BANGALORE BAPTIST HOSPITALSnakebite Study Workshop

Vellore, Mar 2013

Dr Tarun/ Dr Indira Menon

Questionnaire.•Name of centre—BBH•No. of snake bites per year-- 55—60•No. of snake bites in last year-- -65•No. of venomous bites last year --50 approx.•No. of non venomous bites in last year—15•Snake bites due to main syndromes %• Haematotoxic—90% Neuro—10%•Combination 1-2 %•No.of cases where dead snakes are brought

—5

Questionnaire (contd.)• Indications for ASV—systemic or local

envenomation• No prophylactic adrenaline is given prior to ASV• Initial dose of ASV—8—10 vials both

haematotoxic and neurotoxic.• Time duration of administration –1 hour• Response to ASV is monitored by 20 WBCT every

6 hourly• When to repeat dose of ASV?• Haematotoxic every 6 hours—10 vials• Neurotoxic every 1 hour –10 vials • Is continuous low dose of ASV administered after

normalization of coagulation –NO

Questionnaire (contd.)• Ceiling dose—Haematotoxic—30 vials( exceeded

very rarely)• Neurotoxic— 20 vials• Do you use Neostigmine in neurotoxic bites –Yes• Indication for antibiotics—local swelling/

cellulitisChoice of antibiotic—Crystalline penicillin + ciprofloxacin + metronidazole.

• When to admit to ICU ?—all patients are observed in ICU initially.

• When do you refer –we do not refer.• Which ASV do we use—Bharath serum• Stock in pharmacy at any given time—20—30

vials

Questionnaire (contd.)

•Last year cases of allergy to ASV—

- minor -10- angioedema—swelling mouth/ bronchospasm—2- anaphylaxis fall in BP---2- death –nil

Questionnaire (contd.)•Outcomes :

- Mechanical ventilation –10—15 %- Haemodialysis—2-3 %- Deaths—2 %

•Facilities available:- Coagulation parameters –yes- Blood transfusion—yes- Haemodialysis –yes- Mechanical ventilation –yes- ICU yes

•Protocol for snake bite management –yes

•Blood tests routinely done—20WBCT, CBC,PT- PTT ,creatinine, ,ECG Electrolytes, Urine RE

Snake bite management protocol• Check airway breathing circulation• Inj TT 0.5ml IM to all patients• OBSERVE ALL PATIENTS for minimum

24 hrs• Determine time of bite• What was the patient doing at that time ?• Release any tourniquet very slowly• Assess envenomation –local / systemic

Snake bite management protocol (contd.)

•Local- swelling > ½ bitten limb- swollen digits- rapid extension of swelling.

•Systemic- Haematotoxic-deranged 20 WBCT / bleeding gums- Neurotoxic - ptosis/ external ophthalmoplegia/ neck muscle weakness- CVS—hypotension/arrythmias- Persistent vomiting/ abdominal pain.

Investigations

•20 WBCT•CBC•S Creatinine•Electrolytes•CPK/PT /APTT•Urine RE•ECG

Protocol (contd.)

•IF CLOT forms repeat 20 WBCT every ½ hourly x 3 hoursIf still normal repeat every 1 hourly for 3 hours Then every 6 hourly for 24 hours.( done at bedside in glass test tube )

•If NO CLOT at 20 mins repeat 20WBCT every 6 hours till normal.

Snakebite Protocol (contd.)

•Local /systemic envenomation present ?•Premedication –hydrocortisone 100mg +

Avil 1 ampoule•ASV -- 8—10 vials in 500ml N.Saline over

1 hour•No test dose .•Haematotoxic---assess 20WBCT 6 hrly and

give further doses of 5 vials if needed.•Max- 30 vials ( usually)

Snakebite Protocol (contd.)• Neurotoxic- Try neostigmine 1.5mg -2mg IM plus

0.6mg Atropine IV stat.—if response repeat neostigmine every 30 mins and give atropine 0.6mg infusion over 8 hours.

• If no response to Neostigmine – discontinue.• Support with mechanical ventilation till weakness

improves• ASV—initial 8—10 vials. Reassess every 1 hour

and repeat ½ dose of initial ASV till a maximum 20 vials.

• ASV is costly and not freely available therefore do not waste.

• ASV only acts on unbound venom.

Snakebite Protocol (contd.)

•If anaphylaxis to ASV occurs —stop the infusion, administer 0.5ml(1:1000) adrenaline IM stat +avil + hydrocortisone + ranitidine.

•200ml NS bolus.•Repeat adrenaline dose after 10 mins if

required.•Restart ASV as soon as patient stabilizes

Snakebite Protocol (contd.)

•Pain ---give paracetamol IV 1000mg +/- inj tramadol 25—50mg IV

•Antibiotics—Crystalline penicillin+Ciprofloxacin+Metronidazole

•Surgical consult only if severe swelling seen.

•Ensure adequate hydration to maintain an hourly urine output of 0.5ml/kg

•Monitor creatinine and K+ daily•Haemodialysis if needed.

BANGALORE BAPTIST HOSPITALThank you!