Snake bite/scorpion sting/Animal bite...Dr. Sajid Mumtaz Sodhar

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Snake Bite/Scorpion o Bee Sting/Animal Bite/Marine Bite:

Snake Bite/Scorpion o Bee Sting/Animal Bite/Marine Bite Dr. Sajid Mumtaz Sodhar “It is not lawful for a Muslim to sell such a commodity that has a defect, except that the defect is shown to the buyer.”

Snakebites:

Snakebites Poisonous snakes in the U.S/World Wide Rattlesnake Copperhead Water moccasin Coral snake

Snake Bites: What To Do (At the site):

Snake Bites: What To Do (At the site) Get away from snake/may re-strike Have victim lie down and stay calm Keep bitten area immobile and below the level of the heart

First aid in Snake Bite :

First aid in Snake Bite To retard the systemic absorption of venom and prevent life-threatening complications by prompt transport to a medical facility. First aid can be performed by victim himself/herself or by any person who happens to be nearby.

First aid in Snake Bite Not To Do:

First aid in Snake Bite Not To Do None of the traditional remedies have any proven medical benefit. Making local incisions or “tattooing ” at the site of the bite, attempts at suctioning venom out of the wound, use of tight bands (tourniquets) around the limb, and/or local application of ice packs. Should be discouraged as they do more harm than good and delay transport to a medical facility. Incision, suction, electric shocks, cryotherapy, or washing the wound are contraindicated (introduces infection, increases bleeding from the site, and hastens absorption of the venom).

The current guidelines for first aid include the following::

The current guidelines for first aid include the following: Reassure the victim (70% of all snakebites are by nonvenomous snakes and 50% of bites by venomous species are dry bites). Immobilize the affected limb (by bandage or clothes to hold splint, but tight arterial compression is not recommended ) Promptly transfer of victim to hospital.

Non-Poisonous Bites:

Non-Poisonous Bites Horseshoe shaped tooth marks May be painful but no systemic reactions What To Do? Minor wound treatment If in doubt, go to hospital or call Dr.

Snake Bites: What To Do:

Snake Bites: What To Do Seek medical attention immediately Anti-venom available only at hospitals Same anti-venom used no matter type of snake Must be given within 4 hours of the bite.

Hospital treatment of Snake Bite :

Hospital treatment of Snake Bite Emergency care department Assessement of the airway, breathing, circulatory status, and consciousness. Urgent resuscitation will be needed in those in shock (cardiovascular toxicity), those with respiratory failure (neurotoxin), and in those who have had cardiac arrest (due to hypoxia, cardiac toxicity, or hyperkalemia from rhabdomyolysis).

Emergency care department:

Emergency care department 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. Administered specific treatment after a precise history has been taken and thorough physical examination done.

Emergency care department:

Emergency care department History Determine whether a venomous snake has actually bitten the patient and, if so, the severity of the bite . It is essential to establish that the victim has been bitten by a snake and not by some other animal; this can be cross-checked by looking for fang marks and signs of local envenomation. Brief medical history should be obtained (e.g., date of last tetanus immunization, use of any medication, presence of any systemic disease.)

Assessment of severity of envenomation:

Assessment of severity of envenomation No envenomation Absence of local or systemic reactions; fang marks (+/−) Mild envenomation Fang marks (+), moderate pain, minimal local edema (0–15 cm), erythema (+), ecchymosis (+/−), no systemic reactions Moderate envenomation Fang marks (+), severe pain, moderate local edema (15–30 cm), erythema and ecchymosis (+), systemic weakness, sweating, syncope, nausea, vomiting, anemia, or thrombocytopenia Severe envenomation Fang marks (+), severe pain, severe local edema (>30 cm), erythema and ecchymosis (+), hypotension, paresthesia, coma, pulmonary edema, respiratory failure

Emergency care department Physical examination (if pt: is observe in ER or inside the ward:

