Snake bite Dr Deepika. Power point presentation

snake bite case history

1. SNAKE BITE DEEPIKA GOPINATHAN C1 [FMGE INTERN]

2. Introduction Poisonous snakes belong to three families on the basis of poison secreted: 1. Elapidae : Neurotoxic 2. Viperidae: Vasculotoxic 3. Hydrophidae : Myotoxic

3. Case A 55 yr old female, came to ER on 14/07/2024 at 10 pm Presenting complaints: Snake bite in the morning at 6 am Bleeding from the site of bite till now

4. Present History According to the patient she was alright before she was suddenly bitten while she was farming. Pt brought the snake to the ER which was 20 cm long and brownish in color. The pt, went home and only bandaged the wound. In a few hrs the pain got intense and the bleeding didn’t stop from the wound. There was difficulty in walking associated with the pain and she felt numbness in the left leg. There are no associated features of hematemesis, melena, epistaxis or vomiting, haemoptisis . There was no history of bleeding disorder among the family.

5. Past medical/ Surgical: Angiography and angioplasty: 5 yrs ago Personal History: Appetite N, Micturation N Bowels N Sleep- disturbed Family history: Not significant

6. Physical Examination Patient looks ill, but conscious in time/place/person. Vitals: Bp 110/63, pulse 96 bpm R/R 21/min O2 Sat: 96 Temp 37.1 General impression: swelling on left leg from the foot to the knee. Gum bleeding + nt

7. Examination CNS- Senosry was b/l equal, but slightly decreased at the lateral side of the left foot and leg. Tone, power and reflexes were b/l equal and normal Abdomen- Firm, non tender, relax CVS- S1+ S2+, no murmurs Resp- Normal vesicular breathing, no additional sounds No skin rash Flank pain and tenderness in costovertebral junction Black/dark urine (hemoglobinuria) Acute tubular necrosis.

8. Chest X- Ray It was normal

9. Investigations Hb- 9.1 Plt : 1,10,000 WBC’s: 9.5 MCV: 86 RDW: 11.6

10. Investigations Coagulation profile: Electrolytes: PT- 48 [Control- 9 to 13] Potassium: 2.28 [3.5 to 5.5] INR- 4.53 Calcium: 8.17 [8.1 to 10.4] APTT- 98 Magnesium: 1.92 [1.58 to 2.55] Biochemistry: Sodium: 141 [135 to 145] Urea- 22 [10-50] Chloride: 100 [98 to 104] Creatinine: 0.68 Albumin: 4.17 [3.8-4.4] 20 WBCT: 20 min Whole blood clotting test done every 30 mins from the 1 st 3hrs of admission [ then after giving ASV it can be done on an hourly basis.

11. Investigations: LFTs: Bilirubin total: 2.08 [<1.3] Bilirubin direct: 0.47 [<0.3] ALT: 21 [ upto 40] Alk Phosphate: 62 [39 to 117]

12. Diagnosis: Most likely snake bite complicated by DIC

13. Treatment: O2 by nasal cannulae 500 cc NS 100 mg hydrocortisone Anti tetanus serum (ATS) 2 cc 10 U of ASV 120 ml of FFP

14. Treatment Pain: Paracetamol Presence of touriniquet : BP cuff (above the level of the tourniquet and then gradually deflate the B.P cuff) Polyvalent ASV: No effect against humped nose viper. Dose: 10 to 30 vials (same for adult, pregnant females and child) T1/2 of ASV= 90hrs Re-administration of Indian ASV is not required (d/t long half life) 1 vial can neutralize 6mg of russel viper venom Bite to needle time is <4 hrs. Anaphylactic shock: ASV can lead to anaphylactic shock so Adrenaline is given.

15. Treatment: To prevent primary reaction to ASV : Adminster hydrocortisone, H1 blockers. Anaphylactic shock: Stridor, cyanosis, crashing of blood pressure. IM Adrenaline is the 1 st line tx of anaphylactic shock but IM is avoided in case of ASV because there can be muscle hematoma in case of viper bite and hypotension can reduced absorption. Therefore IV Adrenaline (1:1000) is given in case of anaphylaxis d/t ASV.

16. Recovery Phase After adequate dose of ASV the systemic bleeding such as gum bleeding stopped in 30 mins Blood coagulability restored in 6 hrs. [20 min WBCT] Active hemolysis ceased and Urine returned to its normal color. Pt BP increased in 30 mins.

17. THANK YOU!!