Snake Bite

SNAKE ENVENOMATION

SNAKESSSSS…

WHEN A VICTIM ARRIVES FIRST AID REASSURANCE IMMOBILISATION APPLY TORNIQUET MINIMAL WOUND HANDLING SALINE CLEANING, STERILE DRESSING ? INCISION

? SUCTION

? LOCAL ANTIVENOM

ASSESS VITAL SIGNS START AN IV LINE MONITOR – CARDIAC RHYTHM, BP, [O2] SEND BASELINE INVESTIGATIONS

CONFIRMING THE DIAGNOSIS IS IT A SNAKE BITE ? LOOK FOR FANG MARKS COULD IT BE ANYTHING ELSE ? BITES OF OTHER INSECTS SCRATCHES / PENETRATION BY THORNS

CONFIRMING THE DIAGNOSIS IS IT A POISONOUS SNAKE ? WATCH FOR LOCAL / SYSTEMIC TOXICITY

WHICH SPECIES IS INVOLVED ?

SNAKE BITE - PROFILE 2500 - 3000 SPECIES WORLDWIDE 500 VENOMOUS SPECIES 52 POISONOUS SPECIES IN INDIA INCIDENCE > 5 MILLION PER YEAR DEATH IN TRANSIT, ? TRUE INCIDENCE

INDIAN SNAKES

ELAPIDAE - COMMON / KING COBRAS, - KRAIT

INDIAN SNAKES

VIPERIDAE - RUSSELS, SAW SCALED, PIT VIPERS

INDIAN SNAKES • HYDROPHIDAE - SEA SNAKES

SNAKE BITE - PREVALENCE IN INDIA 60 -65% - SAW- SCALED VIPER 20 -25% - RUSSELS VIPER 10 -15% - COBRAS / SEA SNAKES

POISONOUS VS NON-POISONOUS SNAKES

HAZARDOUS BITES ILLEGITIMATE BITES ACCIDENTAL LOWER LIMB BITES DEVELOPING COUNTRIES

SNAKE HANDLING UPPER LIMB BITES DEVELOPED COUNTRIES

SNAKE BITE PATHOPHYSIOLOGY CONSTITUENTS OF SNAKE VENOM ENZYMES NON - ENZYMATIC COMPOUNDS NON - TOXIC PROTEINS

SNAKE VENOM ENZYMES PHOSPHALIPASES HYDROLASES PHOSPHATASES PROTEASES, ESTRASES ACETYLOCHOLINESTERASES TRANSAMINASES HYALURONIDASES ATP ASE, NUCLEOSIDASES

SNAKE VENOM NON ENZYMATIC COMPOUNDS NEUROTOXINS MYOTOXINS CARDIOTOXINS HAEMORRHAGENS

SNAKE VENOM NON TOXIC PROTEINS CARBOHYDRATES METALS INFECTIVE ORGANISMS

VENOM ACTIONS DISRUPT CELLULAR FUNCTIONS BREAK DOWN OF ENDOTHELIUM INCREASE VASCULAR PERMEABILITY ACTIVATE COAGULATION SYSTEM DIRECT CYTOLYTIC ACTION BREAK TISSUE BARRIERS PRODUCE ORGAN DAMAGE

FATAL DOSE SPECIES

VENOM PER BITE

FATAL DOSE

COBRA

60 MG

12 MG

RUSSELS

63 MG

15 MG

KRAIT

20 MG

6 MG

SAW SCALED VIPER

13 MG

8 MG

SNAKE BITE - MANIFESTATIONS FRIGHT & FLIGHT RESPONSES FEAR OF DEATH PALLOR, SWEATING, VOMITING SHOCK & DEATH

SNAKE BITE MANIFESTATIONS

NO SYMPTOMS / SIGNS LOCAL EFFECTS SYSTEMIC EFFECTS

SNAKEBITE NO MANIFESTATIONS

NON POISONOUS SNAKES SUPERFICIAL, DRY BITES PROTECTION BY CLOTHING, FOOT WEAR

SNAKE BITE LOCAL MANIFESTATIONS ONSET WITHIN MINUTES SWELLING , ERYTHEMA , BULLAE, HEAMORRHAGE TISSUE NECROSIS, GANGRENE RAPID AND EXTENSIVE SPREAD REGIONAL LYMPADHENOPATHY SECONDARY INFECTION

