Snake Bite Indian Concern: Snake Bite Indian Concern Dr. Vijaysinh Bhatlawande MD Dr. Apurva Agarwal MD Banded Krait: Banded Krait Russell's Viper: Russell's Viper Python (Ajgar): Python (Ajgar) King Cobra: King Cobra Cobra: Cobra Introduction: Introduction Snake venom varies in potency and action, but several syndromes can be distinguished following envenomation: (A)Neurotoxicity (B)Systemic toxicity including hypotension and shock (C)Coagulopathy (D)Rhabdomyolysis (E)Renal failure (F)Local tissue necrosis Principle of management: Principle of management The principles of management of snake bites are summarized includes: (A)Field management, (B)Hospital assessment, (C)Hospital management. Field management: Field management General Principle: (a)The patient should be removed from the snake's territory , kept warm and at rest, and be reassured. (b)The injured part of the body should be immobilized in a functional position below the level of the heart. (c)The wound should be cleansed, except in areas in which a venom detection kit is used (such as Australia). ( d)Withhold alcohol and drugs that may confound clinical assessment. ( e)Attempt to identify the snake, without endangering the patient or rescuer. A digital photo taken at a safe distance may be useful. Snake parts should not be handled directly. ( f)Transport the patient to the nearest medical facility as quickly as possible. Field management: Field management Pressure imobilization : The pressure immobilization technique is generally recommended following envenomation by snakes with neurotoxic venom , including Australian elapids. It is usually not advised following bites from snakes with locally necrotic venom , such as cobras and vipers. Field management: Field management Methods not recommended : (A)Incision and oral suction, (B)mechanical suction devices, (C)cryotherapy, (D)surgery, and electric shock therapy (E)Tourniquet compression have been widely used but are no longer recommended. Hospital assessment: Hospital assessment 1.Evaluation of the bite 2.The first clinical indications of systemic envenomation are often nonspecific symptoms such as nausea, vomiting, abdominal pain, and headache . 3. Neurotoxicity : ptosis, diplopia, and bulbar palsy with onset between 1 to 10 hours following envenomation. Hospital assessment: Hospital assessment Coagulopathy: (1)WBCT>20min (2)INR>3.0,aPTT>50sec., plt<50,000/ul, fibrinogen<75mg/dl Hypotension and shock Rhabdomyolysis: (1)muscle pain, weakness, and dark urine is suggestive (2)Urine dipstick tests for the presence of blood detect both myoglobin and hemoglobin (as well as hematuria) and positive results Hospital assessment: Hospital assessment Renal failure: (1) Cause: hypotension, rhabdomyolysis and/or disseminated intravascular coagulation (DIC) ( 2)Risk factor: age less than 12 years , a delay in antivenom therapy of >2 hours a creatinine kinase at admission >2000 U/L (3) diuresis at admission >90 mL/hr Hospital management:: Hospital management: Antivenom: Antivenoms are generally indicated: (1)There is evidence of systemic envenomation (neurotoxicity, coagulopathy, rhabdomyolysis, persistent hypotension, and/or renal failure). (2)There is severe local envenomation, manifested by local tissue destruction . Although delays in administration result in lowered effectiveness, anecdotal evidence suggests that some improvement is possible even days after envenomation with some snakes Hospital management:: Hospital management: Antivenom: Adverse reactions : (1)Early allergic reactions (2)Pyrogenic reactions (3)Late allergic reactions (serum sickness) Hospital management:: Hospital management: Premedication with epinephrine is appropriate in the following settings : (1)Use of antivenom is associated with high rates of allergic reactions. (2)There is an appreciable risk of allergic reaction associated with antivenom use and the management of acute allergic reactions is problematic because of limited staffing or facilities. (3)If premedication is not given, epinephrine (0.5 to 1 mL of an 0.1 percent [1:1000] solution) should be prepared prior to the administration of any antivenom in the event that it is needed. Hospital management: Hospital management Prophylactic antihistamines alone were not beneficial in the Brazilian study Corticosteroids are often used with early and late allergic reactions The routine use of antibiotics is controversial and depends in part upon the local rates of infection. Intubation and ventilation is required for airway protection or respiratory support if bulbar palsy, increasing dyspnea, or respiratory failure are present. Hospital management: Hospital management Coagulation: (1)Persisting bleeding should prompt the administration of additional antivenom . (2) Clotting factor replacement with whole blood or fresh frozen plasma is only indicated in cases of life-threatening hemorrhage after the use of antivenom. Rhambdomyolysis: ( 1)Initial fluid resusciation : Plasma volume expansion with intravenous isotonic saline ( 2)Following fluid resusciation : alkaline-mannitol diuresis to a goal urine pH of 6.5. Thanks for your attention! : Thanks for your attention!