final uttarika presenation.pptx FINAL ON THIS IS SIR

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1. W elcome to cne Nepaljung Military Hospital

2. SNAKE BITE IN NEPAL T/ Sub Uttarika Budhathoki

3. CONTENTS:

4. Introduction

5. Cont.. Snake of medical importance in Nepal are: ELAPIDAE- Cobra, Krait VIPERADAE- Pit vipers

6. Non-Poisonous snake

7. Cont...

8. Sign and symptoms of Non-poisonous snake bite Local pain Swelling Redness Puncture/scratch marks No neurotoxic or hemotoxic symptoms Possible mild infection if untreated

9. Common non-venemous snakes found in Nepal

10. Indian Rat snake( Dhamin )

11. Checkered keelback(Paani Sarpa)

12. Himalayan Trinket( Chameli Sarpa)

13. Green keelback( hariyo dhamin )

14. Indian python ( अ ि जङगर )

15. Poisonous Snake

16. Signs and Symptoms of Poisonous snake Neurotoxic symptoms (common in Cobra and Krait): Ptosis (drooping eyelids) Blurred vision, diplopia Difficulty speaking, swallowing, or breathing Progressive paralysis Hemotoxic symptoms (common in Vipers): Pain and progressive swelling at bite site Bleeding gums, hematuria, ecchymosis Hypotension, shock

17. Common cobra(Goman, nag)

18. Krait Common Krait( seto kalo chure sarpa ) Banded krait(laxmi sanp,pahelo kalo chure sarp)

19. Viperadae Russel’s viper Pit viper(Haryou sarpa)

20. BREAK TIME

21. MANAGEMENT

22. Ask

23. Local effects Cobra Swelling and local pain with or without erythema or discoloration at the bite site. Blistering, bullae formation and local necrosis are also common. If it is infected, there may be abscess formation. Krait Usually do not cause signs of local envenoming and can be virtually painless. Viper Swelling, blistering, bleeding, and necrosis at the bite site, sometimes extending to the whole limb. Persistent bleeding from fang marks, wounds or any injured parts of the body. Swelling or tenderness of regional lymph node.

24. Systemic manifestations General manifestations

25. Systemic manifestations Hematotoxic Bleeding may from venipuncture site, gums, Epistaxis Hemoptysis Melena, rectal bleeding Hematuria, bleeding from vagina Subconjunctival hemorrhage Petechiae, purpura, ecchymosis Neurotoxic Ptosis Ophthalmoplegia Pupillary dilatation- often non- responsive to light Inability (or limitation) to open mouth Numbness around lips and mouths Neurotoxic Tongue extrusion- inability to protrude the tongue beyond incisors teeth. Inability to swallow Broken neck sign Skeletal muscle weakness. Loss of gag reflex Paradoxical breathing Respiratory failure

26. Diagnosis No investigations available that can help diagnose the neurotoxic manifestations Neurotoxic

27. Diagnosis Hematotoxic 20- minute whole blood clotting test (20WBCT) Bleeding time (BT) and clotting time (CT) Prothrombin time and International normalization ratio (INR) FDP, fibrinogen, d- dimer Kidney function test and liver function test Complete blood count, blood group Urine for RBCs or myoglobin Creatine kinase

28. 20 WBCT Place 2- 3 ml of freshly sampled venous blood in a small, new, dry, glass tube. Leave the tube standing undisturbed for 20 minutes at ambient temperature. A positive 20WBCT is a reasonable indication for antivenom administration, but a negative 20WBCT does not mean that antivenom should be withheld, especially if other clinical findings of coagulopathy (eg, blood oozing at puncture sites, bleeding gums, or epistaxis) are present.

29. TREATMENT OF SNAKEBITE ENVENOMING

30. Recommended F irst aid T reatment REASSURANCE Most are nonvenomous snakes. Many are dry bites. Treatable condition. IMMOBILIZAT ION With a splint or sling. Pressure immobilization in case of purely neurotoxic snake bite Pressure pad immobilization Remove rings, jewelries, tight fittings and clothing RAPID TRANSPORT To decrease the delay in accessing the emergency care and reduce mortility

31. What to do and what not to do in snake bite

32. ANTIVENOM TREATMENT

33. Antivenom in Nepal

34. Indication Of Antivenom Administration

35. Contraindications No absolute contraindication to antivenom treatment, But patients who have reacted to horse (equine) or sheep (ovine) serum in the past (for example after treatment with equine anti- tetanus serum, equine anti- rabies serum or equine or bovine antivenom) and those with a strong history of atopic diseases (especially severe asthma) are at high risk of severe reactions and Should therefore be given antivenom only if they have signs of systemic envenoming.

36. How long after the bite can antivenom be expected to be effective? Antivenom treatment should be given as soon as it is indicated. It may reverse systemic envenoming even when this has persisted for several days or, in the case of haemostatic abnormalities, for two or more weeks.

37. Route of administration Each vial is diluted with 10 ml. of sterile water as supplied with the antivenom.

38. Response to treatment General symptoms may disappear vary quickly. Spontaneous systemic bleeding usually stops within 15- 30 min. Blood pressure may increase within 30-60 min. Neurotoxicity may improve as early as 30 min. Blood coagulability is usually restored in 3-9 hrs.

39. Reasons for failure to respond to antivenom

40. Prophylactic adrenaline Prophylactic adrenaline should be routinely used before initiation of anti- venom treatment to prevent anti- venom reaction except in older patients with evidence or suspicion of underlying ischemic heart disease or cerebrovascular disease.

41. Antivenom reactions within 3 hours of antivenom initiation. itching, urticaria, fever, angio- edema, dyspnea, laryngeal edema, hypotension etc. . Early anaphylactic reactions Usually develops 1- 2 hrs. after treatment initiation. Chills, rigors, fever, fall of blood pressure, febrile convulsion may develop in children. Pyrogenic reaction May develop 1- 12 (mean 7) days after treatment. Fever, itching, recurrent urticaria, arthralgia, myalgia, lymphadenopathy, proteinuria etc. Late reaction (serum sickness type)

42. Treatment of Early Anaphylaxis INTERRUPT antivenom IM adrenaline IV chlorpheniramine IV fluids Oxygen IV hydrocortisone Nebulized salbutamol

43. Treatment Pyrogenic reaction Do not interrupt antivenom unless hypotension is present. Give injection paracetamol. Treat hypotension with rapid infusion of normal saline. Serum sickness Anti- histaminic Pheniramine maleate If no response to antihistaminic Prednisolone

44. IF ANTIVENOM HAS TO BE RESTARTED

45. Supportive/ancillary treatment Fluid resuscitation Oxygen Intubation and ventilation Dialysis Fasciotomies

46. Rapid clinical assessment and resuscitation Airway - clear airways ,left lateral decubitus position Breathing - oxygen( via nasal prongs, face mask, bag and mask) Circulation ( IV access) Disability of the nervous system Exposure and environmental control

47. Response to treatment General symptoms may disappear vary quickly. Spontaneous systemic bleeding usually stops within 15- 30 min. Blood pressure may increase within 30-60 min. Neurotoxicity may improve as early as 30 min. Blood coagulability is usually restored in 3-9 hrs.

48. When antivenom is not available

49. Treatment of the Bitten Part

50. Prevention o f Snakebite

51. Cont..

52. Nursing care

53. Cont..