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/