snake bite

SNAKE ENVENOMATION

SNAKESSSSS…

FIRST AID

REASSURANCE

IMMOBILISATION

APPLY TORNIQUET

MINIMAL WOUND HANDLING

SALINE CLEANING, STERILE DRESSING

? INCISION ? SUCTION

? LOCAL ANTIVENOM

WHEN A VICTIM ARRIVES

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 SNAKESELAPIDAE - COMMON / KING COBRAS,

- KRAIT

INDIAN SNAKESVIPERIDAE - 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

ACCIDENTAL

LOWER LIMB BITES

DEVELOPING COUNTRIES

ILLEGITIMATE BITES

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, ESTRASESACETYLOCHOLINESTERASESTRANSAMINASES HYALURONIDASESATP ASE, NUCLEOSIDASES

SNAKE VENOM NON ENZYMATIC COMPOUNDS

NEUROTOXINS

MYOTOXINS

CARDIOTOXINS

HAEMORRHAGENS

SNAKE VENOMNON 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

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

FATAL DOSE

SNAKE BITE - MANIFESTATIONS

FRIGHT & FLIGHT RESPONSES

FEAR OF DEATH

PALLOR, SWEATING, VOMITING

SHOCK & DEATH

NO SYMPTOMS / SIGNS

LOCAL EFFECTS

SYSTEMIC EFFECTS

SNAKE BITE MANIFESTATIONS

SNAKEBITE NO MANIFESTATIONS

NON POISONOUS SNAKES

SUPERFICIAL, DRY BITES

PROTECTION BY CLOTHING, FOOT WEAR

SNAKE BITELOCAL 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 BITENEUROTOXICITY

PRODUCES NEUROMUSCULAR BLOCKADE

FLACCID NEUROMUSCULAR PARALYSIS

PTOSIS, OPTHALMOPLEGIA

FACIAL INVOLVEMENT - EARLY

REFLEXES SPARED

INTERCOSTALS / DIAPHRAGM / PUPILLARY

COMA - TERMINAL

SNAKE BITECARDIO VASCULAR MANIFESTATIONS

HYPOTENSION COMMON

DISTURBANCES IN RATE / RHYTHM

PANCARDITIS

ELECTROLYTE DISTURBANCES

SNAKE BITEHAEMATOLOGICAL MANIFESTATIONS

ENDOTHELIAL DAMAGE

INTRAVASCULAR COAGULATION

FIBRINOLYTIC SYSTEM ACTIVATION

INTRAVASCULAR HEMOLYSIS

PLATELET DYS FUNCTION

LOCAL / SYSTEMIC BLEEDING

SNAKE BITERENAL DAMAGE

FEW MINUTES TO DAYS

OLIGURIC OR NON OLIGURIC R.F

ATN, GN, INT-NEPH,

CORTICAL NECROSIS, VASCULITIS

SNAKE BITEUNUSUAL 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 MANIFESTATIONSTOXEMIA WITHOUT BITES

SPITTING COBRAAIMED AT VICTIMS EYE

CONJUNCTIVITIS,

CORNEAL ULCERS

UNUSUAL MANIFESTATIONS

LONGTERM EFFECTS

PERSISTANT EDEMA

SERUM SICKNESS

CORTICAL NECROSIS

FACTORS AFFECTING OUTCOMEHOST FACTORS

BITES IN CHILDREN

PROXIMAL BITES

EXERTION POST BITE

PROTECTION BY CLOTHING /FOOT WEAR

SECONDARY INFECTION

FACTORS AFFECTING OUTCOMEAGENT FACTORS

NUMBER & DEPTH OF BITES

CONDITION OF FANGS

SPECIES OF SNAKES

DURATION OF BITE

? SIZE OF SNAKES

FACTORS AFFECTING OUTCOMEENVIRONMENTAL FACTORS

NATURE OF FIRST AID

TIME TAKEN TO TREAT THE VICTIM

CIRCUMSTANCES THAT PROVOKED

THE BITE

SNAKE BITELAB DATA

HEMOGRAM, PERIPHERAL SMEAR

COAGULATION PROFILE-BT,CT,FDP

URINE ANALYSIS

UREA, CREATININE, E.LYTES, SUGAR

CXR, ECG

PERIODIC MONITORING

SNAKE BITESPECIFIC THERAPY

MONO / POLYVALENT ANTIVENOM

INDICATIONS –

SEVERE LOCAL/SYSTEMIC SYMPTOMS

NO STANDARD PROTOCOL

WATCH FOR HYPERSENSTIVITY

SNAKE BITEANTIVENOM

SENSITIVITY TESTING

0.02 ML OF 1:10 SOLUTION I.D

ERYTHEMIA&WHEAL >10mm IN 30M

SNAKE BITEANTIVENOM

DESENSITATION

0.01 ml of 1:100 SOLUTION SC

INCREASE VOLUME EVERY 15 M TILL 1ml

1 ML SC EVERY 2 HOURS

SNAKEBITE - SEVERITY

MILDMODERATE

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 ENVENOMATIONCELLULITIS > 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 BITEANTIVENOM 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

IMMEDIATE MEASURES

�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

RECORD

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

ON EXAMINATION

����������������������������������������������������������������

PAININDURATION

CREPITUSCELLULITIS

��������������������������������������������������������������������

� � � � ��� �� ���� ����� �� ���� ����� �� ���� ����� �� ���� ��

• 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

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

TREATMENT

•ANTISNAKE VENOM•OTHER MEASURES

PROTOCOL FOR MANAGEMENT OF SNAKE ENVENOMATION

CONCLUSION

SNAKE BITE - UNIVERSAL PROBLEM

EARLY INTERVENTION - LIFE SAVING

NEED FOR UNIVERSAL PROTOCOL

THANK YOU