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Snake bite ICU mangement in INDIA
- 1. Dr. T.R.Chandrashekar Intensivist Institute ofGastrointestinal diseases and Liver Transplant (IGOT), Bangalore. Management of Snake Bite Victims in ICU
- 2. How to preventsnake bites? A world free of snakes Nearly a quarter of us would go hungry Are important elements in the food chain to control the rodent population- Which destroy all major crops. The bottom line is we need snakes to survive
- 3. 1 QRG Snakebite Version4 Final December 22, 2015 STANDARD TREATMENT GUIDELINES Management of Snake Bite Quick Reference Guide January 2016 Ministry of Health & Family Welfare Government of India
- 4. Epidemiology India estimates inthe region of 200,000 bites and 15-20,000 snake bite deaths per year Originally made in the last century, are still quoted. No reliable national statistics are available. Males are bitten almost twice as often as females Majority of the bites being on the lower extremities. 50% of bites by venomous snakes are dry bites. that result in negligible envenomation.
- 5. FAB FOUR InIndia, more than 200 species of snakes but only 52 are poisonous. Saw-scaled viper (Echis carinatus) Russell’s viper (Daboia russelii) Common krait (Bungarus caeruleus) Indian cobra (Naja naja) Majority of bites Nearly 70-80% Hemotoxin Vasculotoxin Neurotoxic 1 2 43
- 6. Species: Medical Implications Signs/Symptoms andPotential Treatments Cobra Krait Russell’s Viper Saw Scaled Viper Other Vipers Local pain/ Tissue Damage Yes No Yes Yes Yes Ptosis/Neurotoxicity Yes Yes Yes! NO No Coagulation No No Yes Yes Yes Renal Problems No No Yes NO Yes Neostigmine & Atropine Yes No? No? NO No
- 7. Syndromic approach Nolocal signs with Neuro-toxicity- Krait With or with out local signs and Neuo-toxicity-Cobra local signs and hemotoxicity and Renal damage and + or – Neurotoxicity -Rusell’s Viper Local signs with hemotoxicity-Saw Scaled Viper
- 8. Snake bite Venomous snakes Antisnake venom Majority is by non-venomous snakes ● ASV -severe adverse reactions, Costly, Limited supply. ● Benefits of ASV treatment is considered to exceed ● the risks. ● About 50% of bites are dry
- 9. Mechanism of Toxicityof Venom – Proteolytic Enzymes: digestive properties – Enzymes :Endopeptidaes, Factor X, Prothrombin activating enzyme – Phospholipases: degrade lipids – Hyaluronidases: speed venom spread through the body Cobra- Post synaptic action Curare-mimetic toxins ASV –rapid reversal Anticholinesterases reverse the neuromuscular blockade Krait- Presynaptic action-Inhibits release of Ach Antivenoms & anticholinesterases have no effect Paralysis lasts several weeks and frequently requires prolonged MV. Recovery is dependent upon regeneration of the terminal axon Hemo-toxicity Neuro-toxicity
- 10. NEUROTOXICITY Starts early-many die before they reach hospitals Many reverse very well with ASV if started early Less number of cases HAEMOTOXICITY Starts late hence most of them reach hospitals Many organ involvement hence MV is mostly supportive to buy time for organs to recover More number of cases 70-80% 20-30%
- 11. ASV is themain stay in snake bite management Supportive care MV Shock management- Fluids, vasopressors Correction of coagulopathy- PRBC, FFP, Platelets, CRYO Antibiotics Renal management- forced alkaline diuresis, HD
- 12. Pre- Hospital Management • Thefirst aid being currently recommended is based around the mnemonic: “Do it R.I.G.H.T.” • R. = – Reassure the patient. 70% of all snakebites are from non-venomous species. Only 50% of bites by venomous species actually envenomate the patient • I = – Immobilise in the same way as a fractured limb. Use bandages or cloth to hold the splints, not to block the blood supply or apply pressure. Do not apply any compression in the form of tight ligatures, they can be dangerous! • G. H. = – Get to Hospital Immediately. Traditional remedies have NO PROVEN benefit in treating snakebite. • T= – Tell the doctor of any systemic symptoms such as ptosis that manifest on the way to hospital.
