Download - Snakebite... Now what?
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Snakebite…Now what?
A Talk by Chris Nickson
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No $
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“Julius Caesar and the Crossing of the Rubicon,” Francesco Granacci, 1494
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Assessment
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If so, what antivenom & treatment is needed?
Is the patient envenomed?
Photo by Iguana Joe
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Snake bite
Lymphatics
Non-specific Systemic Features
Specific Envenoming Syndromes
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Specific Envenoming Syndromes
Venom-inducedConsumptive Coagulopathy
Anticoagulation
Neurotoxicity
Myotoxicity
Others
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Does he look sick?
Photo by JD Hancock
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Life Threats
HypotensionRespiratory failure
SeizureHaemorrhage
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AssessmentGeographic area
Anatomic site of biteNumber of strikes
Use of PIBPre-hospital course and treatment
Previous snakebitesSystemic features
Investigations
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Brown snake Pseudonaja spp
Tiger snake Notechis spp
TaipanOxyuranus spp
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Death AdderAcanthophis spp
Black snake Pseudechis spp
Sea SnakesHydrophiidae
Photo by Gnangarra
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InvestigationsWhole blood clotting test
Coagulation profile (INR, APTT) Fibrinogen, D-Dimer, FDPs
Full blood count Creatine kinase
Renal function and urinalysisLactate Dehydrogenase
Venom Detection Kit (VDK)
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VDK does NOT tell you if a patient is
envenomed
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If envenomed… VDK is an aid to
monovalent antivenom selection
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First Aid
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Pressure Immobilisation Bandage
PIB
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Warrell DA. Treatment of bites by adders and exotic venomous snakes. BMJ. 2005 Nov 26;331(7527):1244-7.
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Management
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Not envenomed
Remove PIBSerial examination
Serial laboratory testsObserve for 12 hours
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Envenomed
Address life threatsReplace PIB
Give AntivenomSerial assessment
Seek and treat complications
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AntivenomIndications
CollapseCoagulopathy
ParalysisRhabdomyolysis
Protracted GI distress
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1. Geography2. Clinical features
3. Laboratory findings
Which Antivenom to give?
http://www.kingsnake.com/aho/species/extras/budden.html
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What about the snake?
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How to give AntivenomResuscitation area
2 x IV lines
Give in 500 mL normal saline over 20 min
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Give Monovalentif Possible
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SevereAnaphylaxis
1% Monovalent
5% Polyvalent
Isbister et al. MJA 2008; 188: 437-476
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Polyvalent Antivenom
Appropriate monovalent AV not available
Need >2 monovalent AVand
No SVDK or no time to wait
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Premedication?Photo by Gaptone
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DoesAntivenom
Work?
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Isbister GK. Antivenom efficacy or effectiveness: the Australian experience. Toxicology. 2010 Feb 9;268(3):148-54.
Efficacy
Effectiveness
Inefficacious antivenom?Irreversible venom effect?Rapid onset venom effect?
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Yeung JM, Little M, Murray LM, Jelinek GA, Daly FF. Antivenom dosing in 35 patients with severe brown snake (Pseudonaja) envenoming in Western Australia over 10 years. Med J Aust. 2004 Dec 6-20;181(11-12):703-5.
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Isbister et al. Pathology (2006) 38(6) 568-572
Expect >8 hours until fibrinogen returns
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FFP: Fuel for the Fire?
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Don’t forget
ASP
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THE END
http://lifeinthefastlane.com
/education/toxicology/
Photo by Peter Firminger