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Snake bite.pptx
- 1. Snake bite
- 2. Case • 18yrs old Male • Pain left leg from below the knee joint • From last one year • Aggravation on standing • Relief on taking rest • No medications were used for pain relief
- 3. HPOC • History dates a year back when he got bitten by something while working in fields. • There was a little bleeding from the area bitten. • Pain was bearable. • First Aid was given by the local quack. • Area got infected and later turned into a pusy wound. • Went to see some Hakim who told that you were bitten by a snake. • The wound took at least a month to heal. • He didn’t seek help from any medical advice for his problem.
- 4. • Occupation • Type of the snake • Site of the bite • Marks of bite • Bleeding • Swelling / Bruising / bleb formation • Pain intensity and progression • Any breathing difficulties • Non specific signs • Time of bite and time of presentation Important Questions to be asked
- 5. Red flags • Presence of two bite marks • Redness and swelling at the site of bite • Blistering around the bite • Bleb formation • Severe tenderness and edema
- 6. Differential Diagnosis of Pain in Leg • Musculoskeletal • Trauma • DVT • Varicose Veins • Ischemia • Necrotizing fasciitis • Neuropathy
- 7. GLOBAL SITUATION OF SNAKE BITE • An estimated 5.4million people each year are bitten with up to 2.7million envenoming. • Around 81000 to 138000 people die each year because of snake bite and around three times as many amputation and other permanent disabilities are caused by snake bites annually. • In Asia up to 2 million people are envenomed every year.
- 8. FACTS • In June 2017,the WHO added snakebite to the list of neglected tropical diseases. • 80% of the total snake species found in the world are non poisonous and only 10% is poisonous. • Primarily only 4 species of snakes are dangerous to man, named Cobra, Krait, Russell’s Viper and Saw scaled Viper. • India has been recognized as the country with highest snake bite mortality.
- 9. CLASSIFICATION OF SNAKE VENOMS • 1. Elapidae: Neurotoxic • 2. Viperidae: Vasculotoxic, Hemotoxic • 3. Hydrophidae: Myotoxic
- 10. ELAPIDAE • These are extremely venomous snakes. • These include Cobra, Mumba, krait, and coral snake.
- 11. Neurotoxic venom Venoms with Neurotoxic activity produce paralysis and respiratory distress by binding the nicotinic acetylcholine receptors and preventing the depolarizing action of acetylcholine The most important effect of neurotoxins is to prevent the transmission of nerve impulses on cholinergic synapses which cause muscle paralysis respiratory failure and death by asphyxiation
- 12. VIPERIDAE • These venomous snakes have long hinged fangs. • They include Adder, rattlesnake, Russel and green viper.
- 13. HEMOTOXIC VENOM • The venom of rattlesnakes and other pit vipers damages tissue around the bite. • Venom may cause changes in blood cells, prevent blood from clotting, and damage blood vessels, causing them to leak. • These changes can lead to internal hemorrhage, respiratory, and kidney failure.
- 14. HYDROPHIDAE • They are the sea snakes and highly venomous • They an be readily identified by their flattened tails.
- 15. MYOTOXIC VENOM • When envenomation occurs in humans, bites are often painless and minimal swelling occurs. Symptoms include headaches, sweating, vomiting, body aches, muscle stiffness, and eventually paralysis. As with the eels that the snakes prey on, the paralysis of any muscles involved in breathing or swallowing may be fatal.
- 16. DRY BITE • About 50% of snakebite cases can be dry bites. • They are characterized by fang and tooth marks and the absence of injected venom.
- 17. ENVENOMATION • Moderate envenomation is more likely to cause symptoms of severe pain, swelling of the whole limb, and general feelings of illness, such as nausea, vomiting, and weakness. • Severe envenomation symptoms include severe pain, severe swelling, difficulty breathing, moderate to severe bleeding, and signs of shock.