- 13. ASV in INDIA Polyvalent active on FAB four Liquid (1 yr shelf life requires cold chain) Lyophilized form (5 yr shelf life at room temp) Average potency of the ASV available is such that 1 ml will neutralize 0.6mg cobra, 0.45mg krait, 0.6mg Russel’s viper 0.45mg saw scaled viper venom ASV’s only role is to neutralize unbound free flowing venom
- 14. ASV Indications Dose / Repeatdose Neurotoxicity Haemotoxicity Local toxicity Renal damage Anaphylaxis management Test dose 12 Oct 2015 n for clotting is prolonged and the blood be liquid at 20 minutes.) This is a useful st to diagnose hemotoxic envenomation. bin ount bin Time, APTT xamination for RBC, Hemoglobin, n eatinine, Urea, Electrolytes (Potassium) The advantage of the lyophilized form is that it does not require refrigeration. However, it is more expensive than the liquid preparation.
- 15. ASV available inIndia • Polyvalent Snake Antivenom I.P 4 Antivenoms effective against the Big 4, mixed together • Manufacturers: 1.VINS Bioproducts Ltd, AP 2.Serum Institute of India Ltd, Pune 3.Haffkine Institute, Mumbai 4.Bharat Serums of India, Mumbai
- 16. Polyvalent ASV No needto waste time or effort at identifying the exact nature of venomous snake Less expensive Easy distribution to all parts of the country • Decreased efficacy (?) • Increased incidence of allergic reactions Advantages Disadvantages
- 17. Skin testing forASV Not reliably to predict early or late antivenom reactions and is not recommended. Intradermal allergy testing IgE mediated reaction Complement mediated ASV reactions Waste of precious time
- 18. ASV administration 24 1 0v ia ls o f A V S d is s o lv e d in 1 0 0 m l o f d is t ille d w a t e r a n d a d d e d t o 4 0 0 m l o f n o r m a l s a lin e A S V in s y r in g e A d m in is t e r 1 0 v ia ls o f A S V in f ir s t h o u r. M a in t a in s lo w d r ip fo r 2 4 h o u r s M e n t io n d a t e a n d t im e o f s t a r t in g in f u s io n Figure 8. ASV infusion and dosage schedule Each vial of AVS be dissolved in 10 ml One ampoule of lyophilized ASV is reconstituted with 10 ml of sterile water for injection. This can then be administered in two ways IV push: at a rate not more than 2 ml/min or Infusion: ASV diluted in 250-500 ml of saline or 5% dextrose and infused over about 1 hour Prophylactic adrenaline must be given subcutaneously along with ASV (0.25 mg of 1:1000 adrenaline).
- 19. Timing of ASV Best effects are observed within four hours of bite . It has been noted to be effective in symptomatic patients even when administered up to 48 hours after bite. Victims who arrive several days have acute renal failure. The key determining factor to administer ASV is there are any signs of current venom activity Venom can only be neutralised if it is unattached! Perform a 20WBCT and determine if any coagulopathy is present. If coagulopathy is present, administer ASV. If no coagulopathy is evident treat any renal failure by reference to a nephrologist and dialysis.
- 20. Antivenom reactions Complementactivation by IgG aggregates or residual Fc fragments or direct stimulation of mast cells or basophils by antivenom protein are more likely mechanisms for these reactions. 20%, of patients, usually more than develop a reaction Types 1. Early anaphylactic reactions- within 10-180 min 2. Pyrogenic (endotoxin) reactions- develop 1-2 hours 3. Late (serum sickness type) reactions- develop 1-12 (mean 7) days. Fatal reactions have probably been under-reported as death after snake bite is usually attributed to the venom.
- 21. Antivenom reactions Atthe earliest sign of a reaction: Antivenom administration must be temporarily suspended Adrenaline-0.1% solution, 1 in 1,000, 1 mg/ml is the effective treatment for early anaphylactic reactions. IV hydrocortisone (adults 100 mg, children 2 mg/kg body weight). The corticosteroid is unlikely to act for several hours, but may prevent recurrent anaphylaxis There is increasing evidence for anti H2 antihistamines- Ranitidine – adults 50 mg, children 1 mg/kg. Pyrogenic reactions require- antipyretics. In case of circulatory collapse- start fluids, inotropes along with IV adrenaline 5-day course of oral antihistamine/ Prednisolone. Chlorpheniramine: 2 mg six hourly Prednisolone: 5 mg six hourly Serum sickness
- 22. Snake bite Neurotoxic Examination ASV dosing+ MV? Repeat ASV dosing Hemotoxin Examination ASV dosing + coagulopathy correction Repeat ASV dosing AKI management Local toxicity Examination ASV+Management
- 23. Evaluation of Snakebite Neurological Local site Bleeding Kidney
- 24.
