arman's snake bite

Dr Arman Bin HawariDr Arman Bin HawariEmergency & Trauma DepartmentEmergency & Trauma Department

www.kecemasan2u.comwww.kecemasan2u.com

Emergency & Trauma Department Hospital Sultanah Emergency & Trauma Department Hospital Sultanah BahiyahBahiyahwww.kecemasan2u.comwww.kecemasan2u.com

IntroductionIntroductionClinical FeaturesClinical FeaturesManagementManagement

•11stst Aid Aid•Antivenom TreatmentAntivenom Treatment•Choice of AntivenomChoice of Antivenom•Antivenom reactionsAntivenom reactions•AnticholinesterasesAnticholinesterases

Pitfalls in managementPitfalls in management

IntroductionIntroductionClinical FeaturesClinical FeaturesManagementManagement

•11stst Aid Aid•Antivenom TreatmentAntivenom Treatment•Choice of AntivenomChoice of Antivenom•Antivenom reactionsAntivenom reactions•AnticholinesterasesAnticholinesterases

Pitfalls in managementPitfalls in management

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IntroductionIntroduction•Not all snakes are venomousNot all snakes are venomous•Malaysia has approx 40 venomous snakesMalaysia has approx 40 venomous snakes

-18 land snakes-18 land snakes -all 22 sea snakes-all 22 sea snakes

•2 Major Groups of medically important 2 Major Groups of medically important snakes:snakes:

1)1) ElapidaeElapidaea)a) CobrasCobrasb)b) KraitsKraitsc)c) Sea SnakesSea Snakes

2)2) ViperidaeViperidae

IntroductionIntroduction•Not all snakes are venomousNot all snakes are venomous•Malaysia has approx 40 venomous snakesMalaysia has approx 40 venomous snakes

-18 land snakes-18 land snakes -all 22 sea snakes-all 22 sea snakes

•2 Major Groups of medically important 2 Major Groups of medically important snakes:snakes:

1)1) ElapidaeElapidaea)a) CobrasCobrasb)b) KraitsKraitsc)c) Sea SnakesSea Snakes

2)2) ViperidaeViperidae

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Common Snakes in MalaysiaCommon Snakes in MalaysiaCommon Snakes in MalaysiaCommon Snakes in Malaysia iNTR

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Malayan Pit ViperMalayan Pit ViperCalloselasma Calloselasma rhodostomarhodostoma

•Bad tempered, aggressive,quick Bad tempered, aggressive,quick to striketo strike•Commonest cause of snake biteCommonest cause of snake bite•Aka “Ular Kapak Bodoh”Aka “Ular Kapak Bodoh”•Length= 0.6-0.8mLength= 0.6-0.8m•Haemotoxic-defibrination & Haemotoxic-defibrination & thrombocytopaeniathrombocytopaenia

Malayan Pit ViperMalayan Pit ViperCalloselasma Calloselasma rhodostomarhodostoma

•Bad tempered, aggressive,quick Bad tempered, aggressive,quick to striketo strike•Commonest cause of snake biteCommonest cause of snake bite•Aka “Ular Kapak Bodoh”Aka “Ular Kapak Bodoh”•Length= 0.6-0.8mLength= 0.6-0.8m•Haemotoxic-defibrination & Haemotoxic-defibrination & thrombocytopaeniathrombocytopaenia

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Temple Pit ViperTemple Pit ViperTrimeresurus wagleriTrimeresurus wagleri

•Ground & treesGround & trees•Sluggish & docileSluggish & docile•Quite rough handling to cause it Quite rough handling to cause it to biteto bite•Species that is displayed at the Species that is displayed at the snake temple in Penangsnake temple in Penang•Severe pain & local swellingSevere pain & local swelling

Temple Pit ViperTemple Pit ViperTrimeresurus wagleriTrimeresurus wagleri

•Ground & treesGround & trees•Sluggish & docileSluggish & docile•Quite rough handling to cause it Quite rough handling to cause it to biteto bite•Species that is displayed at the Species that is displayed at the snake temple in Penangsnake temple in Penang•Severe pain & local swellingSevere pain & local swelling

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COBRASCOBRAS

•Average length: 1-2mAverage length: 1-2m•King 4-6mKing 4-6m•Not aggressive, and always tries Not aggressive, and always tries to evade humanto evade human•Young usually aggressiveYoung usually aggressive•Venom of Naja Sputatrix is Venom of Naja Sputatrix is immunologically different from immunologically different from Naja Khaothia, antivenom doesn’t Naja Khaothia, antivenom doesn’t respondrespond•Neurotoxic,cardiotoxic,Neurotoxic,cardiotoxic,

