Snake bite,first aid, anti-venom treatment and ward management
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Snake bites are a serious public health issue in Sri Lanka, with 65,000 cases annually resulting in 800 deaths. There are 96 snake species in Sri Lanka, but only 5 are deadly: cobra, common krait, Sri Lankan krait, Russell's viper, and saw-scaled viper. A 10-year-old boy was bitten by a snake and brought to the hospital experiencing swelling, vomiting, abdominal pain, and neurological symptoms. Antivenom is the specific treatment for snake bites and helps neutralize venom, with supportive care also important. Education on first aid and rapid medical treatment can help reduce fatalities from snake bites.
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Snake bite,first aid, anti-venom treatment and ward management
- 1. Snake Bite Sanjaya Gihan Weerasinghe
- 2. Snakes Bites in Sri Lanka • • • • 65000 snake bites annually 800 deaths Fatality- 5 in 100000 population Dramatic increase in Hospital admissions • Acceptance of Western Medical therapy • Case fatality rate has been reduced Sanjaya Gihan
- 3. 96 species of snakes in Sri Lanka. Only 5 of the land snakes are considered potentially deadly. Sanjaya Gihan
- 5. Highly Venomous Snakes • • • • • Cobra (Naja naja) Common krait (Bungarus caeruleus) Sri Lanka krait (Bungarus ceylonicus) Russells's viper (Daboia russelii) Saw scaled viper (Echis carinatus) Sanjaya Gihan
- 6. Moderately Venomous Snakes • Hump nosed viper (Hypnale hypnale) • Green pit viper (Trimeresurus trigonocephalus) Sanjaya Gihan
- 7. A 10 years old boy is presented with a swelling in the R/S ankle complaining of a snake bite 12.15 pm •While the boy was playing in an abandoned paddy field, he felt a sharp pain in the R/S ankle. •When he checked there was bleeding from the site of pain and there were bite marks. •Boy didn’t see the snake. Sanjaya Gihan
- 8. • He was taken home immediately by his brother lifting on arms. • They didn’t do anything with the woundwashing, tying tourniquet,etc. • By the time he reached home, the boy was, drowsy vomited (food particles and few drops of fresh blood) burning type of abdominal pain. • Taken to ayurvedic prationer nearby. Sanjaya Gihan
- 9. • After 1 ½ hours after the incident,he was brought to hospital in three wheeler. On admission, • Bite site - Swelling ,Color change,Painful • No Bleeding nor Bruising. • No blister formation. Sanjaya Gihan
- 10. Bite Marks Bleeding from the Site Necrosis Blistering Sanjaya Gihan
- 11. • By then he had neurological involvement . Ptosis External Opthalmoplegia Drowsiness Sanjaya Gihan
- 12. Neurological • • • • • • • • • Drowsiness Paraesthesiae abnormalities of taste and smell “heavy” eyelids ptosis external ophthalmoplegia paralysis of facial muscles difficulty in swallowing respiratory and generalised flaccid paralysis Sanjaya Gihan
- 13. In the Ward.. • A catheter was inserted. • Haematuria was noticed. Sanjaya Gihan
- 15. Management of A Snake Bite Sanjaya Gihan
- 16. Sanjaya Gihan
- 17. Sanjaya Gihan
- 18. First Aids
- 19. Dos •Reassure. •Remove all rings, Bracelets from bitten parts of the body. •Wash the bitten area with soap and water. •Keep the stricken limb below the heart. •Immobilize the bitten limb with splint or slings. •Get medical help as quick as possible. Sanjaya Gihan
- 20. Sanjaya Gihan
- 21. Do Nots •Don’t panic •Don’t make any cut, scratch or incision •Don’t suck at the wound •Don’t apply ice packs to the bitten area. •Don’t use tight bands or tourniquet. •Don’t drink alcohol, take herbal medicine or Aspirin. Sanjaya Gihan
- 22. Transport to hospital • Quickly, but safely and Comfortably • Minimal Movements avoid systemic absorption Sanjaya Gihan
