Nazim jan, a 55-year-old diabetic and hypertensive female, was admitted to the emergency room with severe right foot and leg pain and swelling after being bitten by a snake while walking through a field. She received first aid including antivenom but her condition deteriorated, so she was transferred for further treatment. On examination, she was in shock with fang marks and swelling in her right foot. After resuscitation and antivenom, her condition stabilized but she developed further swelling so a fasciotomy was performed. She has since shown improvement but is being closely monitored due to risks of complications from the snake bite.

1. • My patient Nazim jan a 55 yrs old female resident of chilyana
admitted in FMW bed no. 16. She was admitted via ER with
complain of severe pain in right foot and swelling followed by
hx of snake bite.
• HOPI
• She is a diagnosed hypertensive and diabetic not compliant to
medication. According to her she was walking through the
field when she was bitten by a snake at 2 pm. She was
immidiately taken to jhambar medical battalion where at 4
pm she was given first aid and was given ASV (10 VIALS IN
500ML N/S) and then was referred to cmh muzaffarabad as
she complained of severe pain in right foot and leg and she
reached mzd by 11 30 at night. She also gives hx of 3 episodes
of vomiting, non projectile. Vomitus contained food particles,
no blood/mucus.

2. Examination
• In the ER, she was received in state of shock
• BP- 60/40
• PULSE - 110/-
• Spo2 – 98% with 6L o2
• On local examination:
• Fang marks visible on right foot with rt leg swelling and
cyanosis. Rt post tibial and dorsalis pedis were also not
palpable.
• After initial fluid resuscitation her vitals stabilized
• BP- 100/70 and pulse 100/-
• Her WBCT was done and blood was clotting well.

3. Management in ER
• 2 large bore Iv lines were maintained.
• Baselines were sent ( CBC, RFT, S/E, LFTs, PT/APTT, urine R/E)
• Inf N/S 1000ml IV stat in 30 mins
• Inf R/L 1000ml IV stat.
• Afterwards she was admitted in FMW with following
treatment regimen
• Inf. R/L @150ml/hr with strict monitoring of fluid overload
• Inj solocortif 100mg IV tds
• Inj avl IV BD
• Inj risek 40mg IV OD
• Inj augmentin 1gm IV BD
• Tab danzen DS 1 tab BD
• Leg elevation
• Insulin according to S/S

4. • Surgical review was done and was advised fasciotomy by the
worthy surgeon. At 1 AM at night her fasciotomy was done
and was advised transfusion of 2U FFPs.
• Her labs were
• TLC 16.6
• Hb 11.0
• PLT 11
• Urea 7.6
• Creatnine 91
• K 3,8
• Na 147
• PT/APTT normal.

5. • At present its her 5th DOA and her condition is stable.
• Her vitals are
• BP 140/90
• PULSE 97
• SPO2 98% @R.A
• AFEBRILE
• Chest B/L clear
• CVS s1 s2 no added sound
• P/A SNT BS+
• CNS concious well oriented
• Labs TLC 13.2
• HB 9.1
• PLT 28
• Dressing changes regularly and is monitored by surgical dept.
her swelling has also been reduced.

6. Treatment given
• Inj augmentin IV TDS
• Inj risek 40 mg IV OD
• Inj flagyl 500mg IV TDS
• Tab danzen DS 1BD
• Tab brufen 1 BD
• Tab glusimet 50/500 BD
• BSR charting TDS
• Inj insulin according to S/S

7. SNAKE BITE

8. Classification of snakes
• ELAPIDAE – cobra, kraits
(neurotoxic)
• VIPERIDAE – russell’s viper, saw scaled viper
(vasculotoxic)
• HYDROPHIDAE – sea snakes
( myotoxic)

9. Clinical presentation
• LOCAL
• Pain
• Swelling
• Redness
• Bleeding, bruising, blistering
• Necrosis
• SYSTEMIC
• Abdominal pian, nausea, vomiting, tachycardia, hypotension
• NEUROTOXIC – ptosis, diplopia, paralysis of limbs, respiratory
paralysis
• VASCULOTOXIC – bleeding from bite site, IV site, gums

11. DO IT RIGHT

12. 20 MIN WBCT
• Take 2 ml fresh blood in glass vessel
• Leave undisturbed for 20 mins
• If blood fails to clot- hypofibrinogenemia
• Repeat the test
• Normal WBTC is 6-8 mins.
• We can do PT/INR but not available everywhere.

13. INVESTIGATIONS
• CBC
• CK levels – elevated (myotoxic snakebite)
• RFTs/ Creatinine - AKI (vipers or seasnake)
• Hyperkalemia – rhabdomyolysis (seasnake)
• DIC – low platelets and prolonged PT/APTT and low fibrinogen
levels
• ECG
• Urine R/E – hematuria, myoglobinuria

14. MANAGEMENT

16. In ER
• PRIMARY SURVEY
• Airway
• Breathing (respiration)
• Circulation (pulses, BP)
• Disability (level of conciousness)
• Exposure (protect from cold etc)
• Then ASV – only specific antidote to snake venom.

18. Treatment
• NO TEST DOSE GIVEN
• Prophylactic regimes- inj avil/solocortif
• Administer 10 vials in 500 ml N/S and is administerd at rate of
30 mins to 1 hr
• Monitor the pts vitals
• Fluid resuscitation – inf D/W or R/L 1L
• Analgesia- paracetamol P/O or I/V
• For swelling – denzen DS
• Acute renal failure – correct electrolyte imbalance and
sufficient fluid is given.
• For neurotoxic effects – inj atropine (0.6mg I/V) followed by
neostigmine (1.5-2mg) after ASV

19. Response to ASV
• General – pt feels better. Nausea headache aches and pains
disappear quickly. Spontaneous systemic bleeding may stop
within 15-30 min
• Blood coagubility (as measured by WBCT)- restored in 3-9 hrs
• In shocked pts. BP may increase within first 30-60 mins and
arrythmias such as sinus bradycardia may resolve
• Neurotoxic envenoming may improve as early as within 30
mins.
• Active hemolysis and rhabdomyolysis may cease within few
hours and urine returns to normal color.

22. How long after bite ASV can be
given
• Should be given as soon as possible.
• It may reverse systemic envenoming even when this has
persisted for several days or in case of hemostatic
abnormalities for two or more weeks.
• It is therefore appropriate to give antivenom as long as
evidence of coagulopathy persists.