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Management of Snake Bite Victims  with Respiratory Paralysis in ICU Dr. T.R. Chandrashekar Director Critical Care  K.R.Hospital Bangalore DR TRC/ KRH
Management of Snake Bite Victims  with Respiratory Paralysis in ICU ,[object Object],[object Object],[object Object],[object Object],[object Object]
How to prevent snake bites? ,[object Object],[object Object],[object Object],The bottom line is we need snakes to survive
Epidemiology ,[object Object],[object Object],[object Object],[object Object],[object Object]
FAB FOUR ,[object Object],[object Object],[object Object],[object Object],[object Object],Majority of bites Nearly 70-80% Hemotoxin Vasculotoxin Neurotoxic 1 2 4 3
Species: Medical Implications  Yes NO Yes No No  Renal Problems No NO No? No? Yes  Neostigmine & Atropine Yes Yes Yes No No Coagulation No NO Yes! Yes Yes Ptosis/Neurotoxicity  Yes Yes Yes No  Yes  Local pain/ Tissue Damage Other Vipers Saw Scaled Viper  Russell’s Viper  Krait  Cobra  Signs/Symptoms and Potential Treatments
Syndromic approach ,[object Object],[object Object],[object Object],[object Object]
Snake bite Venomous snakes Anti snake venom Majority is by non-venomous snakes ,[object Object],[object Object],[object Object],[object Object]
Our statistics ,[object Object],[object Object],[object Object],6 required MV 8 Neuotoxic bites 20 required MV 33 Hemotoxic bites 45 snake bite admissions 1998-2008
Snake bite and Respiratory paralysis Neuromuscular paralysis- blockade of neuromuscular transmission. Cobra-  post-synaptic Krait- pre-synaptic Bulbar paralysis-Aspiration Sepsis,  DIC-shock ARF-Pulmonary edema Neurotoxic MV for respiratory paralysis ASV MV as Supportive care More cases why ?
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],70-80% 20-30%
Case scenario……. ,[object Object],[object Object],[object Object],Patient received  in casualty Patient is comfortable, vitals stable  No ptosis, distress Patient is dead –what do you think went wrong ?
[object Object],[object Object],[object Object],[object Object],[object Object],Patient is dead –what do you think went wrong ?
Case scenario……. ,[object Object],[object Object],[object Object],Why does Neurotoxicity occur What are the Management issues? ASV, Anticholineesterases, MV…
Snake venom components
Krait- Pre-synaptic action Beta-bungarotoxin- Phospholipases A2 1) Inhibiting the release of acetylcholine from the presynaptic membrane 2) Presynaptic nerve terminals exhibited signs of irreversible physical damage and are devoid of synaptic vesicles 3) Antivenoms & anticholinesterases have no effect Paralysis lasts several weeks and frequently requires prolonged MV. Recovery is dependent upon regeneration of the terminal axon.
Cobra –post-synaptic ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Anticholinesterases reverse the neuromuscular blockade
Snake envenomation in a north Indian hospital Ptosis RS involvement Bulbar weakness N Sharma, S Chauhan, S Faruqi, P Bhat, S Varma,  Emerg Med J 2005;22:118–120 Ophthalmoplegia
Neurotoxic envenoming-Examination ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Bulbar paralysis ,[object Object],[object Object],[object Object],[object Object]
Local examination   ,[object Object],[object Object]
Treatment   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ASV  ,[object Object],[object Object],ASV is polyvalent Syndromic approach helps in examination and investigations and outcome predictions
Skin testing for ASV ,[object Object]
What is ASV? ,[object Object],[object Object],[object Object],[object Object],[object Object]
Indications for ASV ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Timing of ASV ,[object Object],[object Object],[object Object],[object Object]
Dose   5 vials(50ml) 5-10 vials (50-100ml) 10-20 vials (100-200ml)
Large vs small dose Low dose of snake antivenom is as effective as high dose in patients with severe neurotoxic snake envenoming Agarwal, Aggarwal, Gupta, et al Emerg Med J 2005;22:397–399 . High dose group 100ml stat and 100 ml every 6 hrs Low dose group 100ml stat and 50 ml every 6 hrs Until recovery of neurological signs
High vs low ASV ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Repeat dose ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Causes
Observation of the response to Antivenom Cobra bites-Post synaptic May begin to improve as early as 30 minutes  after anti-venom, but usually take several hours .  Krait and sea snakes- Pre synaptic Depends on the timing of ASV administration If delayed may not produce any action or Minimal delayed action
Antivenom reactions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Antivenom reactions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],5-day course of oral antihistamine/ Prednisolone. Chlorpheniramine: 2 mg six hourly  Prednisolone: 5 mg six hourly Serum sickness
Trial of anticholinesterase ,[object Object],[object Object],[object Object],[object Object],Observe Improvement in ptosis, Respiratory distress, better cough effort, decrease in RR Tearing, salivation, muscle fasciculation, abdominal cramp, bronchospasm, bradycardia, cardiac arrest Neostigmine  Positive response   Atropine IV Negative response   Dose of Neostigmine Neostigmine 25µg/kr/hr  Neostigmine 0.5 mg / 6 hr  IV atropine 0.5 mg / 12 hr
34 yr old male shifted from rural health center with H/O snake bite 6 hrs back has ptosis, respiratory distress, RR 35/mt, BP 120/60, oral secretions present, absent gag and cough reflex shifted to ICU for tertiary care. On ASV 100ml stat, & 50ml in NS over 6 hrs Oxygen 3l/mt Is given neostigmine 0.6mg and 0.6 mg atropine iv You can have alive but a sicker patient You can have dead patient Cobra Krait