- 18. DIAGNOSIS OF SNAKE BITE • FANG MARKS Classically two puncture wounds separated by a distance varying from 8 mm to 4 cm depending on the species involved. However a side swipe may produce only a single puncture while multiple bites could result in numerous fang marks
- 19. SNAKE VENOM • Combination of enzymatic and non enzymatic polypeptides • Acidic • On drying ….. fine needle like crystals • Water soluble • Lethal dose for • Cobra 0.12gms • Krait 0.06gms • Russell snake 0.15 Healthy angered and hungry snake unload more venom than a recently satiated snake.
- 20. EFFECTS OF ENVENOMATION • Local effects • Systemic effects
- 21. CLINICAL FEATURES When venom has not been injected Out of fear • Vasovagal attack • Collapse Slowing of heart rate
- 22. CLINICAL SYMPTOMS • Severe local pain with burning ,bursting and throbbing, at the site of the bite. • Local swelling • Painful enlarged regional lymph nodes • Bites by sea snakes my virtually be painless and may cause negligible local swelling.
- 23. ASSESS SIGNS OF ENVENOMING • Fang marks • Local Swelling • Bruising • Lymphangitis • Blistering • Necrosis
- 24. SYSTEMIC FEATURES Nausea, vomiting, malaise, abdominal pain, weakness, drowsiness, prostration Cardiovascular symptoms Dizziness, faintness, collapse, shock, hypotension, cardiac arrhythmias, pulmonary edema and cardiac arrest Bleeding and clotting disorders Bleeding from gums, epistaxis, hemoptysis, hematemesis, melena, hematuria, petechia, purpura, ecchymosis etc.
- 25. Neurological symptoms Drowsiness, paresthesia, abnormalities of taste and smell, heavy eyelids, ptosis, facial palsy, aphonia, generalized and respiratory paralysis Skeletal muscle breakdown Generalized pain, stiffness and tenderness of muscles, trismus, myoglobinuria, hyperkalemia, cardiac arrest
- 26. SNAKE BITE MANAGEMENT Do it RIGHT • R……Reassure the patient. • I…….Immobilize basically Pressure Immobilization • G. H ..….. Go to Hospital immediately. • Tell the doctor of any specific symptoms such as ptosis that manifest on the way to hospital.
- 27. DONTS IN FIRST AID • Do not apply the tourniquet. • Do not wash the bite site with soap or any other solution to remove the venom. • Do not make cuts or incisions on or near the bitten area. • Do not freeze or apply extreme cold to the area of bite. • Do not apply any kind of potentially harmful herbal or household remedy.
- 28. • Do not attempt to suck out venom. • Do not give the victim anything to drink if semi unconscious. • Do not take the patient to any quack.
- 29. TREATMENT PROTOCOL IN HOSPITAL • Deal with airway, breathing and treatment of shock. • IV access should be established in unaffected extremity. • CBC, coagulation profile and fibrinogen concentration should be assessed. • All the patients should be kept under observation for a minimum of 24 hours. • Many species particularly the krait and the hump nosed pit viper are known for delayed appearance of symptoms which can develop after 6 to 12 hours.
- 30. ASV • Anti snake venom is the mainstay of the treatment.
- 31. ASV • Anti-Snake venom serum is a sterile preparation containing purified and concentrated immunoglobulins (Polyvalent Equine Immunoglobulins) obtained from the serum of healthy horses, donkey or sheep which are immunized against the venoms of one or more species.
- 32. NIH • Biological Production Division National Institute of Health Islamabad, PAKISTAN FOR THE REGISTERED MEDICAL PRACTITIONER ANTI-SNAKE VENOM SERUM (Polyvalent Equine Immunoglobulins)
- 33. SPECIFIC SERUM TREATMENT • At first the dose of 10-30 ml of the serum will be injected intravenously very slowly. • The second dose can be repeated two hours after the first dose or even earlier depending on the condition of the patient and severity of symptoms.
