dr arya jith. best way to a manage is to prevent a snake bite…..!
TRANSCRIPT
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Dr Arya Jith
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Best way to a manage
Is to prevent a snake bite…..!
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A WORLD WITHOUT SNAKES
NEARLY A QUARTER OF US WOULD GO HUNGRY
THEY ARE IMPORTANT ELEMENTS IN FOOD CHAIN THAT CONTROL RODENT POPULATION
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5 DANGEROUSLY POISONOUS SNAKES KING COBRA COMMON COBRA COMMON KRAIT RUSSELL’S VIPER SAWSCALED VIPERMOST COMMON POISONOUS SNAKE IS
COMMON KRAIT
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TO IDENTIFY WHETHER IT WAS A POISONOUS SNAKE.
216 SPECIES- 52 VENOMOUS IF THE PAIN NUMBNESS AND OEDEMA
IS SPREADING THEN IT IS A VENOMOUS SNAKE.
SUSPECTED SNAKE BITE
OBSERVATION 24 HOURS
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Universal fear - a state of shock Bite site -multiple teeth impressions significant local pain or swelling -
ABSENT Adequate reassurance and symptomatic
treatment .
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• To rule out ptosis
Evidence of early external ophthalmoplegia .
• size and reaction of the pupils.
• Early paralysis of pterygoid muscles.
• “broken neck sign
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Oedema petechiae bullae oozing from the wound should be noted
Extent of swelling circumference of the bitten limb should be
noted every 15 minutes- spreading
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CT> 10 MINUTES Bleeding manifestations Oliguria /haematuria Hypotension Ptosis Circumoral paraesthesia Aphonia/Dysarthria
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GRADE0 – NO ENVENOMATION GRADE 1- MINIMAL ENVENOMATION (local pain and swelling) GRADE2-MODERATE ENVENOMATION (Pain ,swelling,ecchymosis spreading +mild systemic/ lab manifestations) GRADE 3-SEVERE ENVENOMATION (Marked local response+severe
systemic findings+significant lab findings)
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Blood grouping Hb, elevated PCV TC-leucocytosis Platelet count- thrombocytopenia Peripheral smear – Haemolysis BT,CT(20 min) prolonged PT ,aPTT Urea Serum Electrolytes- hyperkalemia Urine Routine-haematuria Metabolic /resp acidosis
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Level of consiousness Pulse, BP, Resp rate,Capillary refill time Clotting time 1/2hr -1hourly Urine output Muscle weakness
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GRADE 0-NO ENVENOMATION
Local wound care Injn TT Observation -24 hrs
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MINIMAL ENVENOMATION Injn TT Antibiotics (inj CP/Ampicillin) Observe for 24 hours
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Moderate and Severe Envenomation Injn TT Antibiotics(Ampicillin /CP/ 3 rd genertn cephalosporins+ metronidazole) local anti oedema measures
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NEVER APPLY A TOURNIQUET ABOVE THE SITE
IF THE PATIENT COMES WITH A TOURNIQUET always CHECK FOR VASCULARITY
Do not suck out venom Do not incise the bite wound nor
apply any chemicals
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Antivenom is immunoglobulin (usually the enzyme refined F(ab)2 fragment of IgG) purified from the serum or plasma of a horse or sheep that has been immunized with the venoms of one or more species of snake.
Monovalent or monospecific antivenom Polyvalent India –polyvalent is available which act
against the venom of commonly found snakes in india
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Neurotoxicity Bleeding/coagulopathy Myoglobinuria/haemoglobinuria Cardiac toxicity Local swelling involving more than half of
the bitten limb Rapid extension of swelling Development of an enlarged tender Lymph node draining the bitten limb ARF
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10 vials polyvalent asv(irrespective of body weight and age)
2nd dose - overt bleeding is present 10 vials
OR Do 20 minute clotting time and
give 2 vials Q6H till the coagulation parameters are normal
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No test dose is required
One vial is added with 100 ml of normal saline. After 10 -15 minutes 9 vials can be added in the same fluid over one hour
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Urticaria ,itching ,fever , shaking chills ,nausea ,vomiting ,diarrhoea abdominal cramps ,tachycardia hypotension , bronchospasm and angioedema
ASV is discontinued
0.01mg/kg of Adrenaline is given (1:1000)as IM should be given
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100mg of Hydocortisone(2mg/kg) and
10mg of H1 antihistamine (children- 0.2mg/kg) IV
2nd dose of Adrenaline 0.5 mg (1:1000) IM can be repeated
Patient is recovered ASV can be restarted slowly within 10 – 15 minutes
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Best effect – used within 4 hours Can be administered upto 48 hours Efficacy is seen upto 6- 7 days
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Normalization of BP Bleeding stops within 15 – 30 mts Normalization of coagulation
parameters within 6 hours Neurological sign will be resolving within
30-48 hours
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Neostigmine -0.05mg to 0.1mg/kg every 4 hours
Atropine 0.02mg/kg (5minutes prior to neostigmine)
Watch for ptosis
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Shock Renal failure Myocardial failure Shock lung Bleeding
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PUFFINESS CHEMOSIS PAROTID SWELLING Rx - methyl prednisolone (10mg/kgQ8H) x 3days
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If renal function is normal
Start with volume expanders(20ml/kg of isotonic soln)
Corrected? Symptoms of other shock
hypovolemic shock
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Raised JVP Oedema Signs of pulmonary oedema Feeble heart sounds Changes in ecg Start Dobutamine Drip (5-10microg/min)
Uncorrected-Neurogenic shock
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Dopamine drip(10-12microg /min)
BP is coming up
Nor adrenaline (0.1- 0.5 microgram/kg)
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Early dialysis
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Treat cardigenic shock Treat ccf Avoid fluid overload Oxygen inhalation
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Tacypnea Hypoxemia Unexplained drowsiness Mild acidosis treatment-o2inhalation cpap ventillation
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Correct coagulation failure FFP-10ml/kg Correct platelet deficiency Whole blood– frank bleeding
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