- 25. Examination of thebitten Limb Fang marks The extent of swelling Palpate lymph nodes draining the limb Limb girth Bleeding/necrosis 15 Progressive painful swelling is indicative of local venom toxicity. It is prominent in Russel’s viper bite, Saw scaled viper bite and Cobra bite. This is associated with • Local necrosis which often has a rancid smell. Limb is swollen and the skin is taut and shiny. Blistering with reddish black fluid at and around the bite site. Skip lesions around main lesion are also seen. (Figure 5). • Ecchymoses due to venom action destroying blood vessel wall. • Significant painful swelling potentially involving the whole limb and extending onto the trunk. • Compartment syndrome will present invariably. • Regional tender enlarged lymphadenopathy.
- 26. Local toxicity • Localeffects: –This is related to the digestive function of the venom and causes local tissue necrosis. –It is maximal with a viper bite and least with krait – (so much so that the bite may go unnoticed and symptoms which follow may not be attributed to snake bite). Limbs are marked and circumference measured every 1 hour to assess the edema progression NO ASV around the bite site
- 27. ASV for localtoxicity Severe Local Envenomation: is another indication for ASV. Suspect severe local envenomation if there is Rapidly expanding painful swelling with tender lympadenopathy Local swelling involving more than half of the bitten limb Rapid extension of swelling across a joint over one to two hours following a bite to the hands or feet. Compartment syndrome +or- Surgery 8 to 10 vials in 250-500 ml of saline or 5% dextrose and infused over about 1 hour
- 28. F a sc i o t o m y
- 29. Clinical features ofa 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
- 30. Neurotoxicity Neuroparalytic symptomswithin 30 min– 6 hours –Cobra 6 – 24 hours for Krait. These symptoms can be remembered as 5 Ds and 2 Ps. 5 Ds – dyspnea, dysphonia, dysarthria, diplopia, dysphagia 2 Ps – ptosis, paralysis Diminished or absent deep tendon reflexes and head lag. Additional features like stridor, ataxia may also be seen
- 31. Neurotoxic envenoming-Examination • Askthe patient to look up and observe whether the upper lids retract fully. • Test eye movements for evidence of early external ophthalmoplegia . • Check the size and reaction of the pupils. • Krait can cause fixed, dilated non reactive pupils simulating brain stem death – however, it can recover fully • The muscles flexing the neck may be paralysed, giving the “broken neck sign 12 – In chronological order of appearance of symptoms – furrowing of forehead, Ptosis (drooping of eyelids) occurs first (Figure 3), followed by Diplopia (double vision), then Dysarthria (speech difficulty), then Dysphonia (pitch of voice becomes less) followed by Dyspnoea (breathlessness) and Dysphagia (Inability to swallow) occurs. All these symptoms are related to 3rd , 4th , 6th and lower cranial nerve paralysis. Finally, paralysis of intercostal and skeletal muscles occurs in descending manner. – Other signs of impending respiratory failure are diminished or absent deep tendon reflexes and head lag. – Additional features like stridor, ataxia may also be seen. – Associated hypertension and tachycardia may be present due to hypoxia. Figure 3. Ptosis with neuroparalytic snakebite – To identify impending respiratory failure bedside lung function test in adults
- 32. Bulbar paralysis Canthe patient swallow or are secretions accumulating in the pharynx- an early sign of bulbar paralysis? Bulbar paralysis leads to aspiration- intubation may be Bed side tests of impending respiratory failure Single breath count – number of digits counted in one exhalation - >30 normal Breath holding time – breath held in inspiration – normal > 45 sec Ability to complete one sentence in one breath. required + MV
- 33. Trial of anticholinesterase Anticholinesterase(“Tensilon”/Edrophonium) test Record baseline parameters Give atropine IV Give anticholinesterase drug edrophonium chloride (adults 10 mg, children 0.25 mg/kg body weight) given intravenously over 3 or 4 minutes 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. Management of neurotoxicity ASV 8to 10 vials – in 500ml infused in one hour If there is worsening of neurological deficits or persistence of weakness after 1- 2 hours, repeat 10 vials No more ASV after that MV- respiratory failure + or Bulbar paralysis+ Simple if uncomplicated by aspiration or VAP