COBRASCOBRAS

•Average length: 1-2mAverage length: 1-2m•King 4-6mKing 4-6m•Not aggressive, and always tries Not aggressive, and always tries to evade humanto evade human•Young usually aggressiveYoung usually aggressive•Venom of Naja Sputatrix is Venom of Naja Sputatrix is immunologically different from immunologically different from Naja Khaothia, antivenom doesn’t Naja Khaothia, antivenom doesn’t respondrespond•Neurotoxic,cardiotoxic,Neurotoxic,cardiotoxic,

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NNaja KhaothiaNaja Khaothia

Naja SputatrixNaja Sputatrix

Ophiaphagus Ophiaphagus HannahHannah


KraitsKraits

•Not aggressiveNot aggressive•Mountain and foothillMountain and foothill

•Painless neurotoxicPainless neurotoxic

KraitsKraits

•Not aggressiveNot aggressive•Mountain and foothillMountain and foothill

•Painless neurotoxicPainless neurotoxic

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Bungarus FlavicepsBungarus Flaviceps

Bungarus CandidusBungarus Candidus

Bungarus FasciatusBungarus Fasciatus


Sea SnakesSea Snakes

•All poisonousAll poisonous

•Causes severe myotoxic Causes severe myotoxic damage, myoglobinuria, minimal damage, myoglobinuria, minimal local effects, paralysis can occurlocal effects, paralysis can occur

Sea SnakesSea Snakes

•All poisonousAll poisonous

•Causes severe myotoxic Causes severe myotoxic damage, myoglobinuria, minimal damage, myoglobinuria, minimal local effects, paralysis can occurlocal effects, paralysis can occur

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ClinicalClinical::

General Approach:General Approach:Becareful of dead snakes brought, 1Becareful of dead snakes brought, 1stst aid aidAirway, breathing, circulationAirway, breathing, circulationIdentify the systemic symptomsIdentify the systemic symptoms

Examination of bitten part:Examination of bitten part:Compartment syndromeCompartment syndromeFang marks-? Clues of adult vs juvenileFang marks-? Clues of adult vs juvenileDemarcate local reactionsDemarcate local reactions

Signs of neurotoxicity:Signs of neurotoxicity:Ask the patient to raise the hand, and count loudly in reverse Ask the patient to raise the hand, and count loudly in reverse from hundred and look up…from hundred and look up…

ClinicalClinical::

General Approach:General Approach:Becareful of dead snakes brought, 1Becareful of dead snakes brought, 1stst aid aidAirway, breathing, circulationAirway, breathing, circulationIdentify the systemic symptomsIdentify the systemic symptoms

Examination of bitten part:Examination of bitten part:Compartment syndromeCompartment syndromeFang marks-? Clues of adult vs juvenileFang marks-? Clues of adult vs juvenileDemarcate local reactionsDemarcate local reactions

Signs of neurotoxicity:Signs of neurotoxicity:Ask the patient to raise the hand, and count loudly in reverse Ask the patient to raise the hand, and count loudly in reverse from hundred and look up…from hundred and look up…

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11stst Aid-pressure immobilization for elapids Aid-pressure immobilization for elapidsNot recommended for vipersNot recommended for vipers11stst Aid-pressure immobilization for elapids Aid-pressure immobilization for elapidsNot recommended for vipersNot recommended for vipers

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Antivenom treatmentAntivenom treatment•An immunoglobulin from purified serum or An immunoglobulin from purified serum or plasma of horse/sheep that has been plasma of horse/sheep that has been immunized by one or more species of snakeimmunized by one or more species of snake•Monovalent vs polyvalentMonovalent vs polyvalent

•Specific antivenom-from the specific snake Specific antivenom-from the specific snake that has bitten the patientthat has bitten the patient

Antivenom treatmentAntivenom treatment•An immunoglobulin from purified serum or An immunoglobulin from purified serum or plasma of horse/sheep that has been plasma of horse/sheep that has been immunized by one or more species of snakeimmunized by one or more species of snake•Monovalent vs polyvalentMonovalent vs polyvalent

•Specific antivenom-from the specific snake Specific antivenom-from the specific snake that has bitten the patientthat has bitten the patient

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How long after the bite can antivenom be How long after the bite can antivenom be effective?effective?

•Should be given as soon as indicatedShould be given as soon as indicated

•May reverse systemic envenomation even May reverse systemic envenomation even though it has persisted for several daysthough it has persisted for several days

•Signs of local envenomation may only be Signs of local envenomation may only be effective if given within 1effective if given within 1stst few hours after the few hours after the bitebite

How long after the bite can antivenom be How long after the bite can antivenom be effective?effective?

•Should be given as soon as indicatedShould be given as soon as indicated

•May reverse systemic envenomation even May reverse systemic envenomation even though it has persisted for several daysthough it has persisted for several days

•Signs of local envenomation may only be Signs of local envenomation may only be effective if given within 1effective if given within 1stst few hours after the few hours after the bitebite

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Are there any contraindication to antivenom?Are there any contraindication to antivenom?

