case presentation snake bites
Post on 09-Feb-2016
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Case presentation snake bites
Grampians EMET training Hub
Case 1 - VICTORIA56 year old male Arrived at 1140
- bitten by snake on right hand - 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
What could be done differently here?
Past History Angina => angioplasty
5 yrs ago, nil since
DrugsSimvastatin, Aspirin
AllergiesMorphine
Any specific features on history that you should ask about?
Examination
Anxious, mildly confused, breathalyser 0.32
Bite to 1st web space right hand puncture wounds dorsum
Observations stable
Otherwise NAD
Any specific features that should be documented?
Management- Initial Swab taken from bite
site, then compression bandage applied
IV line
Blood for FBE, U+E, CK, Coagulation profile
ADT given
What further action is appropriate now?
30 minutes later… Venom detection kit positive
for tiger and black snake Patient feels better, alert,
orientated, neuro exam normal APTT 33, INR 0.9 FBE, U+E, CK normal Bandage removed
20 minutes later… A staff member has called the
local wildlife park Snake seen by herpetologist,
identified as copperhead
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
antivenom given in Hartmans solution over 30 minutes
IV hydrocortisone given
Adrenalin and phenergan drawn up
Putting the bandage back on 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
better, with clinical evidence of improvement
No respiratory compromise
Admitted and transferred to ICU overnightfor observation
Following morning Feels well, no
neurological signs/symptoms, no bleeding
Repeated blood tests all normal
Discharged
Case 2 - WESTERN AUST.38 year old male Snake bite to middle finger of
left hand Whilst trying to catch snake in
house Placed a single layer
compression bandage on his own arm from fingers to elbow
Drove to his GP in 10 minutes No symptoms or signs of
envenomation Decision to transfer to Tertiary
referral Hospital by ambulance (60 minutes)
In transit, the patient complained of feeling unwell with chest tightness and rapidly became unresponsive.
Decision to seek medical attention at Urban Hospitalen route (still 30 minutes approx from tertiary referral hospital)
Initial Management 02.15 hours following the bite Unresponsive with no
cardiac output ECG: pulseless electrical
activity, narrow complexes CPR commenced Intubation 1mg adrenalin 1000ml normal saline
Antivenom IV bolus; 1 ampoule polyvalent
2 ampoules brown snake 2 ampoules tiger snake
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
10 ampoules brown snake antivenom given in 100 ml 0.9% saline over 15 minutes
Platelets 111, INR > 10, APTT > 180, Fibrinogen < 0.3, FDP >20 Creatinine108, ALT 201, CK 164, Troponin I < 0.4 CT head normal
Subsequent course No further oozing noted and
compression bandage removed
Patient’s condition remained stable
5 hours following the bite Transferred to ICU, where remained
stable Platelets 214, INR >10, APTT > 180,
Fibrinogen < O.3, FDP > 20 Creatinine 133, ALT 277, CK 259,
Troponin I 2.8 Further 5 ampoules brown snake
antivenom infused
9.30 hours following bite
Platelets 161, INR > 10, APTT > 180, Fibrinogen <0.3, FDP > 20, Creatinine 127, ALT 243, CK 366, Troponin I 10.8
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
pressure immobilisation bandage should allow stable transfer of patients long distances
E.g Flying doctor service
Expert advice is needed
In WA, there is a different profile of snake bites
The recommendations for antivenom have 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 do you correct the coags? Where to?
There are recent updates in recommendations re treatment of coagulopathy
http://www.australianprescriber.com/magazine/35/5/152/5
Replaces 2006 article http://www.australianprescri
ber.com/magazine/29/5/125/9/
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