Get hurt while hiking

AUTHOR

DR. TOMMY LAM SHING KIT

NOV., 2013

HKCEM College Tutorial

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Triage (Category II)

▪ Female 40 year old

▪ Hiking with friends weekend

▪ Get hurt over left ankle in grass

▪ ? Bitten

▪ BP 158/94

▪ Pulse 100/min

▪ Temp 37.2 °C

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Assessment

▪Assess and stabilize ABC if necessary

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Physical Exam

▪ Is it a snake bite ?

▪ Is it a dry bite/ non venomous snake bite ?

▪ Is there envenomation ?

▪ Local sign and symptom?

▪ Systemic sign and symptom ?

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Left ankle

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Physical Exam

▪ Fang mark , Number of fang mark ?

▪ Swelling ? Longitudinal and involved joint

▪ Progression ? Mark by “marker” at different time or taking photo

▪ Clinical compartment syndrome?

▪ Ecchymosis ?

▪ Blisters?

▪ Necrosis?

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4 hours later

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Snake identification

▪History taking

▪Any snake specimen available ?

▪What we can do if in doubt on the snake specimen ?

▪Consult snake identification from Kadoorie Farm & Botanic Garden (KFBG)

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Poisonous snake in HK

▪Viperidae▪Colubridae▪Elapidae▪Hydrophidae

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Local features

▪Pain▪Bruising ▪Blister▪Necrosis

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Systemic features

▪Bleeding tendency▪Oozing from the wound

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Neuromuscular

▪Breathing difficulty

▪Paresthesia

▪Ptosis, diplopia

▪Dysphagia

▪Muscle weakness

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Clinical Feature

Snake Feature

Cobras Severe local pain and swelling, blister, and necrosis (neurotoxic symptoms if king cobra)

Vipers or pit viper Severe local pain with incoagulable blood

Krait Absent or mild local symptom with neurotoxic symptoms

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Investigation

▪ Complete blood picture (especially Platelet count)

▪ Renal and liver function test

▪ Clotting profile

▪ Fibrinogen

▪ ECG

▪ Urine for RBC

Need serial blood tests if present too early

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Treatment

▪ Remove constricting object from injured part or limbs (e.g. remove ring if bitten finger)

▪ Dressing

▪ ATT

▪ Analgesic

▪ Antibiotic for infected wound or significant local reaction

▪ Antivenom

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Some Poisonous Snake in HK

▪ Green Pit Viper/ Bamboo Snake/Cryptelytrops albolabris/ 青竹蛇

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Some Poisonous Snake in HK

▪ Chinese Cobra/Naja atra/ 眼鏡蛇 / 飯鏟頭

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Some Poisonous Snake in HK

▪ King Cobra/Ophiophagus hannah/ 眼鏡王蛇 , 過山烏

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Some Poisonous Snake in HK

▪ Many-banded Krait/Bungarus multicinctus/ 銀腳帶

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Some Poisonous Snake in HK

▪ Banded Krait/Bungarus fasciatus/ 金腳帶

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Some Poisonous Snake in HK

▪ Red-necked Keelback/ Rhabdophis subminiatus/ 紅脖游蛇

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Common envenomation syndrome

Family Clinical Feature

Viperidae Cytotoxic, vasculolytic and haemotoxic

Elapidae Neurotoxic and local tissue necrosis

Hydrophidae Rhabdomyolysis , hyperkalaemia and renal failure

Colubridae Localized pain, swelling, haemolysis and coagulopathy

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Antivenom for common snake bite in HK

Antivenom

Viperidae

Bamboo Snake 青竹蛇 Green Pit Viper/ Agkistrodon halys

Mountain Pit Viper 山烙鐵頭 Agkistrodon halys

Elapidae

Chinese Cobra 眼鏡蛇 , 飯鏟頭 Naja naja

King Cobra 眼鏡王蛇 , 過山烏 King Cobra

Banded Krait 金腳帶 Banded Krait

Many-banded Krait 銀腳帶 Bungarus multicinctus

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Pretreatment

▪ Antihistamine -- Piriton (Chlorpheniramine)

▪ Hydrocortisone

▪ Watch out for anaphylaxis or anaphylactoid reaction

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Our patient

▪ Present with mild wound pain and snake specimen confirmed Green Pit Viper

▪ Observation after 24 hours

▪ Pain controlled by analgesics

▪ Serial blood tests revealed no systemic involvement

▪ Discharge uneventfully

Thank you

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