Mr. Santosh Misal, a 40-year-old male farmer, was brought to the emergency department after collapsing in the field with symptoms of a possible snake bite including sweating, frothing at the mouth, and involuntary urination. Imaging showed an infarction in the right middle cerebral artery territory consistent with a stroke. He developed coagulopathy resistant to 10 vials of antivenom. Despite supportive care including ventilator support and coagulation factor replacement, his condition deteriorated and he suffered cardiac arrest on the third day, passing away. The case highlights the neurotoxic and coagulopathic effects of snake venom that can lead to stroke and the challenges in managing severe envenomation.

1. DR. ARUNDHATI DIWAN
A DEATH TEACHING MANY
LESSONS

3. PATIENT PRESENTATION
 Mr. Misal Santosh, 40 years old
male
 Brought in Emergency Department
at 9:30 Hrs by relatives
 History of unknown bite at around
8:00hrs at Velu ,Bhor while
working in the paddy field. (exact
site of bite not known)

4.  Patient had told the incident to his co-
workers and complained of giddiness
 when he collapsed infront of the coworkers

5. EMERGENCY DEPARTMENT
 09:30hrs
 Patient was brought in unresponsive state
 profuse sweating
 frothing from the mouth
 with involuntary passage of urine.

6.  On Examination:
Pulse- 108/min (regular in rhythm,
normal as well as equal in volume)
All peripheral pulses felt
Blood Pressure - 130/90 mmHg
Respiratory Rate- 20/min
Saturation on room air - 92%
Afebrile
No obvious bite mark

7. Examination
 Neurological Examination done in
Emergency department

8.  Not responding to verbal stimuli.
 Spontaneous movements of only right
upper and lower limb , no movements on
left side of the body
 Facial asymmetry noted
 Right pupil of 3mm while left pupil 4mm
both sluggishly reacting to light
 bilateral extensor plantar response
 No signs of meningitis

9. 10:30 hrs; As the Glasgow Coma Scale was
7/15, patient was intubated by Rapid sequence
Induction.

10. UNKNOWN BITE
ACUTE
HEMIPLEGIA
 More than 200,00
snake bites are
reported in India and
an estimated 35,000 to
50,000 people die each
year due to snake
envenomation.

11. Course in Hospital
11:30hrs ,Patient shifted for Brain imaging
ensuring stability during transport.
Treatment given in Emergency Department
 Midazolam 4+4+2+2+2+2 during
intubation
 Propofol 100mg
 Mannitol 100ml
 Hydrocort 100mg
 Levera 1gm

12. CT BRAIN +MR DIFFUSION
12:15hrs
Patient shifted to ICU for further management

13. On CT images there is loss of grey-white matter differentiation
and hypodense (dark) areas in right fronto – temporo-parietal
region.
MSCT BRAIN AND MR DIFFUSION

16. On FLAIR images there is loss on flow void in right MCA.

17. DAY 1(21/6/18)
 12:30hrs In ICU, patient was taken on
mechanical ventilator support

18. XRAY-CHEST

19. ECG

20. ABG
Pressure AC mode, FiO2-
100%
 Ph-7.40
 PCO2-24.9
 PO2-166
 HCO3-18.1
 Anion gap-16.8
 Lac-5.7
s/o metabolic acidosis with
respiratory alkalosis with
high lactates

21.  While taking 2nd IV access it was noticed
 That there was excessive bleeding from IV
site.

22.  Meanwhile blood investigations revealed

23. 1:00 pm
PARAMETERS OBSERVED
VALUES
NORMAL RANGE
Hb 13.9g/dl 11-15g/dl
TLC 14300/cumm 4000-10000/cumm
Platelet 1.34L/cumm 1.5-4.6L/cumm
PT >180sec 10.3-13.2 sec
APTT >180sec 25.4-34.6sec
INR >15

24. PARAMETERS RESULT RANGE
Serum Sodium 138 mEg/L 130-145mEg/L
Serum Potassium 3.9 mEq/L 3.5-4.5mEg/L
Blood Urea 37 mg/dl 10-45 mg/dl
Serum creatinine 1.27 mg/dl 0.6-1.2 mg/dl
SGOT 122 iu/l 5-40iu/L
SGPT 131 IU/L 5-40iu/L
S. BILIRUBIN (Total) 1.79 Mg/dl 0.2-1.0 mg/dl
s. BILIRUBIN
(direct)
0.54 mg/dl 0.1-0.3 mg/dl

25. AT THIS TIME…key points
h/o unknown bite ?snake bite
Right Middle Cerebral Artery territory
infarct with left hemiplegia with
unresponsiveness ?post-ictal
Associated with Coagulopathy

26. “20 MINUTES WHOLE BLOOD CLOTTING
TEST”

27.  20min Whole Blood Clot test was done and
blood did not clot after 20Min.