- 35. Blood tests QRG SnakebiteVersion 4 Final December 22, 2 Figure 7. 20 minute whole blood clotting test (20 WBCT). – If clotted, the test should be carried out every 1 h from admissio hours and then 6 hourly for 24 hours. In case test is non-clottin hour after administration of loading dose of ASV. In case of envenomationrepeat clottingtest after 6 hours. Other investigationsthat mayassist in the management of snake bite at levelsof healthcare 4.4.2 – Other Labtestsat Primaryhealth centre – Peak flow meter in patients (adolescents and adults) presenting w neuroparalytic syndrome. – If Peak flow meter is not available in PHC then assess respiratory f using bedside tests - single breath count, breath holding time and complete one sentence in one health as described earlier. – Urine examination for albumin and blood by dipstick. 4.4.3 Otherslab test at District Hospital 20 minute whole blood clotting time: 2-3 ml of blood should be withdrawn in a dried glass test tube and left undisturbed for 20 minutes. At the end of 20 minutes the tube is slightly tilted to look for clot formation. Normally, the blood is fully clotted by this time but in hemotoxic snake poisoning, the time taken for clotting is prolonged and the blood may still be liquid at 20 minutes. CBC BUN SC Coagulation profile; PT, aPTT, INR, Fibrinogen, Platelet count Urine examination Not clotted consumption coagulopathy → ASV required Clotted: ASV not necessary (at this stage) Done every 30 minutes from admission for 3 hours and then hourly after that. If incoagulable blood is there, 6 hourly cycle will then be adopted to test for the requirement for repeat doses of ASV
- 36. ASV dosing- Haemotoxicity ASV 8to 10 vials – in 500ml infused in one hour 19 venom-inducedconsumptioncoagulopathy (Figure7). – If blood clot is formed and signs and symptoms of neurotoxic envenomation present,classifyasneurotoxicenvenomation. – If there is any doubt, repeat the test in duplicate, including a “control” (bloodfromahealthyperson). – Caution:If the test tube used for the test is not made of ordinary glass, or if it has been used before and cleaned with detergent, its wall may not stimulate clotting of the blood sample in the usual way and test will be invalid). – Counsel patient and relatives in the beginning that, 20WBCT may be repeatedseveral timesbeforegivinganymedication. Figure7.20minutewholebloodclottingtest(20WBCT). – If clotted, the test should be carried out every 1 h from admission for three hours and then 6 hourly for 24 hours. In case test is non-clotting, repeat 6 hour after administration of loading dose of ASV. In case of neurotoxic envenomationrepeatclottingtest after6hours. Otherinvestigationsthatmayassist inthemanagementofsnakebiteatvarious levelsofhealthcare 4.4.2–OtherLabtestsat Primaryhealthcentre – Peakflowmeterinpatients(adolescentsandadults)presentingwith neuroparalyticsyndrome. – IfPeakflowmeterisnotavailableinPHCthenassessrespiratoryfunction usingbedsidetests- singlebreathcount,breathholdingtimeandability to or if there is clinical bleeding 1-2 hours after the dose, Not clotted Repeat -8 to 10 vials – in 500ml infused in one hour As many as five doses of 10 vials each have been given, if bleeding persists
- 37. ASV in AKI AKI- ASV may not work, Shock management-Fluids, vasopressors and blood and blood products for coagulation correction is required Forced alkaline diuresis may be beneficial. Hemodialysis may be required in a small % Majority make complete recovery in a few weeks time Some may land up in CKD
- 38. Summary Snake bitesmay be by an non venomous snake or a dry bite Not all snake bites require ASV ASV is the main stay in the treatment of snake bites ASV must be initiated if indicated at the earliest Supportive care- MV, shock management , correction of coagulopathy, wound management, antibiotics are important for good outcome Children should be given adult dose Pregnant women also require regular dosing
- 39. T h an k y o u s h i n g y o u a l l a w o n d e r f u l 2 0