- 34. • Further doses can be repeated after six hours interval until the symptoms disappear completely. • One third of first dose of anti-snake venom serum can be administered locally to prevent gangrene development. • Antiserum can be diluted with isotonic solution.
- 35. SUPPORTIVE TREATMENT • Antibiotics • ATT • Antipyretics • Anti-emetics • Steroids • Anti Histamines
- 36. DOG BITE
- 37. FACTS • Rabies is a vaccine-preventable viral disease. • Dogs are the main source of human rabies deaths, contributing up to 99% of all rabies transmissions to humans. • Interrupting transmission is feasible through vaccination of dogs and prevention of dog bites. • 40% of people bitten by suspect rabid animals are children under 15 years of age. • Immediate, thorough wound washing with soap and water after contact with a suspect rabid animal is crucial and can save lives.
- 38. MORTALITY / MORBIDITY • WOUND INFECETION AND CELLULITIS • Puncture wounds have a higher rate of infection than lacerations. • Lacerations cause more damage to tissues than puncture wounds. • Septic arthritis from wounds in joint spaces. • OSTEIOMYELITIS FROM DEEP WOUNDS • MENINGISTI FROM PENETRATING SKULL WOUNDS
- 39. SYMPTOMS INCUBATION PERIOD • Typically 2 to 3 months • May vary from 1 week to 1 month INITIAL SYMPTOMS • Pain with Fever • Unexplained tingling, pricking or burning sensation • Progressive inflammation of brain and Spinal cord
- 40. FORMS OF RABIES • FURIOUS RABIES • Hyperactivity • Excitable behaviors • Hydrophobia • Aerophobia • Death • PARALYTIC RABIES • Muscles gradually become paralyzed • Coma develops slowly • Death
- 41. POST EXPOSURE PROPHYLAXIS (PEP) • Extensive washing and local treatment of the bite wound or scratch as soon as possible after a suspected exposure • Stat dose of ATT • A course of potent and effective rabies vaccine • Administration of rabies immunoglobulin (RIG), if indicated.
- 42. EXPOSURE RISK AND INDICATION FOR PEP • CATEGORY I WASHING OF EXPOSED SKIN AND NO PEP • Bite while feeding the suspect animal where skin is intact • CATEGORY II PEP • Minor scratches without bleeding from contact or licks on broken skin • CATEGORY III PEP AND RIG • One or more bites, scratches. • Licks on broken skin.
- 43. PROTOCOL OF RABIES SHOT • A regimen of four 1-mL vaccines should be administered intramuscularly to previously unvaccinated persons. The first dose of the four-dose course should be administered as soon as possible after exposure. Additional doses should be administered on days 3, 7, and 14 after the first vaccination.
- 44. TYPES OF THE RABIES VACCINE PEP 1. RABIES IMMUNOGLOBULINS RIG HRIG ERIG 2. ANTI RABIES VACCINE HDCV PCECV • HRIG • ERIG • 2. Anti Rabies Vaccine • Human diploid cell vaccine HDCV
- 45. RABIES IMMUNOGLOBULINS • Rabies immunoglobulins are special neutralizinf antibodies that immediately neutralize virus on contqct. • Tabies iimunoglobukins gives a coating to the virus so that it cannot enter the nerveending resulting in reduction or total obliteration of inoculated virus
- 46. RABIES IMMUNOGLOBULINS • There are two types of specific Rabies Immunoglobulins: • 1. Human Rabies Immunoglobulin (HRIG) • 2. Equine Rabies imuunoglibulin (ERIG)
- 47. HUMAN RABIES IMMUNOGLOBULINS • It is a liquid of freeze dried preparation containing immunoglobulins mailny IgG obtained from plasma or serum of donors immunized gainst rabies and ontains specific antibiotics that neutralie the rabies virus • It is prepared from palsm of more than 1000 donors • IT provies passive prtection whrn given immedicately to individuals exposed to rabies virus
- 48. Equine Rabies Immunoglobulin • Advantages • Massice yield • Much afforable than human rabies immunoglobulin low cost • Widely avaialble • Modern purification and ultra filtration technologies has made it safer. • Disadvantages • Presence of forign protien • Chances of immudiate hypersensitvity
- 49. TEST DOSE OF RIG • 0.1ML OF 1:10 DILUTED RIG wih t normak saline is given intradermally on the left forearm. • Observation the patient is observed for 15 minutes for any local or reactions
- 50. MECHANISM OF ACTION OF RIG • Following intramuscular administration – Rabies immunoglobulin provides immediate passive antibodies for a short period of time. This protects the patient until the patient can produce antibodies from the rabies vaccine.An adequate titre of passive antibody is present 24 hours after RIG administration.Duration of Protective Effect:Short: Rabies immunoglobulin has a half-life of approximately 21 days.Cross sensitivity and/or related problems:Patients sensitive to other human immune globulin products may be sensitive to Rabies Immunoglobulin also.
