snake bite presentation there may be some mistakes pls correct it if you find with standard protocols

1. DR. VINOD DAHIYA SR. CPS DCH

2. SNAKE BITE

3.  There are 2000 species of snakes in the world and about 300 species are
found in India out of which 52 are venomous.
 Nearly 67.5% death were due to krait bite (Majumdar et al ,2014)

12.  CLINICAL PRESENTATION
OFSNAKE BITE VICTIM
DEPENDS UPON
 SPECIES OF SNAKE
 AMOUNT OF VENOUM
INJECTED
 WHETHER SNAKE IS FED OR
UNFED
 DRY OR COMPLETE BITE
 VENOUM INJ IN VESSEL
 TIME ELAPSED BETWEEN BITE
AND ADMINISTRATION OF ASV

24. MANAGEMENT
 FIRST AID
MEASURES
 IMMOBILSE THE
LIMB IN THE SAME
WAY AS
FRACTURE

IMMEDIATELY
TRANSFER TO
HEALTH FACILITY

27. INVESIGATIONS
 IF BLOOD CLOTTED
THE TEST SHOULD BE
CARRIED OUT EVERY
1 HOUR FROM
ADMISSION FOR 3
HOURS AND THEN 6
HOURLY FOR 24
HOURS .
 IN CASE BLOOD IS
NOT CLOTTING
REPEAT 6 HOUR
AFTER
ADMINISTRATION OF
LOADING DOSE OF
ASV

28. TERTIARY CARE INVESTIGATIONS
 ADDITIONAL TEST
 PT ,APTT
 PLT COUNT
 LFT
 RFT
 SERUM AMYLASE
 RBS
 ECG
 USG ABD
 2D ECHO
 URINE –R&M

32. ANTISNAKE VENOUM
THERAPY
 IF ASV IS INDICATED i.e. signs and symptoms of
envenomation with or without evidence of laboratory
test,administer full dose.
 THERE ARE NO ABSOLUTE CONTRAINDICATIONS TO
ASV.
 DO NOT ROUTINELY ADMINISTER ASV TO ANY PATIENT
CLAMING TO HAVE BITTEN BY A SNAKE IT EXPOSES TO
THE RISK OF ASV REACTION
 HOWEVER AT SAME TIME DO NOT DELAY, OR
WITHHOLD ASV ON THE GROUNDS OF ANAPHYLACTIC
REACTIONS TO A DESERVING CASE.
 DO NOT GIVE INCOMPLETE TREATMENT

33.  ANTIVENOM –is an immunoglobin purified from the
serum or plasma of a horse or sheep that has been
immunized with venoms of one or more species of
snakes.
 MONOVELENT-neutralises the venom of only one species
of snake
 POLYVALENT-neutralises the venom of several species of
snakes.

39. In oliguric patients restrict fluids and use infusion
pump to give full dose of ASV in 30 min
Adrenaline should always be available before start
of ASV

41. REPEAT DOSE OF ASV
 NEUROPARALYTIC OR NEUROTOXIC ENVENOMATION
 Repeat ASV when there is worsening neurotoxic or
cardiovascular signs even after 1-2 hours max dose 20 vials
of ASV for neurotoxically envenomed patients
 VASCULOTOXIC OR HAEMOTOXIC ENVENOMATION
 Repeat clotting test every 6 hours until coagulation is
restored .Administer ASV every 6 h until coagulation is
restored . If 30 vials of ASV have been administered
reconsider whether continued administration of ASV is
serving any purpose,particularly in the absence of proven
systemic illness.
 IF coagulation abnormality persists ,give FFP, OR
CRYOPRECIPITATE (fibrinogen ,factor VIII),fresh whole
blood,if FFP not available or platelet concentrate

42. TREATMENT OF ASV
REACTION Stop ASV Temporarily.
 Oxygen
 Start iv NS infusion with new iv set
 ADMINISTER adrenaline -0.5 ml (1:1000) in adults I.M.
 IN CHILDREN –dose is 0.01 mg/kg (1:1000)
 TREATMENT OF LATE SERUM SICKNESS-develop after 1-12
days( mean is 7 days)
 Features are-fever nausea vomiting diarrhoea itching
urticaria arthralgia myalgia lymphadenopathy rarely
encephalopathy
 INJ chlorpheniramine 2 mg in adults(in children 0.25
mg/kg/day) 6 hourly for 5 days.
 In patient who fail to respond within 24-48 hours give 5
day course of prednisolone (5 mg 6 hourly in adults and
0.7 mg /kg/day in divided doses in children)

43. DESENSIRIZATION PROCEDURE IN SEVERE ANAPHYLACTIC REACTION TO ASV
PREMEDICATION :-Administer inj hydrocortisone 100 mg iv and inj adrenaline 0.5 ml i.m.

46. TREATMENT OF BITTEN PART
 Keep slightly elevated to encourage reabsorption of edema fluid.
 Prophylactic broad spectrum antibiotic .(inj amoxiclav 1.2 gm iv
trice daily for 7 days then switch to oral tab amoxiclav 625 mg trice
daily for next 3-7 days )
 In children dose is 100 mg/kg/day in tree divided doses iv for oral
dose is 50 mg/kg/day in three divided doses
 Inj metronidazole 400 mg infusion thrice daily for 7 days
 In children metronidazole is given in dose of 30 mg/kg/day in 3-4
divided doses
 Alternatively inj ceftriaxone 1 gm twice daily in adults (in children
the dose is 100 mg/kg/day in 2 divided doses.
 Administer booster dose of tetanus toxoid injection if not vaccinated
earlier or vaccination history is not reliable after correction of
coagulopathy
 Skin grafting ,amputation of necrotic digit may be required and
surgical management of compartment syndrome required.

47. LIFE THREATENING
COMPLICATIONS

48. ATROPINE NEOSTIGMINE DOSE FOR NEURO PARALYSIS
 Atropine 0.6 mg
followed by neostigmine
1.5 mg to be given iv
stat and repeat dose of
neostigmine 0.5 mg with
atropine every 30 min
for 5 doses
 In children inj atropine
0.05mg /kg followed by
inj neostigmine 0.04
mg/kg iv and repeat
dose 0.01mg/kg every
30 min for 5 doses
 There after tapering
doses at 1hour 2 hour 6
hour 12 hour
 Majority of patients
improve with first 5
doses
 Stop atropine
neostigmine when
complete recovery of
neuroparalysis or
patient show
bradycardia and
fasciculations side
effect or if there is no
improvement after 3
doses

51. PAIN MANAGEMENT
 FOR MILD PAIN –PARACETAMOL 500-1000 MG
 FOR CHILDREN –P-MOL 10-15 mg/kg/dose.
 Donot use aspirin
 Use ibuprofen cautiously 5-10 mg/kg/dose every 8
hourly.
 In adults Tramadol 50 mg iv or tab Tramadol 50 mg can
be used for more pain.

52. DISCHARGE
 IF NO SYMPTOMS AND SIGN DEVELOP AFTER 24 HOURS
THE PATIENT CAN BE DISCHARGED .
 KEEP THE PATIENT UNDER OBSERVATION FOR 48 HOURS
IF ASV WAS INFUSED’
 ADVICE FOR FOLLOWUP AND DANGER SIGNS.