management of snake bite - nhm · although total number of bites may be more than 5-6 lakhs but...

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QRGSnakebite Version4Final December22,2015

STANDARD TREATMENT GUIDELINES

Management of Snake Bite

Quick Reference Guide January 2016

Ministry of Health & Family Welfare Government of India

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TableofContent

1. INTRODUCTION.........................................................................................................4

2. INCIDENCEOFSNAKEBITEININDIA...........................................................................5

3. WHENTOSUSPECT/RECOGNIZE.................................................................................6

4. RECOMMENDATIONS................................................................................................84.1FIRSTAIDMEASURES......................................................................................................84.2SIGN&SYMPTOMS..........................................................................................................104.3.ASSESSMENT...............................................................................................................174.4LABINVESTIGATIONS....................................................................................................184.5ANTISNAKEVENOM(ASV)THERAPY............................................................................22

4.5.5ASVdoseinpregnancy..........................................................................................244.5.6ASVdoseinchildren..............................................................................................244.5.7ASVdosageinvictimsrequiringlifesavingsurgery..............................................254.5.8RepeatdoseofASV................................................................................................254.5.9Victimswhoarrivelate..........................................................................................25

4.5.10MONITORINGOFPATIENTSONASVTHERAPY...................................................................264.6.ASVREACTION................................................................................................................264.7MANAGEMENTNEUROTOXIC(NEUROPARALYTIC)ENVENOMATION..........................294.8MANAGEMENTOFVASCULOTOXICSNAKEBITE:...........................................................304.9MANAGEMENTOFSEVERELOCALENVENOMING........................................................324.10RECOVERYPHASEOROBSERVATIONOFTHERESPONSETOADEQUATEDOSEOFANTISNAKEVENOM334.11OTHERMEASURES...........................................................................................................334.12SURGICALPROCEDURESINSNAKEBITE.......................................................................344.12.1DEBRIDEMENTOFNECROTICTISSUE.................................................................................344.12.2COMPARTMENTALSYNDROME.......................................................................................344.12.3CRITERIAFORFASCIOTOMYINSNAKEBITELIMB..................................................................344.13DISCHARGE....................................................................................................................364.14FOLLOW-UP...................................................................................................................364.15REHABILITATION.............................................................................................................36

5.LEVELSPECIFICMANAGEMENTOFSNAKEBITE.............................................................375.1REFERRALCRITERIA......................................................................................................37

5.1.1Vasculotoxicenvenomation...................................................................................375.1.2ReferralCriteria:NeurotoxicEnvenomation..........................................................375.1.3Instructionswhilereferring...................................................................................38

5.2SNAKEBITEMANGEMENTATAPRIMARYHEALTHCARECENTER(PHC).......................39

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5.3SNAKEBITEMANGEMENTATTHEDISTRICTHOSPITAL................................................415.4SNAKEBITEMANGEMENTATTHETERTIARYCAREORMEDICALCOLLEGE..................42

6.PATIENTINFORMATIONSHEET....................................................................................43

7. REFERENCES.............................................................................................................47

8.SNAKEBITEEXAMINATIONPERFORMA.......................................................................51

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1.Introduction

Snakebite is an acute life threatening time limiting medical emergency. It is apreventable public health hazard often faced by rural population in tropical andsubtropicalcountrieswithheavyrainfallandhumidclimate.

Therearemorethan2000speciesofsnakesintheworldandabout300speciesarefoundinIndiaoutofwhich52arevenomous.ThevenomoussnakesfoundinIndiabelong to three families Elapidae, Viperidae and hydrophidae (Sea Snakes). ThemostcommonIndianelapidsareNajanaja (IndianCobra)andBungaruscaeruleus(IndianKrait),Daboiarussalie(Russells’Viper)andEchiscarinatus(Sawscaledviper)(Alirol et al 2010). Clinical effects of envenoming by same species of snake arealmostsimilarexceptafewregionalvariations.Kraitsareactiveduringnighthours,oftenbitingapersonsleepingonfloorbed.MaximumViperandCobrabitesoccurduringthedayorearlydarkness,whilewateringtheplantationorwalkingbarefootingrowngrassorsoybeancrops.