- 51. WHO STANCE ON ADMINSTRQTION OF RIG • RIG hould be administered nly once, preferably at, or as soon as possible after, the infilitration of PEP. • RIG is infiltereated into and around the wound • For optimal effectiveness the maximum dose calculation for RIG is 40IU/Kg body weight for equine derived RIG (eRIG).
- 52. RECOMMENDED TIMELINES FOR RABIES VACCINE • If a dog, cat, bat, or other mammal you might suspect has rabies has bitten you, get to the doctor. The first dose of the vaccine should be administered within the first 24 hours after exposure.
- 53. COURSE OF RABIES VACCINE • The first dose of the 4-dose course should be administered as soon as possible after exposure (day 0). Additional doses then should be administered on days 3, 7, and 14 after the first vaccination.
Editor's Notes
- Todays presentatipn is based on a case who presented almost two amonths ago
- Leg pain turned a constant feature after that incident
- So the imporatn questions to be asked were about his occupation as high risk groups include rural agricultural workers, herders, fishermen etc Its also important to ask if the patinet has happened to see the snake himself Site is imporatnt as Usually such bites are more on extremities Do inquire about twi disticnt bite marks and bleeding Do ask if there was any swelling bruising and even some bleb formation Pain intensity is imporatnat as it progresses with time Its important to ask if there was any breathing difficulty and other non specific signs like nausea vomiting fever vertigo etc Time of bite and time of presentation is also very important
- These red flags should make you think what should be the immediate course of action
- DD for pain in leg is that the paijn might be muscular or may have occurred due to any trauma. Such persistent pain migh tbe due to DVT, varicose viens ichemia necrotizing fasciitis or some neuropathy as well
- So lets talk about global situation of snake bite ACCORDING TO WHO
- SNAKE VENOMS ARE USUALLY CLASSIFIED AS
- Note Krait and russel viper is much more toxic that that of cobra
- These venoms consist primarily of neurotoxins that generally cause death by muscle paralysis, RESPIRSTORY DISTRESS AND DEATHH BY ASPHYXIATION
- Hemotoxins form the rattle snake and pit vipers destroy red blood cells, disrupt blood clotting, and/ can cause organ degeneration These changes can lead to internal hemorrhage, respiratory, and kidney failure and can ultimately lead to death ... Venoms of this kind have a proteolytic action. They produce swelling cardiovascular damage and eventual necrosis. They also disrupt blood clothing and in the process of destroying the bloods functionality severely damage internal organs and other body tissues which can be extremely painful. The intermediate cause of death in such cases is usually hypovolemic shock Envenomation increases capillary permeability that results in blood and plasma loss form the intravascular to the extracellular space creating edema which in case of being sufficiently important nay cause circulatory compromise and hypovolemic shock
- The venom is very potent and toxic. MYOTOXINS IN THE VENOM DAMAGE THE SKELETAL MUSCLES AND CARDIAC TISSUE A
- A dry bite is a bite by a venomous SNAKE in which no venom is released. ... 50 % of the bites by venomous snakes are dry bites that result in negligible envenomation. This is characterized by fang and tooth marks but no injected venom.
