sickness (side effect)
    • 55. Spiders
      • Lactrodectus spiders (Black Widow)
        • Treatment:
        • Severe envenomation
          • Antivenum is recommended:
            • Pregnant women
            • Children under 16 yrs
            • Patients w/ severe reaction:
              • Uncontrolled HPN
              • Respiratory distress
              • Seizures
          • Skin testing = if (+) shd. Receive pretx w/ diphenhydramine.
          • Recommended antivenin dose = 1 vial, repeated as necessary
    • 56. Spiders
      • Brown Recluse (loxosceles):
        • Necrotic arachnidism / loxoscelism
        • North & South America, Africa & Europe
        • Char. = dark brown violin shape marking over the cephalothorax
          • Has 3 pairs of eye
          • Both male & female bites when threatened
    • 57. Spiders
      • Brown Recluse (loxosceles):
        • Toxicology:
        • Sphingomyelinase (phospholipase)
          • Dermonecrotic factor
          • Destroy cell membrane or RBC ---> hemolysis
          • Destroy endothelial cells ---> coagulation
          • Interact w/ platelets ----> platelet
          • aggregation
          • Necrosis – most severe in fatty areas
          • (abdomen & thigh)
    • 58. Spiders
      • Brown Recluse (loxosceles):
        • Manifestation:
        • Local:
          • Mild irritation to severe necrosis w/ ulceration
              • Ischemia (pain, itching, swelling & erythema) ---> blister ----> central area turns purple and peripheral becomes pale due to vasoconstriction ----> necrosis ---> replaced by eschar that separates producing ----> large ulcer that heals w/in 2 months.
    • 59. Spiders
      • Brown Recluse (loxosceles):
        • Manifestation:
        • Systemic:
            • N/V, headache, fever, malaise, arthralgia
            • Maculopapular rash
              • Thrombocytopenia / Disseminated intravascular coagulation
              • Hemolytic anemia
              • Coma and rarely death
    • 60. Spiders
      • Brown Recluse (loxosceles):
        • Treatment:
        • Bite site elevated
        • Cold compress: Cold can
          • Inhibits venom
          • Decrease inflammation & ulcer formation
        • Dapson = reduces local inflammation by inhibiting neutrophil function. (100mg/d)
        • Debridement is recommended be done 1-2 wks after the margin are defined
        • Split thickness skin grafting done while dapsone is being continued
        • No antivenin
    • 61. Scorpion
      • Worldwide / Buthidae family
      • Has neurotoxin that prevent sodium channel closure
      • Manifestation:
        • Local paresthesia & burning symptoms
        • Cranial nerves & neuromuscular dysfunction ----> respiratory distress
    • 62. Scorpion
      • Treatment:
      • Local:
        • Ice pack therapy / analgesic -> for pain
        • Tetanus prophylaxis
      • Systemic:
        • Monitor closely cardiovascular & respiratory status in ICU
        • Antivenin can reverses cranial nerve & neuromuscular symptoms but can cause anaphylaxis & delayed serum sickness
        • Dose = 1 vial; if sensitive (diphenhydramine)
    • 63. Marine Trauma & Envenomation
      • Considerations:
        • Hypothermia
        • Drowning
        • Decompression syndrome (air embolism)
        • Follow ABC
        • Bacterial isolates: C/S impt.
          • Gram (-) rods (vibrio sp.)
          • Staph / strep
        • Tetanus vaccine
    • 64. Marine Trauma & Envenomation
      • Considerations:
        • Antibiotics:
          • 3 rd generation cephalosphorin
          • Quinolones
          • Gentamicin
          • Trimethoprin-sulfamethoxazole
        • Debridement = to lower infection & promote healing
        • Wound are loosely closed & drained; primary closure of distal extremity are avoided.
        • Antivenin if available is given after skin testing
    • 65. Injuries from Nonvenous Aquatic Animals:
      • SHARK:
        • tiger / great white / bull shark
        • Most injuries are lower extremities
        • Powerful jaws & sharp teeth produces crushing & tearing injuries
        • Causes of death:
          • hypovolemic shock
          • drowning
    • 66. Injuries from Nonvenous Aquatic Animals:
      • Moray Eels:
        • Residing in holes or crevices at the floor of the sea
        • Bites and produces multiple puncture wounds
        • Hands is the most frequently bitten
      • Alligators / Crocodile
        • Similar to shark bites
    • 67. Injuries from Venomous Aquatic Invertebrates Animals:
      • Coelenterates: (Jelly fish)
        • Venomous stinging cells called nematocyte
        • Mild envenomation:
          • Sting produces skin irritation
            • Pruritus, paresthesia & throbbing pain
            • Edema and erythema ----> blisters & petechia ----> local infection & ulceration.
    • 68. Injuries from Venous Aquatic Invertebrates Animals:
      • Coelenterates: (Jelly fish)
        • Systemic envenomation:
          • Manifestation of anaphylactic rxn
            • Fever, N/V, body malaise
          • Death due to hypotension and cardio-respiratory arrest.
    • 69. Injuries from Venous Aquatic Invertebrates Animals:
      • Coelenterates: (Jelly fish)
        • Treatment:
        • Clean the wound w/ sea water
        • Apply diluted 5% acetic acid (vinegar) or baking soda; it can inactivate the toxin; applied for 30 mins or until the pain is relieved
        • After wound irrigation ---> remaining nematocyst are removed by applying shaving cream and shave the area w/ razor
        • Local anesthesia, atihistamine or steroids can relieve pain after the toxin is inactivated.
        • Prophylactic antibiotic are usually unnecessary
    • 70. Injuries from Venous Aquatic Invertebrates Animals:
      • Echinodermata ( sea urchins & sea cucumber)
        • Causes contact dermatitis
        • Sea cucumbers feeds on coelenterates and secrete nematocytes hence local therapy for coelenterates shd be done
        • Sea urchins – venomous spines causing local & systemic rxn like coelenterates
    • 71. Injuries from Venous Aquatic Invertebrates Animals:
      • Echinodermata ( starfish, sea urchins & sea cucumber )
        • Treatment:
        • Soak w/ hot water
        • Spines of the organism located w/ x-ray or MRI and shd be removed
        • Swelling alleviated w/ steroids
    • 72. Injuries from Venous Aquatic Invertebrates Animals:
      • Mollusks ( octopus ):
        • Can bite & inject tetrodoxine (paralytic agent)
        • Tx:
          • pressure & immobilize to contain venom
          • Systemic complication --- supportive
    • 73. Injuries from Venous Aquatic Vertebrates Animals:
      • Stingrays:
        • Whiplike appendages w/ spines at its end that can produce puncture wounds & lacerations
        • Venom = vasoconstrictions causing cyanosis of wound ----> myonecrosis
        • Systemic rxn:
          • Cardiac arrhythmia
          • Respiratory arrest
          • seizures
    • 74. Injuries from Venous Aquatic Vertebrates Animals:
      • Stingrays:
        • Treatment:
        • Wound irrigated and soaked w/water for an hour
        • Debridement, exploration and removal of spines
        • Wound is elevated, dressed and not closed primarily
        • Pain relieved locally and systemically
    • 75. Injuries from Venous Aquatic Vertebrates Animals:
      • Sea Snakes: ( Hydrophiidae )
        • neurologic sign and symptoms
        • Death is due to paralysis and resp. arrest
        • Tx similar to coral snake
          • Pressure, immobilize technique
          • Antivenin administration 1 ampule initially then repeated as needed
    • 76. THANK YOU