Although total number of bites may be more than 5-6 lakhs but only 30% arevenomousbites.AccordingtoMahapatraetal(onthebasisofMillionDeathStudy),non-fatal bitesmay be as high as 1.4million per year. Though snakebite is a lifethreateningcenturiesoldcondition, itwasincludedinthelistofneglectedtropicaldiseases byWorldHealthOrganization in the year 2009 (Warrell andWHO2009;BawaskarHS2014).Currently, treatment quality is highly varied, ranging from good quality in someareas,toverypoorqualitytreatmentinothers.ThehighfatalityduetoKraitbiteisattributed to the non-availability of antisnake venom (ASV), delayed andinappropriateadministrationofASV,lackofstandardprotocolformanagementandinexperienceddoctorsandnon-availabilityofventilatororbagandvalve(Bawaskaretal2008).InIndia,therehasalwaysbeenacrisisofantivenomsupply(BawaskarHSandBawaskarPH2001).OnonehandthereisshortageofASVbutontheotherhandscarceASVisbeingwastedduetoexcessivedosageofASVintheabsenceofaStandard Treatment Guideline. Victims are not onlymisdiagnosed as - abdominalcolic, and vomiting due to indigestion, appendicitis, stroke, head injury, ischemicheart disease, food poisoning, trismus, hysteria and Guillain-Barre´ syndrome butalso subjected to unnecessary investigations includingMRI scans of the brain andlumbarpuncturethuscausingunduedelay inASVtherapy.Delayedadministration

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of ASV or waiting until victim develops systemic manifestations i.e., a 6 h waitresultsinsystemicenvenomingandhighfatality(Bawaskaretal2008).

1. IncidenceofSnakeBiteinIndiaThereisahugegapbetweenthenumberofsnakebitedeathsreportedfromdirectsurvey and official data. Only 7.23% snakebite deaths were officially reported(Majumdar, 2014 andMohapatra 2011). Earlier hospital based reports estimatedabout1,300to50,000annualdeathsfromsnakebitesperyearinIndia.Mohapatraetal,2011,reporteddirectestimatesfromanationalmortalitysurveyof1.1millionhomes in 2001–03. The study found 562 deaths (0.47% of total deaths) wereassigned to snakebites, mostly in rural areas, and more commonly among malesthan femalesandpeakingatages15–29.Thisproportion representsabout45,900annual snakebite deaths nationally or an annual age-standardized rate of4.1/100,000,withhigher rates in ruralareas (5.4)andwith thehighest rate in thestateofAndhraPradesh(6.2).Annualsnakebitedeathsweregreatest inthestatesofUttar Pradesh (8,700), Andhra Pradesh (5,200), andBihar (4,500).Other Indianstates with high incidence of snakebites cases are Tamil Nadu, West Bengal,Maharashtra andKerala.Becausea largeproportionof global totalsof snakebitesarisefromIndia,globalsnakebitetotalsmightalsobeunderestimated.(Mohapatraetal2011).Only 22.19%of the snakebite victims attended the hospitals.Nearly 65.7%of thesnakebite deaths were due to common krait bite,most of them occurring in themonthsof June toSeptember (Majumderet al, 2014). This isbecauseeven todaymostofthevictimsinitiallyapproachtraditionalhealersfortreatmentandmanyarenot even registered in the hospital. Singh et al reported among the snakebitevictims,about60.76%receivedfirstaidatthesiteofincident,and20.25%ofthemsoughthospitalcareafterconsultingthetraditionalhealers (ozhas,ormantrikandtandrik).Timelapsedforseekinghospitaltreatmentwaslessthan4hin55.69%ofthecasesandmorethan12h in7.59%of thecases.Most (41.79%)patientswerefrightened, but no local or systemic symptomshad appearedwhen they reportedtheemergency(SinghAetal2015).

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2. WHENTOSUSPECT/RECOGNIZE

CLINICALPRESENTATION:

Clinicalpresentationofsnakebitevictimdependsuponspeciesofsnake,amountofvenominjected,seasonofthebite,whethersnakeisfedorunfed,siteofbite,areacovered or uncovered, dry or incomplete bite, multiple bites, venom injection invessel,weightofthevictimandtimeelapsedbetweenthebiteandadministrationof ASV. Venom concentration and constitution depends on environmentalconditionsaswellassnake’smaturityanddarknessofcolourofsnake(BawaskarHSetal2014).Patientcanpresentinthefourclinicalsyndromesorincombinationi.e.progressiveweakness (neuroparalytic/neurotoxic), bleeding (vasculotoxic/haemotoxic),myotoxicandpainfulprogressiveSwelling(Figure1).