- In moderate envenomation there could be severe pain, some swelling of the whole limb and general feeling of illlness. But in severe cases three could be signs of breathing difficulty and shock
- To confirm snake bite one should look for fang marks separated by some distance depending uponth especies involved
- Briefly about snake venom It’s a combination of enymatic and non enzymatic polypeptides
- ENVENOMATION HAS LOCAL AND SYSTEMIC EFFECTS BOTH
- After a dry snake bite due to fear there might be misleading symptoms like vasovagal shock and collapse
- Following the bite there is increasing local pain with burning ,bursting and throbbing, at the site of t Local swelling that gradually extends proximally up the bitten limb with extreme tenderness and paInful enlarged regional lymph nodes draining the site of the bite. Bites by sea snakes my virtually be painless and may cause negligible local swelling. Someone who is sleeping may not even wake up when bitten by krait and there may be no detectable fang marks or signs of local envenoming.
- APART FROM FANG MARKS THERE COULD BE Local swelling AND bruising and THERE MAY BE inflammation OF MORE THAN HALF OF THE LIMB. AND THAT TOO WITHIN FEW HOURS AFTER THE BITE LOOK FOR THE Enlarged tender lymph nodes draining the bitten limb. Any Blister or bullae. Also check Necrosis of part of limb
- Generalized or systemic symptoms INCLUDE Nausea, vomiting, malaise, abdominal pain, weakness, drowsiness, prostration cardiovascular symptoms Dizziness, faintness, collapse, shock, hypotension, cardiac arrhythmias, pulmonary edema and cardiac arrest Bleeding and clotting disorders Apart from the bleeding from the wound there might be bleeding from gums, epistaxis, hemoptysis, hematemesis, melena, hematuria, petechia, purpura, ecchymosis etc.
- First Aid is based primarily around this mnemonic RIGHT R is to reassure the patient as 70% of all the snakebites are form non venomous species and Only 50% of bites by venomous species actually envenomate the patient. Second we need to Immobilize the same way as fractured limb. Its purpose is to retard the movement of venom from bite into the circulation , thus buying time for the patient to reach medical care. Since Traditional remedies have no proven benefit in treating snakebite so patient should be immediately taken to any government hospital where antivenom is available Tell the doctor of any specific symptoms such as ptosis that might manifest on the way to hospital.
- These donts are recommended by WHO
- Initial management is to deal with airway, breathing and treatment of Shock Also give tetanus toxiid IV access should be establised in unaffected extremity Coagluation profile and fibrinogen concentration should also be assessed . All the patinets should be kept under observation for a minimum of 24 hours Because some species are known for delayed appearance of symptoms which can develop after 6 to 12 hours.
- anitvenom is immunoglobulin usually pepsin refined fragments of whole IgG purified form the plasma of hrse, mule or donkey or sheep that hs been immunized with venoms of one or nore species of snakes Anti-Snake venom serum is a sterile preparation containing purified and concentrated immunoglobulins obtained from the serum of healthy horses immunized against the vBiological Production Division National Institute of Health Islamabad, PAKISTAN FOR THE REGISTERED MEDICAL PRACTITIONER ANTI-SNAKE VENOM SERUM (Polyvalent Equine Immunoglobulins)enoms of all the four poisonous snakes of Pakistan
- We need to have a little info about what ASV is. anitvenom is immunoglobulin usually pepsin refined fragments of whole IgG purified form the plasma of hrse, mule or donkey or sheep that hs been immunized with venoms of one or nore species of snakes Anti-Snake venom serum is a sterile preparation containing purified and concentrated immunoglobulins obtained from the serum of healthy horses immunized against the vBiological Production Division National Institute of Health Islamabad, PAKISTAN FOR THE REGISTERED MEDICAL PRACTITIONER ANTI-SNAKE VENOM SERUM (Polyvalent Equine Immunoglobulins)enoms of all the four poisonous snakes of Pakistan
- And this ASV is produced in biological production division of NIS Islamabad.