Emergency care department Physical examination (if pt: is observe in ER or inside the ward During the initial evaluation , the bite site should be examined for signs of local envenomation (edema, petechiae, bullae, oozing from the wound, etc ) and for the extent of swelling. 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. The 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 antivenom. Lymph nodes draining the limb should be palpated and the presence of lymphangitic lines noted

Physical examination (if pt: is observe in ER or inside the ward:

Physical examination (if pt: is observe in ER or inside the ward Distal pulses should be checked and monitored if there is presence of gross swelling. The presence of a pulse does not rule out compartment syndrome The diagnosis is established if the compartment pressure, measured directly by inserting a 22G IV cannula and connecting it with manometer, is raised above 55 cm water/saline . Fasciotomy done without correction of hemostatic abnormality may cause the patient to bleed to death.

Clues for severe snake envenomation should be sought :

Clues for severe snake envenomation should be sought Snake identified is a very venomous one . Rapid early extension of local swelling from the site of the bite Early tender enlargement of local lymph nodes, indicating spread of venom in the lymphatic system Early systemic symptoms Early spontaneous systemic bleeding (especially bleeding from the gums) Passage of dark brown urine.

LABORATORY INVESTIGATIONS :

LABORATORY INVESTIGATIONS Although lab tests are of little value in the diagnosis of snake envenomation, they are useful for prognosticating and for making decisions about specific interventions.

Specific investigations :

Specific investigations (a) The 20-min whole blood clotting test (20 WBCT): The 20 WBCT is a simple bedside test of coagulopathy to diagnose viper envenomation and rule out elapid bite. It requires a new clean, dry test tube made up of simple glass that has not been washed with any detergent. A few milliliters of fresh venous blood is drawn and left undisturbed in the test tube for 20 min; the tube is then tilted gently. If the blood is still liquid after 20 min, it is evidence of coagulopathy and confirms that the patient has been bitten by a viper. Cobras or kraits do not cause antihemostatic symptoms.

Specific investigations :

Specific investigations Enzyme linked immunosorbent assay (ELISA): ELISA tests are now available to identify the species involved, based on antigens in the venom. These are expensive and not freely available and thus have limited value in diagnosis. At present, they find use mainly in epidemiological studies.

PowerPoint Presentation:

FBC Biochemistry. Coagulation Profile. C X Ray Urinalysis/urine for myoglobins The first blood drawn from the patient should be typed and cross-matched, as the effects of both venom and antivenom can interfere with later cross-matching .

MANAGEMENT OF SNAKE BITE :

MANAGEMENT OF SNAKE BITE WHO/SEARO has published guidelines, specific for the South East Asia region , for the clinical management of snakebites

SPECIFIC THERAPY:

SPECIFIC THERAPY Anti–snake venom ASV are immunoglobulins prepared by immunizing horses with the venom of poisonous snakes and subsequently extracting and purifying the horses serum. They are the only effective antidote for snake venom. Antivenoms may be species specific (monovalent/monospecific ) or may be effective against several species (polyvalent/polyspecific). As per the recommendations of WHO, the most effective treatment for snakebite is the administration of monospecific ASV; however, this therapy is not always available to snakebite victims because of its high cost.

Indications for anti-snake venom :

Indications for anti-snake venom SystemClinical features Spontaneous systemic bleeding Whole blood clotting time >20 min Thrombocytopenia (platelets <100,000/mm3) Shock Arrhythmia Abnormal electrocardiogram Neurological; Ptosis and paralysis RenalAcute renal failure Generalized rhabdomyolysis and muscular pains Hyperkalemia Local swelling involving more than half of the bitten limb Rapid extension of swelling Development of an enlarged lymph node draining the bitten limb

ASV:

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

Antivenom therapy:

Antivenom therapy Antivenom should be ideally administered within 4 h of the bite, but is effective even if given within 24 h. The dosage required varies with the degree of envenomation.