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Suspected snake bite

Overt biteHistory of biteNonvenomous (70%) / venomous (30%)

Occult biteNo history of bite

Asymptomatic Symptomatic*Predominant symptom manifestation

Progressive painful swelling

Neuroparalytic Vasculotoxic Myotoxic

• Muscleache• Muscleswelling• Involuntarycontractionsofmuscles

• Compartmentsyndrome

1. ASV**2. AN***3. Ventilation

• Neuroparalyticsymptomswithnolocalsigns

• Severeabdominalpain,vomiting

Anxiety, palpitations, tachycardia, Paraesthesia

* Eventhoughpresentaspredominantmanifestationbuttheremaybeoverlapofsyndromeaswell.

# ASVindicatedinrapidlydevelopingswellingonly.PurelylocalizedswellingwithorwithoutbitemarksisnotanindicationofASV.

** Forreactiontoantisnakevenom(ASV)DoseofAdrenaline0.5mgIM(inchildren0.01mg/kg)¥ SpecificASVforseasnakeandPitviperbiteisnotavailableinIndia.However,availableASV

mayhavesomeadvantagebycrossreaction.*** Atropine0.6mgfollowedbyneostigmine (1.5mg)tobegivenIVstat(InchildrenInj.Atropine

0.05mg/kgfollowedbyInj.Neostigmine 0.04mg/kgIV.) Repeatneostigmine dose0.5mg(inchildren0.01mg/kg)withatropineevery30minutesfor5doses.Thereaftertaperdoseat1hour,2hour,6hoursand12hour.Positiveresponseismeasuredas50%ormorerecoveryoftheptosisinonehour.Ifnoresponseafter3rd dose.StopANinjection.

• Localnecrosis• Ecchymosis• Blistering• Painfulswelling

• Compartmentsyndrome

Drybite

CobraKrait

Russel’s viperSawScaleviper

• Bleeding• DIC• Shock• Acutekidneyinjury

• Ptosis• Diplopia• Dysarthia• Dysphonia• Dyspnoea• Dysphagia• Paralysis

ASV**¥SupportivetreatmentDialysisBloodtransfusion

1. ASV2. AN***3. Ventilation

Krait

FlattailedSeasnake

ASV**¥SupportivetreatmentDialysis

Viper

ASV#

Figure1.Fourpresentingclinicalsyndromesofsnakebitei.e.progressiveweakness(neuroparalytic/neurotoxic),bleeding(vasculotoxic/haemotoxic),myotoxicandpainfulprogressiveSwellinganditsmanagement.

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3. Recommendations

4.1FIRSTAIDMEASURES

4.1.1-bybystanderorvictim-Immediatelytransferafterprovidingfirstaidtoahealthfacilitywhereoptimalmedicalcarewithantisnakevenom(ASV)isavailable,closeobservationcanbemaintained,facilityforlaboratoryinvestigationisavailable,anddefinitetreatmentcanbeprovided.

4.1.2AtTheCommunityorVillageLevel

– Checkhistoryofsnakebiteandlookforobviousevidenceofabite(fangpuncturemarks,bleeding,swellingofthebittenpartetc.).However,inkraitbitenolocalmarksmaybeseen. Itcanbenotedbymagnifying lensasapinheadbleedingspotwithsurroundingrash.

– Reassure the patient as around70%of all snakebites are fromnon-venomousspecies.

– Immobilizethelimbinthesamewayasafracturedlimb.Usebandagesorclothtoholdthesplints(woodenstick),butdoNOTblockthebloodsupplyorapplypressure. Ideally thepatient should lie in the recoveryposition (prone,on theleft side) with his/her airway protected to minimize the risk of aspiration ofvomitus.

– Nilbymouthtillvictimreachesamedicalhealthfacility.– TraditionalremedieshaveNOPROVENbenefitintreatingsnakebite.– Shiftthevictimtothenearesthealthfacility(PHCorhospital)immediately.– Arrangetransportofthepatienttomedicalcareasquickly,safelyandpassively

as possible by vehicle ambulance (toll free no. 102/108/etc.), boat, bicycle,motorbike,stretcheretc.

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– Victim must not run or drive himself to reach a Health facility. MotorbikeAmbulancemaybeafeasiblealternativeforruralIndia.

– IfpossiblePHCmedicalofficercanaccompanywithpatienttoknowtheprogressandmanagementandfacilitateresuscitationontheway.

– Informthedoctorofanysymptomssuchasprogressofswelling,ptosisornewsymptomsthatmanifestonthewaytohospital.

– Removeshoes,rings,watches,jewellaryandtightclothingfromthebittenareaastheycanactasatourniquetwhenswellingoccurs.