- Once the venom is into the circulation, it is then the ASV that can neutralize it.
- Anti-Tetanus Serum or any other supportive therapy can be given as needed
- Rabies is a vaccine-preventable, zoonotic, viral disease. Once clinical symptoms appear, rabies is virtually 100% fatal. In up to 99% of cases, domestic dogs are responsible for rabies virus transmission to humans. It is spread to people and animals through bites or scratches, usually via saliva. AGE GROUP IS USUALLY LES THAN 15 YRS AS Provoked bites are significantly more frequent than unprovoked bites THIS POINT IS VERY CRUCIAL THAT IMMEDIATE THOROUGH WOUND WASHING WITH SOAP AND RUNNING WATER CAN SAVE MANY LIVES . THAT WHY ITS IMPORTANT TO KEEP SOOFI OR GAI SOAPS AT HOME THAT IF ANY SUCH SITUATUION ARISES YOU ARE TO TAKE PROPER TIMELY ACTION.
- ONE CAN END UP INTO WOUND INFECTION CELLLULITIS OSTEOMYLITIS FROM DEEP WOUNDS EVEN MENINGITIS FROM PENETERATING SKULL WOUNDS
- The incubation period for rabies is typically 2–3 months but may vary from 1 week to 1 MONTH, depending upon factors such as the location of virus entry and viral load. Initial symptoms of rabies include a fever with pain and unusual or unexplained tingling, pricking, or burning sensation (paraesthesia) at the wound site. As the virus spreads to the central nervous system, progressive and fatal inflammation of the brain and spinal cord develops.
- There are two forms of the disease: Furious rabies results in signs of hyperactivity, excitable behaviour, hydrophobia (fear of water) and sometimes aerophobia (fear of drafts or of fresh air). Death occurs after a few days due to cardio-respiratory arrest. Paralytic rabies accounts for about 20% of the total number of human cases. This form IS less dramatic BUT HAS A longer course than the furious form. Muscles gradually become paralysed, starting at the site of the bite or scratch. A coma slowly develops, and eventually death occurs. ITS IMORTANTT TO MENTION HERE THAT The paralytic form of rabies is often misdiagnosed, contributing to the under-reporting of the disease. Diagnosis
- Post-exposure prophylaxis (PEP) Post-exposure prophylaxis (PEP) is the immediate treatment of a bite victim after rabies exposure. This prevents virus entry into the central nervous system, which results in imminent death. PEP consists of: Extensive washing and local treatment of the bite wound or scratch as soon as possible after a suspected exposure; a course of potent and effective rabies vaccine that meets WHO standards; and the administration of rabies immunoglobulin (RIG), if indicated. Starting the treatment soon after an exposure to rabies virus can effectively prevent the onset of symptoms and death.
- DOG BITE IS TREATED ACCORDING TO CATEGORY OF EXPOSURE
- HRIG ERIG 2. Anti Rabies Vaccine Human diploid cell vaccine HDCV Prified Chick Embbryo cell culture vaccine
- SINCE RIG IS EQUINE RABIES IMMUNOGLOBULINS, IT IS MANDATORY TO CARRY OUT AN INTRADERMAL TEST TO KNOW THE SENSITIVITY OF THE INDIVIDUAL.
- If a dog, cat, bat, or other mammal you might suspect has rabies has bitten you, get to the doctor. The first dose of the vaccine should be administered within the first 24 hours after exposure.
- The vaccine should be given at recommended intervals for best results. Talk to your doctor or state or local public health officials if you will not be able to have your shots at the recommended interval. Rabies prevention is a serious matter and changes should not be made in the schedule of doses