28. 20 min whole blood clotting test

29.  Neurophysician opinion
 10 vials of ASV and 6 FFP.
 With Monitoring of 6hrly PT/APTT

30. LYOPHILIZED ASV (in powder form)

31. Repeat coagulation profile at 1:00am
PT- 15.5
APTT- 21.1
INR- 1.35

32.  The 20 minute whole blood clotting test was
repeated
 The repeat 20min WBCT showed that the blood got
clotted 12:00 am

33. REPEAT 20min WBCT

34. Day 2 (22/6/18)
 Patient on ventilator support
 On Fentanyl and Midazolam infusion @ 4ml/hr
 Pulse- 80/min
 BP- 130/80mmHg
 I/O- 2485/2350ml
 RS- AEBE
 CVS- S1s2 +
 PA- soft, bowel sound +
 GCS- E2VtM2

35. DAY 2 Coagulation profile
2:00 am 9:00 am 3:00 pm 9:00 pm
PT 15.5 16 12.6 15.6
APTT 21.1 26.4 25.9 27.1
INR 1.35 1.39 1.09 1.36

36. INVESTIGATIONS (22/6/18) RESULTS
Urine routine RBC-15-20
Pus- occasional
Epithelial cells- occasional
USG (abdomen + pelvis) Minimal free fluid is seen in the pelvis
XRAY Chest Lung fields clear

37. Day 3 (23/6/18)
 7:00 am ;Patient on ventilator support
 On Fentanyl infusion @ 5ml/hr
 Pulse- 76/min
 BP- 140/90mmHg
 Output @ 150ml/hr
 RS- AEBE
 CVS-s1s2 +
 CNS- E2M2Vt

38.  3:00 pm
 Patient BP dropped to 90/50mmHg
(started on noradrenaline infusion)
 Pulse rate- 140/min
 RS- new onset B/L crepts+
 CVS- S1S2 +
 CNS- E1M1Vt

39. ECGS

40.  4:00 pm; Repeat Brain imaging done.

42.  5:45pm; Neurosurgery reference taken
Advised to continue conservative line of
management. No surgical intervention.

43.  At 19:30 hrs patient had brady
arrest.
 CPR was started according to ACLS
protocol
 CPR continued for 20mins
 ROSC not attained
 Pulse not palpable, BP not
recordable, dolls eye reflex absent
 ECG- no electrical activity
 Patient declared dead at 19:52 hrs

44. BODY SENT FOR POST MORTEM

45. UPON REFLECTION
? REPEAT DOSE OF ASV
? ROLE OF NEOSTIGMINE

46. DISCUSSION
1. SNAKE BITE AND STROKE
2. TREATMENT
3. ASV DOSE

47. MAJOR FAMILIES OF POISONOUS SNAKES
 Common Cobra
 King Cobra
 Common Krait
 Russell Viper
 Saw-scaled Viper
 Pit Viper
 Sea Snakes

48. SNAKES

49.  The viper venom is a mixture of
numerous enzymes some of which appear
to have opposing effects
 Some enzymes causes
hypofibrinogenemia,
hypopothrombinemia, thrombocytopenia
and fibrinolysis
 There are potent proteases (arginine
esterase hydrolase) acting as activators of
clotting factors X and V thereby
promoting coagulation.

50.  The net effect of these enzymes is the
activation of intrincsic coagulation pathway
which leads to consumptive coagulopathy
 These leads to small and even large vessels
occlusion due to microthrombi formed
resulting in cerebral infarct

51. NEUROTOXIC MANIFESTATIONS
 Ptosis
 Opthalmoplegia
 Diplopia
 Dysphagia
 Respiratory paralysis

52. VASCULOTOXIC MANIFESTATIONS
 Gangrene
 Local swelling
 Blistering, necrosis

53.  A pre existing pro coagulant state due to
mutation in factor V, deficiency of Protein C
or S, antithrombin 3 and antiphospholipid
antibodies could account tendency towards
thrombosis in large vessels
 Special test for pre existing coagulant state
could not be done in this patient.

54. ASV administration criteria
 Evidence of coagulopathy
 Evidence of neurotoxicity
 Cardiovascular abnormality
 Persistent and severe vomiting, per abdominal pain
 Severe local swelling
 Rapid extension of swelling

55. ASV ADMINISTRATION
 Total required dose will be approximately around
10 vials to 30 vials
 Each vial neutralises 6mg of viper venom
 Not all victim requires 10 vials as some may be
injected less than 63mg
 Decision of the treating physician is of utmost
importance because guidelines may not be useful for
all patients

56. ANTI SNAKE VENOM DOSE
 INITIAL DOSE
mild envenomation (systemic symptoms manifest
>3 hrs after bite) neurotoxic/hemotoxic 8-10 vials
severe envenomation (systemic symptoms
manifest < 3 hrs after bite) neurotoxic or hemotoxic 8
vials
Each vial is 10ml of reconstituted ASV.

57.  FURTHER DOSES
It will depend on the response to the initial dose.
ASV should be administered either as intravenous
infusion (5-10ml/kg body weight) or as slow
intravenous injection i.e 2ml/min)
ASV should be administered over 1 hour at constant
speed and patient should be closely monitored.

58. IMPORTANT POINT TO REMEMBER
 After initial ASV dose, no additional ASV should be
given until the next clotting test at 6 hours.
 This is due to the inability of the liver to replace
clotting factors in less than 6 hours
 The ASV regime for neurotoxic envenomation is not
clear. After 1-2 hrs of initial dose, patient should be
reassessed and if symptoms have worsened or have
not improved, a second dose of ASV should be give.

59. REFERENCES
 1. JAPI, management of snake bite in India, Aug
2016, vol64
 2. Journal of The Indian Academy of
Geriatrics, Vol 7, no. 1, March, 2011, K
Krishna, AG Diwan, N Mendiratta, S Jadhav,
S Reddy
 3. Snake bite: Indian Guidelines and protocol, Surjit
singh, Gagandip Singh
 4. API textbook of Medicine, 10th edition, vol2

60. T H A N K Y O U