– Leavetheblistersundisturbed.

Importantdon’tsl Donotattempttokillorcatchthesnakeasthismaybedangerous.l Discard traditional first aid methods (black stones, scarification) and

alternativemedical/herbal therapy as they have no role and domore harmthangoodbydelayingtreatment.

l Do not wash wound and interfere with the bite wound (incisions, suction,rubbing, tattooing, vigorous cleaning, massage, application of herbs orchemicals, cryotherapy, cautery) as this may introduce infection, increaseabsorptionofthevenomandincreaselocalbleeding.

l DoNOTapplyorinjectantisnakevenom(ASV)locally.l Donottietourniquetsasitmaycausegangrenouslimbs.l If victim is expected to reach thehospital inmore than30minutesbut less

than3hourscrepebandagemaybeappliedbyqualifiedmedicalpersonneltillthepatientisshiftedtothehospital.Thebandageiswrappedoverthebittenareaaswell as theentire limbwith the limbplaced ina splint. It shouldbecapableofadmittingafingerbeneathit(SeeFigure2.)

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Figure2:Pressureimmobilization(Sutherlandmethod)

4.1.3AtAHealthCareFacility

– Admit all victims of snakebite confirmed or suspected and keep underobservationfor24hours.

– Provide first-aidmeasures, supportivemeasures immediately. Observe forsignsofenvenomation.AdministerASVtherapyassoonasthereisevidenceofenvenomation.

4.2Sign&Symptoms

Examinethebitesiteandlookforfangmarks,oranysignsoflocalenvenomation.Fangmarkortheirpatternshavenoroletodeterminewhetherthebitingspecieswasvenomousornonvenomousoramountofvenominjected,severityofsystemicpoisoningandnatureofpoisoning–Elapidaeorviperidaevenometc.SomespecieslikeKraitmayleavenobitemarks.

Seefigure1forpresentingclinicalsyndromesofvenomoussnakebite.

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4.2.1Asymptomatic(i.e.,nonVenomrelatedsymptoms)

Patients many a times present with nonspecific symptoms related to anxiety.Commonsymptomsinthesepatientsare:

– Palpitations, sweating, tremoulessness, tachycardia, tachypnoea, elevatedbloodpressure,coldextremitiesandparaesthesia.Thesepatientsmayhavedilatedpupilssuggestiveofsympatheticoveractivity.

– Differentiatefromsymptomsandsignsofenvenomationlistedbelow.– Redness,increasedtemperature,persistentbleedingandtendernesslocally.

However,localswellingcanbepresentinthesepatientsduetotightligature4.2.2DryBite

– Bitesbynonvenomoussnakesarecommonandbitesbyvenomousspeciesarenotalwaysaccompaniedbytheinjectionofvenom(drybites).

– The percentage of dry bites ranges from 10–80% for various poisonoussnakes.

– Somepeoplewhoarebittenbysnakes(orsuspectorimaginethattheyhavebeen bitten) or have doubts regarding bite may develop quite strikingsymptoms and signs, even when no venom has been injected due tounderstandablefearoftheconsequencesofarealvenomousbite.

– Even in case of dry bite, symptoms due to anxiety and sympathetic over-activity(asabove)maybepresent. Assymptomsassociatedwithpanicorstress sometimes mimic early envenoming symptoms, clinicians may havedifficultiesindeterminingwhetherenvenomingoccurredornot.

4.2.3-Neuroparalytic(Progressiveweakness;Elapidenvenomation)

– Neuroparalytic snakebitepatientspresentwith typical symptomswithin30min–6hoursincaseofCobrabiteand6–24hoursforKraitbite;however,ptosis in Krait bite have been recorded as late as 36 hours afterhospitalization.

– Thesesymptomscanberememberedas5Dsand2Ps.• 5Ds–dyspnea,dysphonia,dysarthria,diplopia,dysphagia• 2Ps–ptosis,paralysis

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– Inchronologicalorderofappearanceofsymptoms–furrowingofforehead,Ptosis (drooping of eyelids) occurs first (Figure 3), followed by Diplopia(doublevision),thenDysarthria(speechdifficulty),thenDysphonia(pitchofvoice becomes less) followed byDyspnoea (breathlessness) andDysphagia(Inability toswallow)occurs. All thesesymptomsarerelatedto3rd,4th,6thandlowercranialnerveparalysis.Finally,paralysisofintercostalandskeletalmusclesoccursindescendingmanner.

– Othersignsof impending respiratory failurearediminishedorabsentdeeptendonreflexesandheadlag.