- 23. In the ETU • Rapid Clinical Assessment & Resuscitation. (ABC) • Bite site was cleaned with soap and water. • IV canulae was inserted. • Blood was taken for 20WBCT (20 minute whole blood clotting test) • O.Paracetamol 500mg • IV Ranitidine 25mg • Patient was sent to the ward. Sanjaya Gihan
- 24. Detailed Clinical Assessment History • 3 Preliminary Qs – In which part of the body? – How long ago? – Brought the snake? Can describe it? Sanjaya Gihan
- 26. Sanjaya Gihan
- 27. Cobra නන න •“Spectacle” like marking in Dorsum of the Hood. •When excited this fold expands into a hood . Sanjaya Gihan
- 28. Common/Indian Krait නන නන න නන න න • Oily,shiny,Bluish black appearance • Paired white bands on the dorsal surface Sanjaya Gihan
- 29. Sri Lankan Krait දද දදද දද දද • Blackish brown snake with white bands on the body Sanjaya Gihan
- 30. Russell’s Viper දද ද දද දද දදද • Highly poisonous 40% of deaths is due to this snake in Sri Lanka • Largest & most widely distributed viper in Sri Lanka. Sanjaya Gihan
- 31. • “V” shaped white marking in the head. • Has 3 rows of black elliptical markings running alone the length. Sanjaya Gihan
- 32. Sanjaya Gihan
- 33. Saw Scaled Viper දද දදද දද දද ද • Sandy brown in colour • birds foot mark over the head • When disturbed, it rubs the coils against each other producing a hissing noise (characteristic) Sanjaya Gihan
- 34. Sanjaya Gihan
- 35. Hump Nosed Viper දද දද/ දදදද දද ද ද දදද දදද ද ද දද ද • Brown in colour with dark brown & black markings. • Upturned hump. Sanjaya Gihan
- 36. Sanjaya Gihan
- 37. Green Pit Viper දද දද ද දදද ද • Bright green in colour with black markings Sanjaya Gihan
- 38. Sanjaya Gihan
- 39. If the snake is identified as non venomous , patient can be discharged after a booster dose of Tetanus toxoid. Sanjaya Gihan
- 40. Sanjaya Gihan
- 41. Sanjaya Gihan
- 42. Investigations • • • • • • • 20 WBCT FBC SC & BU SE SGOT/SGPT Blood Grouping IP OP chart Sanjaya Gihan
- 43. 20 mins Whole Blood Clotting Test Incoagulable blood is diagnostic of a viper bite Sanjaya Gihan and rules out an elapid bite
- 44. Snake Venom Antiserum • Only specific antidote to snake venom • most important decision in the management • IV Immunoglobulin (IgG) • “polyvalent anti-snake venom serum” • Covers Cobra, Krait, Russell’s viper, Sawscaled viper. • Not against Hump nosed viper. Sanjaya Gihan
- 45. Indications for Antivenom • Signs of systemic envenomation (ARF,Dark color urine,Generalized Rhabdomyolysis) • Haemostatic abnormalities (20WBCT) • Spontaneus Bleeding • Neurotoxic signs Sanjaya Gihan
- 46. Administration of antivenom Serum • 3 IV lines • Keep adrenaline ready in a syringe 0.5mg (1:1000) • 10 ampoules of AVS • Each dissolved in 10ml of water • 100ml AVS into 200ml of Normal Saline • Slow IV infusion for 1 hour Sanjaya Gihan
- 47. • Watch for any reaction such as, – Fever ,Chills – Itching,Urticaria – Bronchospasms • If a Early Anaphylactoid reaction occurs ??? Sanjaya Gihan
- 48. • • • • Stop AVS infusion Give adrenaline 0.5mg (1:1000) IM IV Chlorpheniramine 5mg IV Hydrocortisone 200mg • Restart AVS after the reaction settled • In Shock ----> Sub lingual Adrenaline Sanjaya Gihan
- 49. More Antivenom?? • Persistant or Recurrent Incoagulability by 20WBCT after 6 hours • Further Deterioration Sanjaya Gihan
- 50. Supportive/ancillary treatment • In severely envenomed patients – Assisted ventilation. – renal dialysis. – Wound Debridement. – Fasciotomy. Sanjaya Gihan
- 51. Treatment of the bitten part • The bitten limb is nursed in the most • comfortable position, slightly elevated • Bullae aspirated only if likely to rupture Sanjaya Gihan
- 52. Rehabilitation • Restoration of normal function in the bitten part. • Conventional physiotherapy. Sanjaya Gihan
- 53. Long Term Complications • • • • Chronic Ulceration Osteomyelitis Chronic Renal Failure Chronic Neurological deficit Sanjaya Gihan
- 54. Sanjaya Gihan