Dose of ASV :

Dose of ASV Despite widespread use of antivenom, there have been virtually no clinical trials to determine the ideal dose. The dosage has remained a matter of much debate. The conventional dosing in our setup is based on the degree of envenomation

Dose of anti-snake venom:

Dose of anti-snake venom Degree of envenomationInitial dose Mild= 5 vials (50 ml) Moderate= 5–10 vials (50–100 ml) Severe= 10–20 vials (100–200 ml ) Additional infusions containing 5–10 vials (50–100 ml) are repeated until progression of swelling in the bitten part ceases and systemic signs and symptoms disappear.

PowerPoint Presentation:

Response to infusion of antivenom is marked by normalization of blood pressure . Within 15–30 min bleeding stops, though coagulation disturbances may take up to 6 h to normalize. Neurotoxicity begins to improve within the first 30 min , but patients may require 24–48 h for full recovery. A repeat dose of ASV should be given when there is persistence of blood incoagulability even after 6 h or continued bleeding after 1–2 h of the initial dose. ASV should also be repeated when there are worsening neurotoxic or cardiovascular signs even after 1–2 h

ASV administration:

ASV administration ASV can be administered either by slow intravenous injection at a rate of 2 ml/min or by intravenous infusion (antivenom diluted in 5–10 ml per kilogram body weight of normal saline or D5 W and infused over 1 h). Slow intravenous injection has the advantage when there is a risk of some early reaction to the ASV . Strictly observed for an hour for development of any anaphylactic reaction. Epinephrine should always be kept ready before administration of antivenom.

PowerPoint Presentation:

ASV should never be given locally at the site of the snakebite since it has not been shown to be effective and, moreover, this route of administration is associated with significant risks. For example, it is extremely painful and may increase intracompartmental pressure. Intramuscular injections are also not preferred since ASV is composed of large molecules (IgG or fragments) which are absorbed slowly via lymphatics, making the bioavailability by this route poor as compared to intravenous administration. Other disadvantages include pain on injection and risk of hematoma formation and sciatic nerve damage in patients with hemostatic abnormalities. Intramuscular injections should only be given in settings where intravenous access cannot be obtained and/or the victim cannot be transported to a hospital immediately.

ASV sensitivity testing:

ASV sensitivity testing ASV sensitivity testing is no longer recommended as a lack of response does not predict the large majority of early (anaphylactic) or late (serum sickness type) reactions.

ASV reaction:

ASV reaction Approximately 20% patients treated with ASV develop either early or late reaction . Early anaphylactic reactions occurs within 10–180 min of start of therapy and is characterized by itching, urticaria, dry cough, nausea and vomiting, abdominal colic, diarrhea, tachycardia, and fever. Some patients may develop severe life-threatening anaphylaxis characterized by hypotension, bronchospasm, and angioedema. Pyrogenic reactions usually develop 1–2 h after treatment. Symptoms include chills and rigors, fever, and hypotension. These reactions are caused by contamination of the ASV with pyrogens during the manufacturing process. Late (serum sickness–type) reactions develop 1–12 (mean 7) days after treatment. Clinical features include fever, nausea, vomiting, diarrhea, itching, recurrent urticaria, arthralgia, myalgia, lymphadenopathy, immune complex nephritis and, rarely, encephalopathy.

Treatment of ASV reaction:

Treatment of ASV reaction Temporarily stopped and adrenaline (1 in 1000) given intramuscularly in an initial dose of 0.5 mg in adults or 0.01 mg/kg body weight in children. The dose can be repeated every 5–10 min if necessary. After adrenaline, an anti-H1 antihistamine such as chlorpheniramine maleate (adult dose 10 mg, children 0.2 mg/kg) should be given intravenously. It may be followed by intravenous hydrocortisone (adult dose 100 mg, children 2 mg/kg). Late (serum sickness–type) reactions usually respond to a 5-day course of oral antihistamine (e.g., chlorpheniramine 2 mg six hourly in adults and 0.25 mg/kg/day in divided doses in children). Patients who fail to respond within 24–48 h should be given a 5-day course of prednisolone (5 mg six hourly in adults and 0.7 mg/kg/day in divided doses in children).