•No absolute contraindicationNo absolute contraindication

•Be careful to those patients who has reactions Be careful to those patients who has reactions towards past equine/sheep products such as towards past equine/sheep products such as ATT, anti rabies,strong asthma atopics…ATT, anti rabies,strong asthma atopics…

•Only give the above patients when there are Only give the above patients when there are signs of systemic envenomationsigns of systemic envenomation

•Role of pretreatment with iv adrenaline 2-Role of pretreatment with iv adrenaline 2-5mcg/min, IV piriton 10mg, IV hydrocortisone 5mcg/min, IV piriton 10mg, IV hydrocortisone 100mg, IV ranitidine 50 mg and salbutamol 100mg, IV ranitidine 50 mg and salbutamol inhalerinhaler

Are there any contraindication to antivenom?Are there any contraindication to antivenom?

•No absolute contraindicationNo absolute contraindication

•Be careful to those patients who has reactions Be careful to those patients who has reactions towards past equine/sheep products such as towards past equine/sheep products such as ATT, anti rabies,strong asthma atopics…ATT, anti rabies,strong asthma atopics…

•Only give the above patients when there are Only give the above patients when there are signs of systemic envenomationsigns of systemic envenomation

•Role of pretreatment with iv adrenaline 2-Role of pretreatment with iv adrenaline 2-5mcg/min, IV piriton 10mg, IV hydrocortisone 5mcg/min, IV piriton 10mg, IV hydrocortisone 100mg, IV ranitidine 50 mg and salbutamol 100mg, IV ranitidine 50 mg and salbutamol inhalerinhaler

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How to administer the antivenom?How to administer the antivenom?

•Ask history of high risk (as previous)Ask history of high risk (as previous)

•Prepare adrenaline infusion, piriton, Prepare adrenaline infusion, piriton, hydrocortisone, 2 large branullas etc…hydrocortisone, 2 large branullas etc…

•Given in close observation unitGiven in close observation unit

•Gentle swirl on mixtureGentle swirl on mixture

•Give the antivenom slowly at 10ml/h, if no Give the antivenom slowly at 10ml/h, if no reaction can give over 1 hourreaction can give over 1 hour

•Assess for control (clinical & labs)Assess for control (clinical & labs)

•If No control, repeat the dose, if controlled If No control, repeat the dose, if controlled maintain with 2 vials every 6 hours X 3dosemaintain with 2 vials every 6 hours X 3dose

How to administer the antivenom?How to administer the antivenom?

•Ask history of high risk (as previous)Ask history of high risk (as previous)

•Prepare adrenaline infusion, piriton, Prepare adrenaline infusion, piriton, hydrocortisone, 2 large branullas etc…hydrocortisone, 2 large branullas etc…

•Given in close observation unitGiven in close observation unit

•Gentle swirl on mixtureGentle swirl on mixture

•Give the antivenom slowly at 10ml/h, if no Give the antivenom slowly at 10ml/h, if no reaction can give over 1 hourreaction can give over 1 hour

•Assess for control (clinical & labs)Assess for control (clinical & labs)

•If No control, repeat the dose, if controlled If No control, repeat the dose, if controlled maintain with 2 vials every 6 hours X 3dosemaintain with 2 vials every 6 hours X 3dose

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Antivenom reactions:Antivenom reactions:

•EARLY ANAPHYLACTIC REACTIONSEARLY ANAPHYLACTIC REACTIONS

a)a) 10-180mins10-180mins

b)b) Urticaria,dry cough, fever, nausea, Urticaria,dry cough, fever, nausea, vomiting,abdominal colic, diarrhoea, vomiting,abdominal colic, diarrhoea, tachycardia,tachycardia,

•PYROGENIC REACTIONSPYROGENIC REACTIONS

a)a) 1-2 hours after treatment1-2 hours after treatment

•LATE (SERUM SICKNESS)LATE (SERUM SICKNESS)

Antivenom reactions:Antivenom reactions:

•EARLY ANAPHYLACTIC REACTIONSEARLY ANAPHYLACTIC REACTIONS

a)a) 10-180mins10-180mins

b)b) Urticaria,dry cough, fever, nausea, Urticaria,dry cough, fever, nausea, vomiting,abdominal colic, diarrhoea, vomiting,abdominal colic, diarrhoea, tachycardia,tachycardia,

•PYROGENIC REACTIONSPYROGENIC REACTIONS

a)a) 1-2 hours after treatment1-2 hours after treatment

•LATE (SERUM SICKNESS)LATE (SERUM SICKNESS)

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Any BIG Any BIG questionsquestions??

arman's snake bite

Health & Medicine