Treatment protocol of snake bite


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Treatment protocol of snake bite

  1. 1. Kaushik.H.M 080201388
  2. 2.  Rapid clinical assessment and resuscitation Detailed clinical assessment and species diagnosis Investigations/laboratory tests Specific treatment
  3. 3.  Attend to AIRWAY , BREATHING, CIRCULATION Secure an IV line (wide bore). Booster dose of tetanus toxoid is recommended. Identify the snake responsible
  4. 4.  All patients should be kept under observation for a minimum period of 24 hrs. Determine the exact time of bite Bacterial Infections- Prophylactic course of penicillin (or erythromycin for penicillin- hypersensitive patients)and a single dose of gentamicin or a course of chloramphenicol
  5. 5. •Care must be taken when removing tight tourniquetstied by victim. Sudden removal can lead to massivesurge of venom leading to neurological paralysis,hypotension.•Pain-paracetamol/ 50 mg of tramadol maybe given.NSAIDs and Aspirin are contraindicated.
  6. 6. Investigations 20 minute whole blood clotting test -considered most reliable test of coagulation. Platelet count : may be decreased – viper WBC cell count : Early neutrophil leucocytosis in systemic envenoming from any species. Blood film : Fragmented RBC(“helmet cell”, schistocytes) are seen in microangiopathic haemolysis. Plasma/serum : may be pink or brownish if there is gross haemoglobinaemia or myoglobinaemia.
  7. 7.  Aminotransferases, creatine kinase, aldolase elevated if there is severe local damage or, particularly generalised muscle damage. Bilirubin is elevated following massive extravasation of blood. Creatinine, urea or blood urea nitrogen levels are raised in the renal failure Early hyperkalaemia may be seen following extensive rhabdomyolysis in sea snake bites. Bicarbonate will be low in metabolic acidosis (eg renal failure). Arterial blood gases and pH may show evidence of respiratory failure (neurotoxic envenoming) and acidaemia (respiratory or metabolic acidosis).
  8. 8.  Urine for RBC – Viper Bite – Hematuria, Proteinuria, Hemoglobinuria, Myoglobinuria ECG – Normal, Bradycardia with ST elevation or depression, T inversion, QT prolongation. Chest X- ray – Normal or may show Pulmonary Oedema, Intrapulmonary Hemorhages, Pleural Effusion.
  9. 9. Monitor vital signs Observe every patient for minimum 24 hours. Monitor thepatient every 6 hours. Pulse, BP, Respiration Urine output Blood urea, Creatinine Bleeding tendency Local swelling Vomiting Diplopia, Ptosis, Muscle Weakness, Breathlessness
  10. 10. Anti Snake Venom Antivenom is immunoglobulin (usually the enzyme refined F(ab)2 fragment of IgG) purified from the serum or plasma of a horse or sheep that has been immunised with the venoms of one or more species of snake. It neutralises the free, unbound venom & to some extent also dissociates the bound toxin ASV is manufactured in India by the Haffkine Central Research Institute, Kasauli & Serum Institute of India, Pune & both are POLYVALENT(neutralizes venom of different species of snakes.)
  11. 11. 1 ml of ASV neutralises Cobra – 0.6 mg Common krait – 0.45mg Russels viper – 0.6 mg Saw scaled viper – 0.45 mg
  12. 12. Indications As per W.H.O Guidelines ONLY if a patient develops one / more of the following signs/symptoms ASV should be administered :SYSTEMIC ENVENOMING• Evidence of coagulopathy: detected by 20WBCT or visible spontaneous systemic bleeding• Evidence of neurotoxicity : ptosis, ext.ophthalmoplegia
  13. 13. • CVS abnormalities : hypotension, shock, arrhythmias• Acute renal failure• Hemoglobinuria / myoglobinuria• Persistent severe vomiting / abdominal pain
  14. 14. LOCAL ENVENOMING• Local swelling > ½ of involved limb• Rapid extension of swelling• Enlarged tender lymph nodes draining the bitten limb
  15. 15. ASV administration NO ASV TEST DOSE MUST BE ADMINISTERED . Recommended initial dosages are 100 ml( 10 vials) of polyvalent ASV for adults & children based on published research that russells viper injects on an average of 63 mg of venom. Our initial dose must be calculated to neutralize the average dose of venom injected.
  16. 16.  Range of venom injected = 5mg – 147 mg Suggested ASV dose = 100 -250 ml Initial dose of 100 ml must be diluted in 100 ml of NS & given over 1 hour. Patient should be carefully monitored for 2 hrs. Local administration of ASV, near the bite site – ineffective, painful, raises intracompartmental pressure. – SHOULD NOT BE DONE
  17. 17. Victim who arrives late ? Often after several days , usually with acute renal failure. Are there any signs of current venom activity ? Perform 20WBCT & determine if any coagulopathy is +, if + administer ASV. If - , treat ARF – dialysis Neurotoxic envenoming – look for ptosis, respiratory failure , + administer 1 dose of ASV , respiratory support
  18. 18. ASV reactions Patient should be monitored closely First sign of any one of the following : 1. Utricaria 6. Vomiting 11.Bronchospasm 2. Itching 7. Diarrhoea 12.Angioedema 3. Fever 8. Abdominal cramps 4. Chills 9. Tachycardia 5. Nausea 10. Hypotension Discontinue ASV & give 0.5 mg of 1 :1000 adrenaline IM/ IV diphenhydramine(antihistamines).
  19. 19. Repeat doses of ASV HEMATOTOXIC POISONING :• 20 WBCT – abnormal – initial dose given over 1 hr.• Repeat 20WBCT after 6 hrs• Abnormal – another dose to be given. Repeat same dose again.• 20WBCT & Repeat doses of ASV – to be continued on 6 hourly manner until coagulation is restored.
  20. 20.  NEUROTOXIC POISONING• Assess the patient 1-2 hrs after the initial dose• If symptoms persist / worsen , 2 nd dose which is same as 1st dose is to be given & then ASV can be discontinued
  21. 21. Role of Neostigmine inNeurotoxic poisoning Anticholinestrase & prolongs life of Ach - which can reverse resp.failure & neurotoxic symptoms ( post synaptic ) Neostigmine test : 1.5 -2.0 mg IM preceeded by 0.6 mg atropine IV• Observe for 1 hr• If victim responds , continue 0.5 mg Neostigmine IM ½ hrly with 0.6 mg Atropine IV over 8 hrs• If no improvement in symptoms after 1 hr , stop Neostigmine
  22. 22. Supportive Therapy RESPIRATORY FAILURE :• ABG• Intubate & Ventilate• Neostigmine & Atropine HYPOTENSION :• Plasma expanders-crystalloids• Dopamine 2.5 – 5 micrograms/Kg/min
  23. 23.  PERSISTANT / SEVERE BLEEDING :• Majority – timely use of ASV will stop systemic bleed• ASV + Blood Transfusion RENAL FAILURE• Hemodialysis / peritoneal dialysis COMPARTMENT SYNDROME :• Fasciotomy SURGICAL DEBRIDEMENT OF WOUND: Necrosis