Arman's snake bite

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Arman's snake bite

  1. 1. Dr Arman Bin Hawari Emergency & Trauma Department www.kecemasan2u.com
  2. 2. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>Introduction </li></ul><ul><li>Clinical Features </li></ul><ul><li>Management </li></ul><ul><ul><li>1 st Aid </li></ul></ul><ul><ul><li>Antivenom Treatment </li></ul></ul><ul><ul><li>Choice of Antivenom </li></ul></ul><ul><ul><li>Antivenom reactions </li></ul></ul><ul><ul><li>Anticholinesterases </li></ul></ul><ul><li>Pitfalls in management </li></ul>iNTRoDuCTioN
  3. 3. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>Introduction </li></ul><ul><li>Not all snakes are venomous </li></ul><ul><li>Malaysia has approx 40 venomous snakes </li></ul><ul><ul><li>-18 land snakes </li></ul></ul><ul><ul><li>-all 22 sea snakes </li></ul></ul><ul><li>2 Major Groups of medically important snakes: </li></ul><ul><ul><ul><li>Elapidae </li></ul></ul></ul><ul><ul><ul><ul><li>Cobras </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Kraits </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sea Snakes </li></ul></ul></ul></ul><ul><ul><ul><li>Viperidae </li></ul></ul></ul>iNTRoDuCTioN
  4. 4. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com Common Snakes in Malaysia iNTRoDuCTioN
  5. 5. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>Malayan Pit Viper </li></ul><ul><li>Calloselasma rhodostoma </li></ul><ul><li>Bad tempered, aggressive,quick to strike </li></ul><ul><li>Commonest cause of snake bite </li></ul><ul><li>Aka “Ular Kapak Bodoh” </li></ul><ul><li>Length= 0.6-0.8m </li></ul><ul><li>Haemotoxic-defibrination & thrombocytopaenia </li></ul>iNTRoDuCTioN
  6. 6. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>Temple Pit Viper </li></ul><ul><li>Trimeresurus wagleri </li></ul><ul><li>Ground & trees </li></ul><ul><li>Sluggish & docile </li></ul><ul><li>Quite rough handling to cause it to bite </li></ul><ul><li>Species that is displayed at the snake temple in Penang </li></ul><ul><li>Severe pain & local swelling </li></ul>iNTRoDuCTioN
  7. 7. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>COBRAS </li></ul><ul><li>Average length: 1-2m </li></ul><ul><li>King 4-6m </li></ul><ul><li>Not aggressive, and always tries to evade human </li></ul><ul><li>Young usually aggressive </li></ul><ul><li>Venom of Naja Sputatrix is immunologically different from Naja Khaothia, antivenom doesn’t respond </li></ul><ul><li>Neurotoxic,cardiotoxic, </li></ul>iNTRoDuCTioN Naja Khaothia Naja Sputatrix Ophiaphagus Hannah
  8. 8. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>Kraits </li></ul><ul><li>Not aggressive </li></ul><ul><li>Mountain and foothill </li></ul><ul><li>Painless neurotoxic </li></ul>iNTRoDuCTioN Bungarus Flaviceps Bungarus Candidus Bungarus Fasciatus
  9. 9. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>Sea Snakes </li></ul><ul><li>All poisonous </li></ul><ul><li>Causes severe myotoxic damage, myoglobinuria, minimal local effects, paralysis can occur </li></ul>iNTRoDuCTioN
  10. 10. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com Clinical : General Approach: Becareful of dead snakes brought, 1 st aid Airway, breathing, circulation Identify the systemic symptoms Examination of bitten part: Compartment syndrome Fang marks-? Clues of adult vs juvenile Demarcate local reactions Signs of neurotoxicity: Ask the patient to raise the hand, and count loudly in reverse from hundred and look up… CLiNiCaL
  11. 11. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com TeST
  12. 12. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com 1 st Aid-pressure immobilization for elapids Not recommended for vipers 1 st aiD
  13. 13. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>Antivenom treatment </li></ul><ul><li>An immunoglobulin from purified serum or plasma of horse/sheep that has been immunized by one or more species of snake </li></ul><ul><li>Monovalent vs polyvalent </li></ul><ul><li>Specific antivenom-from the specific snake that has bitten the patient </li></ul>aNTi-VeNoM
  14. 14. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com aNTi-VeNoM
  15. 15. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>How long after the bite can antivenom be effective? </li></ul><ul><li>Should be given as soon as indicated </li></ul><ul><li>May reverse systemic envenomation even though it has persisted for several days </li></ul><ul><li>Signs of local envenomation may only be effective if given within 1 st few hours after the bite </li></ul>aNTi-VeNoM
  16. 16. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>Are there any contraindication to antivenom? </li></ul><ul><li>No absolute contraindication </li></ul><ul><li>Be careful to those patients who has reactions towards past equine/sheep products such as ATT, anti rabies,strong asthma atopics… </li></ul><ul><li>Only give the above patients when there are signs of systemic envenomation </li></ul><ul><li>Role of pretreatment with iv adrenaline 2-5mcg/min, IV piriton 10mg, IV hydrocortisone 100mg, IV ranitidine 50 mg and salbutamol inhaler </li></ul>aNTi-VeNoM
  17. 17. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>How to administer the antivenom? </li></ul><ul><li>Ask history of high risk (as previous) </li></ul><ul><li>Prepare adrenaline infusion, piriton, hydrocortisone, 2 large branullas etc… </li></ul><ul><li>Given in close observation unit </li></ul><ul><li>Gentle swirl on mixture </li></ul><ul><li>Give the antivenom slowly at 10ml/h, if no reaction can give over 1 hour </li></ul><ul><li>Assess for control (clinical & labs) </li></ul><ul><li>If No control, repeat the dose, if controlled maintain with 2 vials every 6 hours X 3dose </li></ul>aNTi-VeNoM
  18. 18. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com aNTi-VeNoM
  19. 19. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com <ul><li>Antivenom reactions: </li></ul><ul><li>EARLY ANAPHYLACTIC REACTIONS </li></ul><ul><ul><li>10-180mins </li></ul></ul><ul><ul><li>Urticaria,dry cough, fever, nausea, vomiting,abdominal colic, diarrhoea, tachycardia, </li></ul></ul><ul><li>PYROGENIC REACTIONS </li></ul><ul><ul><li>1-2 hours after treatment </li></ul></ul><ul><li>LATE (SERUM SICKNESS) </li></ul>aNTi-VeNoM
  20. 20. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com aNTi-VeNoM
  21. 21. Emergency & Trauma Department Hospital Sultanah Bahiyah www.kecemasan2u.com aNTi-VeNoM
  22. 22. Any BIG questions?

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