– Additionalfeatureslikestridor,ataxiamayalsobeseen.– Associatedhypertensionandtachycardiamaybepresentduetohypoxia.

Figure3.Ptosiswithneuroparalyticsnakebite

– Toidentifyimpendingrespiratoryfailurebedsidelungfunctiontestinadultsviz.

• Singlebreathcount–numberofdigitscountedinoneexhalation->30normal

• Breathholdingtime–breathheldininspiration–normal>45sec• Abilitytocompleteonesentenceinonebreath.

– Cryinachildwhetherloudorhuskycanhelpinidentifyingimpending

respiratoryfailure.– Bilateraldilated,poorlyoranon-reactingpupilisnotthesignofbraindead

inelapidenvenoming(Figure3).

– Referpatientspresentingwithneuroparalyticsymptomsimmediatelytoahigher facility for intensivemonitoring after giving AtropineNeostigmine(AN)injection(scheduleofANinjectiondescribedbelow).

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4.2.4 Vasculotoxic (haemotoxic or Bleeding) - General signs and symptoms ofViperineenvenomation)

VasculotoxicbitesareduetoViperspecies.Theycanhavelocalmanifestationsaswellassystemicmanifestations.

– Localmanifestations–

thesearemoreprominentinRussel’sviperbitefollowedbySawscaledviperandleastinPitviperbite.Localmanifestationsareinformof:

• Localswelling,bleeding,blistering,andnecrosis.• Painatbitesiteandsevereswelling leadingtocompartmentsyndrome.

Pain on passive movement. Absence of peripheral pulses andhypoesthesiaover the fuelsofnervepassing through thecompartmenthelpstodiagnosecompartmentsyndrome.

• Tenderenlargementoflocaldraininglymphnode.

– Systemicmanifestations–

• Visible systemic bleeding from the action of haemorrhagins (Figure 4) e.g.gingival bleeding, epistaxis, ecchymotic patches, vomiting, hematemesis,hemoptysis,bleedingperrectum,subconjunctivalhemorrhages,continuousbleeding from the bite site, bleeding from pre-existing conditions e.g.haemorrhoids,bleedingfromfreshlyhealedwounds.

• Bleeding or ecchymosis at the injection site is a common finding in Viperbites.

• Theskinandmucousmembranesmayshowevidenceofpetechiae,purpuraecchymoses,blebsandgangrene.

• Swellingandlocalpain.• Acute abdominal tenderness may suggest gastro-intestinal or retro

peritonealbleeding.• Lateralizing neurological symptoms such as asymmetrical pupils may be

indicativeofintra-cranialbleeding.• Consumption coagulopathy detectable by 20WBCT, develops as early as

within30minutesfromtimeofbitebutmaybedelayed.

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Figure4.LocalandsystemicVasculotoxic(haemotoxicorBleeding)manifestationsofViperineenvenomation.

4.2.5Lifethreateningcomplicationsareduetorenalinvolvement.Patientpresentswithhematuria,hemoglobinuria,myoglobinuriafollowedbyoliguriaandanuriawithacutekidneyinjury(AKI).• Bilateralrenalangletenderness.• Passageofdiscolored(reddishordarkbrownurineordecliningurineoutput.• AcuteKidney Injury e.g. decliningornourineoutput, deteriorating renal signs

suchas rising serumcreatinine,ureaorpotassium.Somespeciese.g.Russell’sviper(Daboiasp)andSawscalevipers(Echissp)frequentlycauseacuteKidneyInjury.

• Hypotension due to hypovolaemia or direct vasodilatation or directcardiotoxicityaggravatesacutekidneyinjury.

• Parotid swelling, conjunctiva oedema, sub-conjunctival haemorrhage, renalfailure, acute respiratory distress syndrome [leaking syndrome] and refractoryshock.

• Longtermsequelaee.g.pituitaryinsufficiencywithRussell’sviper(Daboiasp),Sheehan’ssyndromeoramenorrheainfemales.

4.2.6PainfulProgressiveSwelling(PPS)

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Progressivepainfulswellingisindicativeoflocalvenomtoxicity.ItisprominentinRussel’sviperbite,SawscaledviperbiteandCobrabite.Thisisassociatedwith• Localnecrosiswhichoftenhasarancidsmell.Limbisswollenandtheskinistaut

and shiny. Blisteringwith reddish black fluid at and around the bite site. Skiplesionsaroundmainlesionarealsoseen.(Figure5).

