MANAGEMENT OF NEUROTOXIC

SNAKE BITE

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700615/#!po=36.5385

DEVASHREE NADGAUDA IX SEMESTER

70% of all snakebites are by nonvenomous snakes and 50% of bites by venomous species are dry bites

MANAGEMENT OF NEUROTOXIC SNAKE BITE

First Aid

I. Reassure the Victim

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by bandage or clothes to hold splint, but tight arterial compression is not recommended.

II. Immobilize the affected limb

III. Promptly Transfer Victim to Hospital

When the patient reaches the emergency department, evaluation should begin with the assessment of the airway, breathing, circulatory status, and consciousness.

Emergency Care Department

MANAGEMENT OF NEUROTOXIC SNAKE BYTEA

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Hospital Treatment

Urgent resuscitation will be needed in those with respiratory failure (neurotoxin).

Oxygen should be administered to every envenomed patient and a large-bore intravenous catheter should be inserted.

A bolus of normal saline or Ringer's lactate should be given to all patients with suspected envenomation.

History

1 Whether a venomous snake has actually bitten the patient?

2 Cross-check by looking for fang marks and signs of local envenomation.

3 If the victim has brought the snake, identification of the species. (crotalids can envenomate even when dead so be careful in ED)

4Time elapsed since the snakebite? Brief medical history - date of last tetanus immunization, use of any medication, presence of any systemic disease, history of allergy.

Bite Mark

1To a large extent the manifestation of snakebite depends upon the species of snake, and therefore identification of the type of snake is important.

2At times the bite mark might not be visible as in the case of Krait.

Bite Mark

Physical Examination

1

Initial evaluation begin with the bite site :signs of local envenomation - edema, petechiae, bullae, oozing from the wound etc and for the extent of swelling.

2

The bite site and at least two other, more proximal, locations should be marked and the circumference of the bitten limb should be measured every 15 min thereafter, until the swelling is no longer progressing.

3The extremity should be placed in a well-padded splint for at least 24 h. Serial measurement of circumference helps in estimating spread of venom and effect of anti-venom.

4 Lymph nodes draining the limb should be palpated and the presence of lymphangitic lines noted.

5 Distal pulses should be checked and monitored if there is presence of gross swelling.

Assessment of Severity of envenomation

Supportive Therapy

PATIENT

MILD ENVENOMATION SEVERE ENVENOMATION

INTENSIVE CARE UNIT ICU

CLOSE MONITORING IN WARD

Specific Treatment

Anti-snake venom treatment alone cannot be relied upon to save the life of a patient with bulbar and respiratory paralysis.

Loss of the gag reflex, failure to cough, or respiratory distress

Endotracheal intubation and initiation of mechanical ventilation is indicated.

Tracheostomy and placement of a cuffed tracheostomy tube can be done whenever expertise for endotracheal intubation is not

available.

Specific Treatment - continued

Pathophysiological changes resembling those of myasthenia gravis, anticholinesterase drugs can have a useful effect in patients with neurotoxic envenomation, especially in those bitten by cobras.

A trial of anticholinesterase should be performed in every patient with neurotoxic envenomation.

Injection neostigmine can be given as 50–100 μg/kg 4 hourly or as a continuous infusion.

Anti Snake-Venom

In India, Polyvalent anti snake venom PAV (Kasauli HP) and

Haffkine Corporation, Mumbai) is effective against the most common Indian species.

Administration and Dose of PAV

ASV is supplied in dry powder form and has to be reconstituted by diluting in 10 ml of normal saline/D5 W. Mixing is done by swirling

and not by vigorous shaking.

Administration and Dose of PAV - continued

Each vial of PAV will neutralize about 6 – 8 mg of venom. Its half life is about 90 hours.

Care of Bitten Part

As most snakes harbor aerobic as well as anaerobic bacteria in their mouths, a prophylactic course of penicillin or erythromycin for

penicillin-hypersensitive patients.

And

A single dose of broad spectrum antibiotic course which will cover anaerobes.

Booster dose of tetanus toxoid is recommended.

There is painless and mark less bite mark.

Pain in Abdomen is a very common presenting symptom.

COMMON KRAIT : THE MYSTERIOUS SNAKE

There is painless and mark less bite mark.

Convulsion is a very common feature.

Pain in Abdomen is a very common presenting symptom.

PTOSIS may come even after 24 hrs of Krait bite .  

AVS if administered at the onset of Ptosis, it is life saving in a case of Krait bite.

There is painless and mark less bite mark.

Convulsion is a very common feature.

Pain in Abdomen is a very common presenting symptom.

PTOSIS may come even after 24 hrs of Krait bite .  

AVS if administered at the onset of Ptosis, it is life saving in a case of Krait bite.

CASE : PRESENTING AS PARALYSIS One Patient named Zakir Sardar , 21 yrs , male from, West Bengal was brought to the Canning Hospital at 8 AM on 29th May 2010.

The patient was confused and had signs like hemiperesis of Rt. side of body and ptosis.

On interrogation, the Emergency Medical officer said that they got some positive history to suggest a Kalach ( Common Krait ) bite.

The patient was treated with IV infusion of 15 vials of Indian Poly Valent AVS and survived. 

What was the history from the patient’s relatives?

There was no history of any bite. Most relevant history was open floor bed in the previous night.

Sudden pain in abdomen which broke the sleep of the patient followed by vomiting.  

There was whole body ache and blurring of vision which came latter on in that order. 

THANK YOU !

References :1. NCBI NIH Pubmed – WHO guidelines (Internet)2. Text book of Forensic Medicine and Toxicology.3. www.kalachkrait.webs.com