Case presentation

snake bites

Grampians EMET training Hub

Case 1 - VICTORIA
56 year old male
Arrived at 1140 What could be done
- bitten by snake on right
hand differently here?
- whilst trying to scare it
away from his children
- in afternoon at nearby
picnic ground
- He had consumed alcohol
- snake killed by friends and
brought in
States feels weird and
nauseated

No bandage applied initially

Past History
Angina => angioplasty Any specific features on
5 yrs ago, nil since history that you should
ask about?
Drugs
Simvastatin, Aspirin

Allergies
Morphine
Examination

Anxious, mildly confused, Any specific features that

breathalyser 0.32 should be documented?

Bite to 1st web space right

hand
puncture wounds dorsum

Observations stable

Otherwise NAD
Management- Initial
Swab taken from bite What further action is
site, then compression appropriate now?
bandage applied

IV line

Blood for FBE, U+E,

CK, Coagulation profile

ADT given
30 minutes later
Venom detection kit positive 20 minutes later
for tiger and black snake A staff member has called the
Patient feels better, alert, local wildlife park
orientated, Snake seen by herpetologist,
identified as copperhead
neuro exam normal
APTT 33, INR 0.9
FBE, U+E, CK normal
Bandage removed
What do we learn from this
case?
Pre hospital issues
include public
education, and first aid
In Victoria, Australia
The only antivenom
required is tiger and
brown snake
Exceptions include
snake handlers, the
wildlife park/zoos, and
people with other
snakes as pets
25 minutes after the snake
identification
Patient disorientated, slurred speech c/o
weak arms and legs, and blurred vision
Slight ptosis
What action is needed?
Do you put the bandage back on?
Do give antivenom?
If yes, which antivenom?
Who can you ask for help?
Further management
One vial tiger snake Putting the bandage back on
antivenom given in
Hartmans solution over
30 minutes
IV hydrocortisone given
Adrenalin and
phenergan drawn up
while getting the antivenom
ready is a good idea
But then the antivenom must
come in contact with the
venom, so after infusion
commenced and patient is
stable, take off bandage
Tiger antivenom is given for
black or tiger snake
HELP - seek senior help, and
POISONS centre 131126 is
available PRN
40 minutes later (10 mins post
infusion complete)
Patient feels a bit Following morning
better, with clinical Feels well, no
evidence of
improvement neurological
signs/symptoms, no
No respiratory
compromise bleeding
Admitted and Repeated blood tests
transferred to ICU all normal
overnight Discharged
for observation
Case 2 - WESTERN AUST.
38 year old male
Snake bite to middle finger In transit, the patient
of left hand complained of feeling unwell
Whilst trying to catch snake with chest tightness and
in house rapidly became unresponsive.
Placed a single layer Decision to seek medical
compression bandage on attention at Urban Hospital
his own arm from fingers to en route (still 30 minutes
elbow approx from tertiary referral
Drove to his GP in 10 hospital)
minutes
No symptoms or signs of
envenomation
Decision to transfer to
Tertiary referral Hospital by
ambulance (60 minutes)
Initial Management 02.15
hours following the bite
Unresponsive with no
cardiac output
ECG: pulseless electrical
activity, narrow complexes
Antivenom IV bolus;
1 ampoule polyvalent
2 ampoules brown snake
2 ampoules tiger snake

CPR commenced
Intubation
1mg adrenalin
1000ml normal saline

Subsequent course
Spontaneous circulation
resumed within 1 minute of this
antivenom, total 11 minutes
CPR
Platelets 33, INR >10, APTT
>180, Fibrinogen < 0.3, FDP >
20
Discussed with on-call
toxicologist
Further antivenom:
1 ampoule polyvalent
3 ampoules brown snake
Creatinine 108, ALT 113, CK
143, Troponin I < 0.4,
Stabilised and transferred to
tertiary centre, developed
bleeding lips and gums en
route
 3 hours following the bite
Pulse 105, BP 135/60,
pupils 4mm equal and
reactive
Bleeding gingivae and
venepuncture sites,
petechiae around eyes,
haematuria
ECG: sinus tachycardia,
RBBB, mild ST-segment
depression
Venom detection kit from
bite site positive for brown
snake
Compression bandage
reinforced and extended
to include the whole limb
Subsequent course
10 ampoules brown snake No further oozing noted and
antivenom given in 100 ml compression bandage
0.9% saline over 15 minutes removed

Platelets 111, INR > 10, APTT Patients condition remained

> 180, Fibrinogen < 0.3, FDP stable
>20

Creatinine108, ALT 201, CK

164, Troponin I < 0.4

CT head normal
 5 hours following the bite 9.30 hours following bite
Transferred to ICU, where remained
stable Platelets 161, INR > 10, APTT > 180,
Platelets 214, INR >10, APTT > 180, Fibrinogen <0.3, FDP > 20,
Fibrinogen < O.3, FDP > 20 Creatinine 127, ALT 243, CK 366,
Creatinine 133, ALT 277, CK 259, Troponin I 10.8
Troponin I 2.8
Further 5 ampoules brown snake
antivenom infused
15 hours following bite
Platelets 148, INR 1.8, APTT 44.7, Fibrinogen 0.5, FDP > 20,
Creatinine 134, ALT 223, CK 462, Troponin I 6.8

Extubated, neurologically normal.

Commenced on 5 days oral prednisolone 50 mg

1 month later
Follow up, well

Flu like illness with rash and sore joints

between days 17 and 21 after envenomation
Learn from this case?
A correctly applied Expert advice is
pressure immobilisation needed
bandage should allow In WA, there is a
stable transfer of different profile of
patients long distances snake bites
E.g Flying doctor The recommendations
for antivenom have
service changed since this
case, and will continue
to change, hence seek
advice
Scenario 3
A 23 yr old man present to your emergency
department complaining of dizziness, blurred
vision, nausea and vomiting. He was well
until about 1 hour ago. Today he has been
chopping wood and re organising the wood
heap, he sustained a scratch to his R thumb,
but did not see what did it.
What is your assessment & management?
Assessment/examination
cubicle
ABC
consider risk of snake bite
swab wound for VDK
pressure/immobilization
full hx & ex
bloods fbe, uec, clotting, glucose
Investigation
VDK + for brown snake
FBE 12.3, 12(10), 120
UEC NAD
Clot INR 4 APTT 65 Fibrinogen 0.5
what now?
Management
Resus
prepare antivenom & give
1unit now recommended starting dose
dilute as described
consider premedication
when do you remove the Pressure immobilisation
neuro obs
what next
continued
recheck coags There are recent updates in
do you correct the coags? recommendations re
Where to? treatment of coagulopathy
http://www.australianprescri
ber.com/magazine/35/5/152
/5
Replaces 2006 article
http://www.australianprescri
ber.com/magazine/29/5/125
/9/