PowerPoint Presentation:

Neurotoxic Snake bite ASV treatment alone cannot be relied upon to save the life of a patient with bulbar and respiratory paralysis . Once there is loss of the gag reflex, failure to cough, or respiratory distress. Endotracheal intubation and initiation of mechanical ventilation is indicated.

Snake Bite Prevention :

Snake Bite Prevention Use caution around wood piles, rock crevices etc. Watch where you step Do not reach into holes or hidden ledges Wear boots, long pants, long sleeved shirts Don’t sit or step over logs without checking it out Use a walking stick When camping, keep tent zipped at all times.

Scorpion Sting:

Scorpion Sting Across the globe there are over 1400 different species, 75 of which are in the US Scorpions can range in size from ½ to 7 ¼ inches They can live from 3 to 25 years.

Scorpion Sting:

Scorpion Sting Scorpions use a neurotoxin venom that is carried in the stinger located on their long tail. The sting can cause inflammation and swelling around the bite In the United States scorpions are venomous but not to a deadly level. Anti-venoms are available

Clinical manifestations of Scorpion Sting:

Clinical manifestations of Scorpion Sting Stimulation of ANS Local signs – painful, tingling, burning or numbing sensation at the sting site , edema, sweating and muscular fasciculations Transient parasympathetic overactivity manifests as vomiting , salivation and bradycardia

PowerPoint Presentation:

Phase of sustained sympathetic stimulation results in Hypertension Tachycardia Nnon-sustained VT Cold extremities Pulmonary edema Shock Premonitory signs of systemic envenomation includes vomiting, sweating, hypotension and cool extremities

Grading of systemic features of Scorpion Sting:

Grading of systemic features of Scorpion Sting Grade 1: Severe excruciating local pain at the site of sting which radiates along with corresponding dermatomes Grade 2: Local signs associated with profuse sweating, salivation, hyper or hypo tension, cold extremities, VPC and bradycardia Grade 3: Pulmonary edema with hypertension or hypotension and cold extremities Grade 4: Warm extremities, tachycardia, hypotension, pulmonary edema, air hunger and shock Grade 5: Death

Management Of Scorpion Sting:

Management Of Scorpion Sting Reassurance to the victim reduces the anxiety. Wash the sting with soap and water and remove all jewelry because swelling of tissue may impede the circulation if it not allowed to expand (for example, a sting on a finger that has a ring surrounding it). Apply cool compresses, usually 10 minutes on and ten minutes off of the site of the sting. Profound loss of fluids due to sweating, salivation and vomiting should be replaced with crystalloids Local pain treated with NSAIDS (preferrable paracetamol( and Diazepam . Do not cut into the wound or apply suction

Management Of Scorpion Sting:

Management Of Scorpion Sting Antivenom therapy has been approved for use against the bark scorpion sting in 2011 by the FDA. Specific antidote to circulating venom It is species specific and given diluted in NS over 30 mts Presence of parasympathetic features indicates early activity of venom and its presence in circulation At this stage, antivenin is effective and should be given along with prazosin.

Prazosin:

Prazosin Post synaptic alpha1 blocker Ideally suited to counteract the sympathetic over activity seen in scorpion sting Prazosin reduces preload and LV impedance without altering heart rate

PowerPoint Presentation:

Prazosin inhibits the PDE enzyme resulting in accumulation of cGMP, leading to enhanced insulin secretion Recommended dose Children - 500 µ gms Adults – 1000 µ gms Can be repeated every 3 hrs till extremities are cold and then 6 th hourly

PowerPoint Presentation:

Peak concentration of prazosin reached in 1 - 3 hrs with a plasma half life of 2 – 3 hrs Advent of prazosin has reduced fatality due to scorpion sting from 29% to < 1% Massive pulmonary edema treated with SNP 3 – 5 micrograms /kg/minute infusion for up to 48 hrs