SNAKE BITE - SYSTEMIC MANIFESTATIONS ONSET FROM FEW MINUTES - DAYS DEPENDS ON VENOM COMPOSITION NEUROTOXIC - COBRA / KRAIT HEAMORRHAGIC - VIPERS MYOTOXIC - SEA SNAKES

SNAKE BITE NEUROTOXICITY PRODUCES NEUROMUSCULAR BLOCKADE FLACCID NEUROMUSCULAR PARALYSIS PTOSIS, OPTHALMOPLEGIA FACIAL INVOLVEMENT - EARLY REFLEXES SPARED INTERCOSTALS / DIAPHRAGM / PUPILLARY COMA - TERMINAL

SNAKE BITE CARDIO VASCULAR MANIFESTATIONS HYPOTENSION COMMON DISTURBANCES IN RATE / RHYTHM PANCARDITIS ELECTROLYTE DISTURBANCES

SNAKE BITE

HAEMATOLOGICAL MANIFESTATIONS ENDOTHELIAL DAMAGE INTRAVASCULAR COAGULATION FIBRINOLYTIC SYSTEM ACTIVATION INTRAVASCULAR HEMOLYSIS PLATELET DYS FUNCTION LOCAL / SYSTEMIC BLEEDING

SNAKE BITE RENAL DAMAGE FEW MINUTES TO DAYS OLIGURIC OR NON OLIGURIC R.F ATN, GN, INT-NEPH, CORTICAL NECROSIS, VASCULITIS

SNAKE BITE UNUSUAL MANIFESTATIONS DELAYED TOXICITY RECURRENT TOXICITY TOXEMIA WITHOUT BITES LONG TERM EFFECTS

UNUSUAL MANIFESTATIONS DELAYED TOXICITY LOCAL BLEBS AS VENOM DEPOT INACCESSIBLE TO ANTI - VENOM

UNUSUAL MANIFESTATIONS RECURRENT TOXICITY VENOM RELEASE FROM BLEBS PARTIAL THERAPY

UNUSUAL MANIFESTATIONS TOXEMIA WITHOUT BITES

SPITTING COBRA AIMED AT VICTIMS EYE CONJUNCTIVITIS, CORNEAL ULCERS

UNUSUAL MANIFESTATIONS LONGTERM EFFECTS PERSISTANT EDEMA SERUM SICKNESS CORTICAL NECROSIS

FACTORS AFFECTING OUTCOME HOST FACTORS BITES IN CHILDREN PROXIMAL BITES EXERTION POST BITE PROTECTION BY CLOTHING /FOOT WEAR SECONDARY INFECTION

FACTORS AFFECTING OUTCOME

AGENT FACTORS

NUMBER & DEPTH OF BITES CONDITION OF FANGS SPECIES OF SNAKES DURATION OF BITE ? SIZE OF SNAKES

FACTORS AFFECTING OUTCOME ENVIRONMENTAL FACTORS

NATURE OF FIRST AID TIME TAKEN TO TREAT THE VICTIM CIRCUMSTANCES THAT PROVOKED THE BITE

SNAKE BITE LAB DATA HEMOGRAM, PERIPHERAL SMEAR COAGULATION PROFILE-BT,CT,FDP URINE ANALYSIS UREA, CREATININE, E.LYTES, SUGAR CXR, ECG PERIODIC MONITORING

SNAKE BITE SPECIFIC THERAPY MONO / POLYVALENT ANTIVENOM INDICATIONS – SEVERE LOCAL/SYSTEMIC SYMPTOMS NO STANDARD PROTOCOL WATCH FOR HYPERSENSTIVITY

