snake bite signs, symptoms and management management .pptx

Snake bite signs and symptoms and management

1. SNAKE BITE

2. POISONOUS SNA K ES FOUND IN PAKISTAN COBRA KRAIT Neurotoxic snakes Pre - synaptic enzymes Post - synaptic enzymes

3. POISONOUS SNA K ES FOUND IN PAKISTAN SAW - scaled viper Russel ’ S viper Hemotoxic snakes Pro-coagulant enzymes Hemorrhagins Hemolytic & Myolytic enzymes

4. Local signs and symptoms Fang Marks Local Bleeding Bruising Lymph Node Enlargement Inflammation (Swelling, Redness, Heat) Blistering Local Infection Necrosis SIGNS AND SYM PTO MS

5. SIGNS AND SYMPTOMS Non-venomous bite - DRY BITE- Panic attack, vasovagal shock, agitation Generalized - Nausea, vomiting, malaise, abdominal pain, weakness, prostration Cardiovascular - Hypotension, shock, arrythmias, bleeding from wounds, epistaxis, hematuria, gum bleeding Neurological - Drowsiness, ptosis, ophthalmoplegia, paralysis of facial muscles, difficulty swallowing, aphonia Renal - Uremic syndrome, dark brown urine

6. SIGNS AND SYMPTOMS - Bilateral ptosis & ophthalmoplegia - Facial paralysis Gum bleeding Sub - conjunctival hemorrhage

7. MANAGEMENT STEPS First aid treatment Rapid clinical assessment and resuscitation Investigations Antivenom treatment Observation of the response to antivenom: decision about the need for further dose(s) of antivenom. Additional treatment. Treatment of the bitten part

8. FIRST AID TREATMENT Reassurance to the victim who may be very anxious Immobilization of the bitten limb with a splint or sling. Pressure immobilization, not recommended if there is local necrosis. Avoid traditional methods as this may introduce infection, increase absorption of the venom and increase local bleeding.

9. Pressure Immobilization T echnique - Not recommended if there is local necrosis. - The bandage s hould not be released until the administration of ASV.

10. RAPID CLINICAL ASSESSMENT AND RESUSCITATION IN A&E Clinical Presentation Depends upon the time since bite. Assess Airway , Breathing , Circulation , Disability , Exposure (ABCDE). P atient might require securing of airway , assisted ventilation and IV fluids accordingly. Rapid examination for hemotoxic and neurotoxic signs such as gum bleeding, epistaxis, ptosis, ophthalmoplegia, difficulty swallowing, neck holding test.

11. ANTI - VENOM TRE A TMENT Anti Snake Venom (ASV) - Antivenom is an I g G immunoglobulin, purified from the serum of a horse or sheep that has been immunized with the venoms of one or more species of snake. - It neutralizes only the free unbound venom in the body of victim. Liquid ASV Lyophilized ASV NIH Isb Imported Ready-form Reconstituted Cold chain req No cold chain req Dosage is same. Mode of administration is same; IV inf over 1 hr or slow IV injection. ASV available in Pakistan

12. ASV ADMINISTRATION Avoidance of inappropriate use . As per JPMA, the criteria for ASV administration are ; 1. Incoagulable blood determined by the 20WBCT 2. Visible neurological signs such as ptosis , ophthalmoplegia or other evidence of a scending paralysis. e.g. Neck holding inability 3. Clear evidence of spontaneous systemic bleeding e.g. hemoptysis, hematuria, gum bleeding Pre medications: IV hydrocortisone plus anti histamine, S/C 0.25 mg epinephrine (optional) Dosage: 8 -10 vials over 1 hr IV infusion after dilution in 250-500 ml of NS or 5% dextrose. Or slow IV injection ASV test dose must NOT be given

13. ASV ADMINISTRATION Adverse Reactions to ASV: a. Monitor continuously in initial 20 min for urticaria on trunk where first sign often occur. b. At the first sign of any reaction e.g. itching and urticaria, the ASV should be temporarily suspended c. Administer Epinephrine 0.5mg IM , hydrocortisone and anti histamine IV. d. If symptoms are not improving by 12-15 min, a second dose of Epinephrin e i s given. e . Resume ASV as soon as the reaction is managed.

14. ASV ADMINISTRATION Failure to respond to antivenom Repeat doses of ASV Hemotoxic Envenomation : Carry out 20WBCT after 6 hrs of completion of ASV. If blood is still incoagulable then another dose of ASV is given and 20WBCT is performed again after a further 6 hrs lapse . This cycle is repeated until coagulation is restored . Neurotoxic envenomation: Patient is assessed after 1-2 hr, if paralysis has descended further or has not improved then a second dose of ASV is given . Once 2 nd dose is given, no further dose is recommended , patient now either recovers or requires mechanical ventilation.

15. ADDITIONAL TREATMENT Neurotoxic envenomation: a . Antivenom treatment alone cannot be relied upon to save the life of a patient . Death may result even after ASV administration. So close observation is critical and secure airway if required. b . Edrophonium test 1. Note Baseline observations of Ptosis and single breath count. 2. Give atropine IV, followed by edrophonium IV. 3. Observe for any improvement over next 10-20 min. 4. If symptoms improve, give atropine and Neostigmine 0.5 mg IM every 30 min. 5. This test can also be done with n eostigmine but observe up to 1 hr for any improvement.

16. EDROPHONIUM TEST

17. ADDITIONAL TREATMENT Hemotoxic Envenomation Use of Blood Products: Bleeding and clotting disturbances usually respond satisfactorily to treatment wi th ASV. In exceptional circumstances such as severe bleeding , FFPs or platelets can be administered only after ASV has been given. Renal failure: C onservative management or Hemodialysis depending upon severity of renal failure. Treatment of bitten part : Debridement, Fasciotomy. Empiric antibiotics is NOT recommended.

18. REFE R RAL CRITERIA TO TERTIARY CARE HOSP Occult systemic bleeding and renal failure Patient should be transferred in 6 hrs window after administration of ASV . Neurotoxic cases requiring long term mechanical ventilation Patient should be transferred along with an Ambo bag and NPA inserted in both nostrils . Surgical cases requiring debridement of necrotic tissue.

19. THE IDEAL SNAKE BITE KIT IN PAKISTAN CONTEXT Anti snake venom Test tube to carry out 20WBCT Neostigmine and atropine Adrenaline, hydrocortisone, antihistamine (for adverse effects) Ambo bag, NPA, LMA Paracetamol as pain medication If such a kit is made available in each hospital, especially in snake bite prevalent areas, mortality will be dramatically reduced.

20. QUESTIONS

21. QUESTION 1 What is the time period after which 20WBCT is repeated after giving ASV and WHY A) 12 hours B) 6 hours C) 8 hours D) 10 hours 6 hours Liver takes almost 4-6 hours to synthesize enough levels of clotting factors to restore coagulability.