• Ecchymosesduetovenomactiondestroyingbloodvesselwall.• Significant painful swelling potentially involving the whole limb and

extendingontothetrunk.• Compartmentsyndromewillpresentinvariably.• Regionaltenderenlargedlymphadenopathy.

Figure5.Snakebitemarksandlocalswellingandnecrosis4.2.7MyotoxicThispresentationiscommoninSeasnakebite.Patientpresentswith:• Muscleaches,muscleswelling,involuntarycontractionsofmuscles.• Passageofdarkbrownurine.• Compartment syndrome, cardiac arrhythmias due to hyperkalaemia, acute

kidneyinjuryduetomyoglobinuria,andsubtleneuroparalyticsigns.4.2.8-Occultsnakebite• Kraitbitevictimsoftenpresentintheearlymorningwithparalysiswithnolocal

signs. Kraithasnocturnalhabitatandhasfineslenderteeth.Hencebitemarksusuallycannotbeidentifiedevenoncloseexamination.

• Typicalpresentinghistoryisthatthepatientwashealthyatnight,inthemorninggetsupwithsevereepigastric/umbilicalpainwithvomitingpersisting for3–4hoursandfollowedbytypicalneuroparalyticsymptomswithinnext4-6hours.Thereisnohistoryofsnakebite.

• Unexplainedrespiratorydistressinchildreninthepresenceofptosisorsuddenonset of acute flaccid paralysis in a child (locked-in syndrome) are highlysuspicious symptoms inendemicareasparticularlyofKraitbiteenvenomation.Sometimespatientsmaypresentwiththroatpainorchestpainalso.

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Earlymorningsymptomsofacutepainabdomenwithorwithoutneuroparalysiscanbe mistaken for a acute appendicitis, acute abdomen, stroke, GB syndrome,myasthenia gravis and hysteria (Bawaskar 2002). Krait bite envenoming isdiagnosed by developing descending neuroparalysis while GB syndrome is byascendingparalysis.

Strong clinical suspicion and careful examination can avoid not only costly andunnecessary investigations such as CT scan, MRI, nerve conduction studies, CSFstudies and many others but also help in avoiding undue delay in initiation of aspecific treatment with ASV. Atropine neostigmine (AN) test helps to rule outmyastheniagravis.

4.2.9Differentialidentificationoftypeofsnakebitebasedonthesymptomsandsigns

Thoughtoa largeextentthemanifestationofsnakebitedependsuponthespeciesof snake,unfortunately, inmanycases thebitingsnake isnot seen,and if it is, itsdescription by the victim is often misleading (Harris et al 2010). Thereforeidentificationofthetypeofsnakeshouldnotholdthetreatment.Attimesthebitemarkmightnotbevisible (e.g., in thecaseofKrait).Theclinicalmanifestationsofthe patient may not correlate with the species of snake brought as evidence.However,itisadvantageoustoknowtheappearanceofthesnakesoastorecognizethespecies(Figure6).Thekilledsnakebroughtasevidencehelpsinidentificationofsnake, in which case species-specific monovalent Antisnake venom (ASV) can beadministered.However,monovalentASVisnotavailableinIndia.Inspection of local site of bite can also help to identify snake’s species. Localswelling,bleeding,blistering,necrosissuggestsCobrabite.Minimumlocalchangesindicate Krait bite. Local bleeding suggests Nilgiri Russel’s viper. Pain in abdomenandhyperperistalsisindicatesKraitbite.

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Figure6.Snakeidentificationbythepatient

ONPRESENTATION,PATIENTSCANBECRITICALORNONCRITICAL(SeeFIGURE1).

4.3.ASSESSMENT

4.3.1CriticalArrival:Patientassessmentonarrival

– Vasculotoxic patients presenting with bleeding from multiple orifices withhypotension, reduced urine output, obtunted mentation (drowsy, confused),cold extremities need urgent attention and ICU care for volume replacement,pressorsupport,dialysisandinfusionofbloodandbloodproducts(Seefollowingsections).

– Neuroparalytic patients presenting with respiratory paralysis, tachypnoea orbradypnoea or paradoxical respiration (only moving abdomen), obtundedmentation, and peripheral skeletal muscle paralysis need urgent ventilatormanagement with endotracheal intubation, ventilation bag or ventilatorassistance.

– Otherpatientscanbeevaluatedtodecideseverityoftheirillness.

4.3.2 Patient assessment: Non critical arrival and Critical patients afterstabilization

– Determinethetimeelapsedsincethesnakebiteandastowhatthevictimwasdoingatthetimeofthebite,historyofsleepingonfloorbedinpreviousnight.