SNAKE BITE ANTIVENOM SENSITIVITY TESTING 0.02 ML OF 1:10 SOLUTION I.D ERYTHEMIA&WHEAL >10mm IN 30M

SNAKE BITE ANTIVENOM DESENSITATION 0.01 ml of 1:100 SOLUTION SC INCREASE VOLUME EVERY 15 M TILL 1ml 1 ML SC EVERY 2 HOURS

SNAKEBITE - SEVERITY MILD MODERATE SEVERE

MILD ENVENOMATION CELLULITIS < 2CM/HR PT, APTT - NORMAL FDP < 5 , BT, CT - NORMAL CARDIOTOXICITY - NIL NEUROTOXICITY - NIL HYPOTENSION - NIL MYOTOXICITY - NIL

MODERATE ENVENOMATION CELLULITIS 2-5 CM/HR PLATELET > 20,000 FDP > 5 , BT, CT - NORMAL CARDIOTOXICITY–LV DYSFUNCTION(MILD-MOD) NEUROTOXICITY - MILD PTOSIS WEAKNESS OF LIMBS NO RESPIRATORY FAILURE HYPOTENSION - SYSTOLIC > 90

SEVERE ENVENOMATION CELLULITIS > 5CM/HR PLATELET COUNT < 20,000 FDP > 200, BT, CT - PROLONGED CARDIOTOXICITY - SEVERE LV DYSFUNCTION NEUROTOXICITY - SEVERE PTOSIS, RESPIRATORY INSUFFICIENCY HYPOTENSION - SYSTOLIC < 90 MYOTOXICITY - RHABDOMYOLYSIS,MYOGLOBINURIA

SNAKE BITE ANTIVENOM DOSAGE MILD ENVENOMATION - 15 VIALS PER DAY MODERATE ,,

- 30 VIALS PER DAY

SEVERE

- 60 VIALS PER DAY

,,

SUPPORTIVE THERAPY DIC

-

BLOOD & BLOOD PRODUCTS

SHOCK - VOLUME SUPPLEMENTS /INOTROPHS ARF

- CONSERVATIVE / DIALYSIS

CNS

-

NEOSTIGMINE + ATROPINE

CVS

-

ANTI ARRYTHMICS / INOTROPHS

ANTIBIOTICS - TETANUS PROPHYLAXIS

ABC REASSURE IV ACCESS 18G REMOVE TOURNIQUET BP ECG CORRECT SHOCK WOUND TOILET AND DRESSING INJ TT IMMOBILISE LIMB INJ PETHIDINE 20MG I.V INJ DICLOFENAC 1 AMP IM

IMMEDIATE MEASURES TYPE OF SNAKE TIME OF BITE SITE OF BITE NUMBER OF FANG MARKS TYPE OF FIRST AID GIVEN

PAIN INDURATION CREPITUS CELLULITIS

•BT,CT,PT,APTT,FDP, •PLATLET COUNT,HB,TC,DC, •S.CREATITNE,S.ELECTROLYTES •ABG,ECG,CPK(WHEN REQUIRED)

RECORD • • • • • • • •

PETECHIAE PURPURA LOCAL BLEED ENT BLEED TACHYCARDIA HYPOTENSION PROLONGED CLOTTING TIME HEMOCONCENTRATION

• • • •

WEAKNESS,PTOSIS,OPTHALMOPLEGIA PALATAL,PHARYNGEAL PARALYSIS RESP MUSCLE PARALYSIS-HYPOXIA,ACIDOSIS CONVULSIONS,COMA

• • •

CARDIOTOXICITY,ARRHYTHMIAS RENAL FAILURE-OLIGURIA,UREMIA,VOMITING COMPARTMENT SYND,GANGRENE,NECROSIS

PROTOCOL FOR MANAGEMENT ON EXAMINATION OF SNAKE ENVENOMATION INVESTIGATIONS

TREATMENT •ANTISNAKE VENOM •OTHER MEASURES

CONCLUSION

SNAKE BITE - UNIVERSAL PROBLEM EARLY INTERVENTION - LIFE SAVING NEED FOR UNIVERSAL PROTOCOL

THANK YOU