SNAKE BITE

Shella Sucy Yanti 08310284 Pembimbing dr. H. Asep Hermana, Sp.B

POISONOUS SNAKES

Neurotoxic cobra,krait & coral Haemotoxic vipers

Myotoxic sea snake

POISONOUS

NON POISONOUS

Head scales : small Large and opening / pit b/w eye & nostril (pit viper) Teeth : 2 Loong fang

Large Short and solid

several small teeth

INDIAN COBRA Neurotoxic Fatal period 8 h

COMMON KRAIT Neurotoxic Fatal period : 18 h

INDIAN COBRA

KING COBRA

Banded Krait ( Bungarus Fasciatus )

Common Krait

DIAGNOSIS LOOK FOR FANG MARKS

IDENTIFY THE SNAKE FEATURES OF POISONOUS SNAKES

Usually dull coloured (Brown, Black, Grey) Stout body with abruptly compressed and tapering tail Broad belly scales extending entire width of belly Small scales on triangular head Presence of fangs

GRADES OF ENVENOMATION
GRADE Non-envenomated FEATURES Presence of fang marks without local / systemic reactions Local swelling & pain without systemic reaction Extensive local effects with minima systemic effects

Mild envenomation Moderate envenomation

GRADES OF ENVENOMATION
GRADE Severe envenomation FEATURES Extensive local effects & maximal systemic effects

BITES BY ELAPIDS
Generally cause minimal local effects Swelling, local pain & local necrosis ( cobra ) Descending paralysis, initially of muscles innervated by cranial nerves commencing with PTOSIS, DIPLOPIA, OPHTHALMOPLEGIA Numbness around lips & mouth, progressing to pooling of secretions, bulbar paralysis & resp.failure Paradoxical resp intercostal muscle paralysis Stomach pain ( Krait ) submucosal hage in stomach Krait bites present in early morning with paralysis can be mistaken for STROKE .

BITES BY VIPERIDAE
Severe local effects as early as within 15 min of bite Extensive swelling spreading quickly to involve whole limb. Asso with blistering , necrosis & regional tender lymphadenopathy. Hemostatic persistant ooze & bleeding from venepuncture sites, fang marks & later bleeding from gums, epistaxis, petechiae, purpura & ecchymoses Abdominal tenderness gi / retroperitoneal bleed Passage of reddish / dark brown urine / diminishing / nil urine output.

HYDROPHID BITES
Stiffness, ache, tenderness in muscles Later, rhabdomyolysis, myoglobinuria resulting in acute renal failure .

FIRST AID- DO IT R.I.G.H.T

R Reassure the patient . 70 % snake bites nonvenomous

species. Only 50 % of bites by venomous species actually

envenomate the pt.

I Immobilise in the same way as # limb. Use bandages /

cloth to hold splints, not to block blood supply / apply

pressure. Do not apply any compression in the form of tight ligatures

GH Get to the hospital immediately

T- Tell the doctor of any systemic symptoms that manifest on way to the hosp

TRADITIONAL METHODS TO BE DISCARDED

Tourniquets traditionally used to stop venom flow. ( increased risk of ischemia , loss of limb, necrosis, massive neurotoxic blockade when tourniquet is released, embolism viper , false sense of security ) Incision & Suction increases risk of severe bleeding as clotting mech is ineffective & infection . No venom is removed by this method Washing the wound it increases the flow of venom into system by stimulating the lymphatic system.

TREATMENT PROTOCOL
Attend to AIRWAY , BREATHING, CIRCULATION Tetanus toxoid Routine antibiotic is not necessary Identify the snake responsible All patients should be kept under observation for a min period of 24 hrs. Determine the exact time of bite

INVESTIGATIONS

Complete Blood Count Anemia, Leucocytosis, Thrombocytopenia, HCT Evidence of Hemolysis Fragmented RBCs Prolonged Clotting Time Ampoule method Prolonged APTT Serum Electrolytes Hyperkalemia Raised Urea, Creatinine

INVESTIGATIONS

Urine for RBC Viper Bite Hematuria, Proteinuria, Hemoglobinuria, Myoglobinuria ECG Normal, Bradycardia with ST elevation or depression, T inversion, QT prolongation Chest X- ray Normal, Pulmonary Oedema, Intrapulmonary Hemorhages, Pleural Effusion

MONITOR VITAL SIGNS

Observe every patient for minimum 24 hours Pulse, BP, Respiration Urine output Blood urea, Creatinine

Bleeding tendency
Local swelling Vomiting Diplopia, Ptosis, Muscle Weakness, Breathlessness

ANTI SNAKE VENOM

ASV is prepared by hyperimmunising horses against venoms of snake It neutralises the free, unbound venom & to some extent also dissociates the bound toxin ASV is manufactured in India by the Haffkine Central Research Institute, Kasauli & Serum Institute of India, Pune & both are POLYVALENT. Sugg ASV dose = 100 -250 ml

SUPPORTIVE THERAPY

RESPIRATORY FAILURE : ABC Intubate & Ventilate Neostigmine & Atropine HYPOTENSION : Plasma expanders Dopamine 2.5 5 micrograms/Kg/min

SUPPORTIVE THERAPY

PERSISTANT / SEVERE BLEEDING : Majority timely use of ASV will stop sys.bleed ASV + Blood Transfusion RENAL FAILURE Hemodialysis / peritoneal dialysis COMPARTMENT SYNDROME : Fasciotomy SURGICAL DEBRIDEMENT OF WOUND

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