– Determineifanytraditionalmedicineshavebeenused.– Obtainabriefmedicalhistory(e.g.,dateoflasttetanusimmunization,useofany

medication,presenceofanysystemicdisease,andhistoryofallergy)– If the victim has brought the snake, identification of the species should be

carried out carefully, since crotalids can envenomate evenwhen dead. This iswhy bringing the killed snake into the emergency department should bediscouraged.

4.3.3Physicalexamination– Carefulassessmentofthesiteofthebiteandsignsof localenvenomationand

examination of the patient should be carried out and recorded (Annexure 1).Monitorthepatientcloselyandrepeatallabove,every1-2hourly.

– Checkforandmonitorthefollowing:Pulserate,respiratoryrate,bloodpressureand20minutesWholeBloodclottingtest(20WBCT)everyhourforfirst3hoursandevery4hoursforremaining24hours.

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– Check distal pulses and monitor if there is presence of gross swelling. Thepresenceofapulsedoesnotruleoutcompartmentsyndrome.Painonpassivemovement, pallor, pulseless limb, hypoaesthesia over the sensory nervepassing through the compartmentare suggestiveof compartment syndrome.Measurecompartmentpressuredirectlyifthereisconcernthatacompartmentsyndrome is developing. The diagnosis is established if the compartmentpressure,measureddirectlybyinsertinga16GIVcannulaandconnectingitwithmanometer, is raised above 40 cm water/saline. Direct measurement isnecessarybeforeresortingtofasciotomysincecompartmentsyndromeisrareinsnakebite victims and fasciotomy done without correction of hemostaticabnormalitymaycausethepatienttobleedtodeath

4.3.4Examinationofpregnantwomen

Monitoruterinecontractionsandfoetalheartrate.Lactatingwomenwhohavebeenbittenbysnakesshouldbeencouragedtocontinuebreastfeeding.

Cluesforseveresnakeenvenomationshouldbesoughtare:• Rapidearlyextensionoflocalswellingfromthesiteofthebite.InCobrabite

onfinger,necrosismaystartinfewminutes.• Earlytenderenlargementoflocallymphnodes,indicatingspreadofvenom

inthelymphaticsystem• Visiblesignsofneurological impairmentsuchasptosis,muscularweakness,

respiratorydistressorrespiratoryarrest.• Earlyspontaneoussystemicbleedingespeciallybleedingfromthegums,bite

site,haematuria,haemoptysis,epistaxisorecchymoses.• Unconsciousnesseitherwithorwithoutrespiratoryarrest.• Passageofdarkbrownurine• Snakeidentifiedasaveryvenomousonei.e.,Cobra,Russel’sviper.

4.4LABINVESTIGATIONS

4.4.120minutewholebloodclottingtest(20WBCT):

– Itisabedsidetest.– Place 2ml of freshly sampled venous blood in a small glass test tube and

leaveundisturbedfor20minutesatambienttemperature.– Gently tilt the test tube to see if the blood is still liquid; the patient has

hypofibrinogenaemia (“incoagulable”bloodor “not clotted”) as a result of

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venom-inducedconsumptioncoagulopathy(Figure7).– Ifbloodclotisformedandsignsandsymptomsofneurotoxicenvenomation

present,classifyasneurotoxicenvenomation.– If there is any doubt, repeat the test in duplicate, including a “control”

(bloodfromahealthyperson).– Caution:Ifthetesttubeusedforthetestisnotmadeofordinaryglass,orif

it has been used before and cleaned with detergent, its wall may notstimulate clotting of the blood sample in the usual way and test will beinvalid).

– Counsel patient and relatives in the beginning that, 20WBCT may be

repeatedseveraltimesbeforegivinganymedication.

Figure7.20minutewholebloodclottingtest(20WBCT).

– Ifclotted,thetestshouldbecarriedoutevery1hfromadmissionforthree

hoursandthen6hourlyfor24hours. Incasetest isnon-clotting,repeat6hour after administration of loading dose of ASV. In case of neurotoxicenvenomationrepeatclottingtestafter6hours.

Otherinvestigationsthatmayassistinthemanagementofsnakebiteatvariouslevelsofhealthcare

4.4.2–OtherLabtestsatPrimaryhealthcentre– Peakflowmeterinpatients(adolescentsandadults)presentingwith

neuroparalyticsyndrome.– IfPeakflowmeterisnotavailableinPHCthenassessrespiratoryfunction

usingbedsidetests-singlebreathcount,breathholdingtimeandabilitytocompleteonesentenceinonehealthasdescribedearlier.