Lytic cocktail:

Lytic cocktail Traditional therapy for scorpion sting Consists of Pethidine 100 mg Chlorpromazine 50 mg Promethazine 50 mg in 50 ml of 5% glucose Beneficial due to alpha blocking action of chlorpromazine

Supportive measures:

Supportive measures Correct acid base abnormalities Oxygen and respiratory support as needed Correct fluid loss Vasopressor support if needed

Complications in Scorpion sting:

Complications in Scorpion sting Dilated cardiomyopathy Ankylosis of small joints Rhabdomyolysis Antivenom anaphylaxis Pulmonary edema Respiratory failure

Dog Bites:

Dog Bites If approached: Stop/ Stand still Talk softly Move slowly Never turn your back on a dog Use: stick, mace, pepper spray Concern for rabies

Rabies: Be Concerned If Skin Is Penetrated By::

Rabies: Be Concerned If Skin Is Penetrated By: Unprovoked animal (squirrel) Strange acting dog or other animal Animal of high risk species Raccoons Bats Foxes Skunks

Bites and Rabies:

Bites and Rabies An acute virus disease of the nervous system of warm-blooded animals, usually transmitted through the bite of a rabid animal. Results in hydrophobia: throat muscles go into spasm if they try to drink and they choke. No cure once symptoms develop

Rabies: What To Do:

Rabies: What To Do If bitten by a wild animal - suspect rabies Clean wound with soap and water (under pressure) Seek medical attention Tetanus shot may be required Start rabies treatment immediately (5 arm injections over one month)

Rabies: What To Do With The Animal:

Rabies: What To Do With The Animal Kill animal and transport entire body to a vet Wear gloves to avoid infected saliva Vet will decapitate and submit the head for rabies testing

Spider Bites:

Spider Bites Tarantula Black Widow Brown Recluse

Black Widow Bites:

Black Widow Bites Bite: Pin-prick or no “bite” sensation Immediate pain, swelling, redness Headache, chills, fever, heavy sweating, dizziness, nausea, vomiting, severe abdominal pain Faint red bite marks appear Severe muscle pain, cramps, and stiffness Severe pain peaks in 2-3 hours but can last up to 48 hours

Spider Bites: What To Do:

Spider Bites: What To Do Save spider for identification Keep bite area below the heart Clean bite site Ice Monitor ABC,s Seek medical attention immediately.

Insect Stings:

Insect Stings Worrisome Reactions: Normally, the sooner the symptoms develop, the more serious Flushed skin /blue skin Hives Swelling of lips, tongue, throat Wheezing, “tickle in throat” Abdominal cramps, diarrhea Trouble breathing Seizures

Bee Sting:

Bee Sting Bee stings are either annoyingly painful or deadly depending on if the victim is allergic to the venom. Best way to reduce any anaphylactic reaction to bee venom is to remove the bee stinger as rapidly as possible

Stings: First Aid:

Stings: First Aid Remove stinger by scraping with a credit card or like item (back out the stinger) Stinger injects poison for 2-3 minutes up to 20 minutes after sting Stung in the throat? Suck on ice or flush with cold water, hold baking soda water in the mouth

Stings: First Aid #2:

Stings: First Aid #2 Cleanse site Use extractor if available Apply ice (slows absorption, relieves pain) Baking soda paste Vinegar or lemon juice suggested for wasp sting . Apply calamine lotion to help relieve itching and pain. Aspirin, Tylenol, hydrocortisone cream Benedryl (or other antihistamine) if given early may prove helpful

Stings: First Aid #3:

Stings: First Aid # 3 Observe for 30 minutes Keep anaphylaxis in mind Epinephrine Re-inject after 15 minutes if necessary Watch for delayed allergic reaction (possibly the next day)

PowerPoint Presentation:

Jasakallah for ur attention Let’s go back to work! “If anyone keeps goods till the price rises, he is a sinner.”

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