Alive but a sicker patient Shifted to ICU placed on a Ventilator lot of secretions Do we continue anticholinesterases ? Issues to consider Increased secretions Increased incidence of VAP ? We rarely use these drugs once the patient is in the ICU under observation
Repeat dose ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Mechanical ventilation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ASV and children ,[object Object],[object Object],[object Object]
Pregnancy and snake bite ,[object Object],[object Object],[object Object],[object Object]
Treatment issues in non Neurotoxic respiratory paralysis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Rhabdomyolysis  Mismatched Blood transfusion Treatment   Fluids, Mannitol, Alkalinize the urine,  Manage electrolytes Fasciotomy RRT
Fasciotomy
Krait  ,[object Object],[object Object],[object Object]
Viper ,[object Object],[object Object]
Clinical features of a compartmental syndrome •  Disproportionately severe pain •  Weakness of intracompartmental muscles •  Pain on passive stretching of intracompartmental muscles •  Hypoaesthesia of areas of skin supplied by nerves running through the compartment •  Obvious tenseness of the compartment on palpation Criteria for fasciotomy in snake-bitten limbs Haemostatic abnormalities have been corrected (antivenom, with or without clotting factors) •  Clinical evidence of an intracompartmental syndrome •  Intracompartmental pressure >40 mmHg (in adults) Early treatment with antivenom remains the best way of preventing irreversible muscle damage
Summary  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Thank you Wishing you all a wonderful 2009
Fasciotomy ,[object Object],[object Object]
High-Dose Anti-Snake Venom Versus Low-Dose Anti- Snake Venom in The Treatment of Poisonous Snake Bites — A Critical Study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],JAPI • VOL. 52 • JANUARY 2004
High vs low ASV ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Snake Bite Icu Management

  • 1. Management of Snake Bite Victims with Respiratory Paralysis in ICU Dr. T.R. Chandrashekar Director Critical Care K.R.Hospital Bangalore DR TRC/ KRH
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  • 6. Species: Medical Implications Yes NO Yes No No Renal Problems No NO No? No? Yes Neostigmine & Atropine Yes Yes Yes No No Coagulation No NO Yes! Yes Yes Ptosis/Neurotoxicity Yes Yes Yes No Yes Local pain/ Tissue Damage Other Vipers Saw Scaled Viper Russell’s Viper Krait Cobra Signs/Symptoms and Potential Treatments
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  • 10. Snake bite and Respiratory paralysis Neuromuscular paralysis- blockade of neuromuscular transmission. Cobra- post-synaptic Krait- pre-synaptic Bulbar paralysis-Aspiration Sepsis, DIC-shock ARF-Pulmonary edema Neurotoxic MV for respiratory paralysis ASV MV as Supportive care More cases why ?
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  • 16. Krait- Pre-synaptic action Beta-bungarotoxin- Phospholipases A2 1) Inhibiting the release of acetylcholine from the presynaptic membrane 2) Presynaptic nerve terminals exhibited signs of irreversible physical damage and are devoid of synaptic vesicles 3) Antivenoms & anticholinesterases have no effect Paralysis lasts several weeks and frequently requires prolonged MV. Recovery is dependent upon regeneration of the terminal axon.
  • 17.
  • 18. Snake envenomation in a north Indian hospital Ptosis RS involvement Bulbar weakness N Sharma, S Chauhan, S Faruqi, P Bhat, S Varma, Emerg Med J 2005;22:118–120 Ophthalmoplegia
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  • 28. Dose 5 vials(50ml) 5-10 vials (50-100ml) 10-20 vials (100-200ml)
  • 29. Large vs small dose Low dose of snake antivenom is as effective as high dose in patients with severe neurotoxic snake envenoming Agarwal, Aggarwal, Gupta, et al Emerg Med J 2005;22:397–399 . High dose group 100ml stat and 100 ml every 6 hrs Low dose group 100ml stat and 50 ml every 6 hrs Until recovery of neurological signs
  • 30.
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  • 32. Observation of the response to Antivenom Cobra bites-Post synaptic May begin to improve as early as 30 minutes after anti-venom, but usually take several hours . Krait and sea snakes- Pre synaptic Depends on the timing of ASV administration If delayed may not produce any action or Minimal delayed action
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  • 36. 34 yr old male shifted from rural health center with H/O snake bite 6 hrs back has ptosis, respiratory distress, RR 35/mt, BP 120/60, oral secretions present, absent gag and cough reflex shifted to ICU for tertiary care. On ASV 100ml stat, & 50ml in NS over 6 hrs Oxygen 3l/mt Is given neostigmine 0.6mg and 0.6 mg atropine iv You can have alive but a sicker patient You can have dead patient Cobra Krait
  • 37. Alive but a sicker patient Shifted to ICU placed on a Ventilator lot of secretions Do we continue anticholinesterases ? Issues to consider Increased secretions Increased incidence of VAP ? We rarely use these drugs once the patient is in the ICU under observation
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  • 47. Clinical features of a compartmental syndrome • Disproportionately severe pain • Weakness of intracompartmental muscles • Pain on passive stretching of intracompartmental muscles • Hypoaesthesia of areas of skin supplied by nerves running through the compartment • Obvious tenseness of the compartment on palpation Criteria for fasciotomy in snake-bitten limbs Haemostatic abnormalities have been corrected (antivenom, with or without clotting factors) • Clinical evidence of an intracompartmental syndrome • Intracompartmental pressure >40 mmHg (in adults) Early treatment with antivenom remains the best way of preventing irreversible muscle damage
  • 48.
  • 49. Thank you Wishing you all a wonderful 2009
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