– Urineexaminationforalbuminandbloodbydipstick.

4.4.3OtherslabtestatDistrictHospital

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Inadditiontotheabove– Prothrombintime– Plateletcount,– Clotretractiontime– Liverfunctiontest(LFT)– RenalFunctiontest(RFT)– SerumAmylase– Bloodsugar– ECG– Abdominalultrasound– 2DEcho(ifavailable)

4.4.4OthersLabtestatTertiaryHealthCareCentreInadditiontotheabove

– Inneuroparalyticenvenomation

• Arterialbloodgases.Caution:Arterialpunctureiscontraindicatedinpatientswithhaemostaticabnormalities.

• Pulmonaryfunctiontests– InVasculotoxicvenomation

• Forcoagulopathy-BT,CT,PT,APTT,Platelet,SerumFibrinogen,FDPD-Dimerassay,LDH,peripheralbloodsmear

• Hemolysis-Urineformyoglobin,Urinehaemoglobin• For renal failure- Urine microscopy for RBC, casts, RFT, urinary proteins,

creatinineratio• Hepatic injury – LFTs including SGOT, SGPT, Alkalien phosphatase, serum

proteins• Cardiotoxicity-CPK-MB,2DEcho,BNP• Myotoxic–CPK,SGOT,Urinemyoglobin,compartmentpressure• Infection-Serumprocalcitonin,culture(blood,urine,wound)andsensitivity

– Arterialbloodgasesandurineexaminationshouldberepeatedatfrequent

intervalsduringtheacutephasetoassessprogressivesystemictoxicity).

4.4.5-Rationaleandinterpretationofthetests:

4. Hemogram: The hemogram may show transient elevation ofhemoglobinlevelduetohemoconcentration(becauseoftheincreasedcapillary leak) or may show anemia (due to hemolysis, especially in

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viper bites). Presence of neutrophilic leucocytosis signifies systemicabsorption of venom. Thrombocytopenia may be a feature of viperenvenomation.

5. Plateletcount:Thismaybedecreasedinvictimsofenvenomingbyvipers.Whitebloodcellcount:Anearlyneutrophil leucocytosis isevidenceofsystemicenvenomingfromanyspecies.Blood film: Fragmented red cells (“helmet cell”, schistocytes) are seen whenthereismicroangiopathichaemolysis.Plasma/serum:Maybepinkishorbrownish if there isgrosshaemoglobinaemiaormyoglobinaemia.

6. Serumcreatinine:Thisisnecessarytoruleoutacutekidneyinjuryafterviperandseasnakebite.

7. Serum creatinine phosphokinase (CPK): Elevated levels of these markerssuggestsmuscledamage(cautionforrenaldamage)andraisedamylasesuggestspancreaticinjury

8. Prothrombin time (PT) and activated partial thromboplastin time (aPTT):Prolongationmaybepresentinviperbite(toberepeated6hourly,ifabnormal).

9. Fibrinogenandfibrindegradationproducts(FDPs):LowfibrinogenwithelevatedFDPispresentwhenvenominterfereswiththeclottingmechanism.

10. Urineexamination forProteinuria/RBC/Haemoglobinuria/Myoglobinuria: Thecolour of the urine (pink, red, brown, black) should be noted and the urineshouldbetestedbydipsticksforbloodorhaemoglobinormyoglobin.Standarddipsticks do not distinguish blood, haemoglobin andmyoglobin. Haemoglobinand myoglobin can be separated by immunoassays but there is no easy orreliable test. Microscopy will confirm whether there are erythrocytes in theurine.

11. Electrocardiogram (ECG): Nonspecific ECG changes such as bradycardia andatrioventricularblockwithST-Tchangesmaybeseen.

12. Electroencephalogram (EEG): Recently, EEG changeshavebeennoted in up to96%ofpatientsbittenby snakes.Thesechanges startwithinhoursof thebitebutarenotassociatedwithany featuresofencephalopathy.Sixty-twopercentshowedgrade I changes, 31%casesmanifestedgrade II changes (moderate tosevere abnormality), and the remaining4% showed severe abnormality (gradeIII). These abnormal EEG patterns were seen mainly in the temporal lobes(RamachandranSetal1995).However,rarelyneededforpatientmanagement.

13. Pulseoximetryforoxygeninpatientswithrespiratoryfailureorshock.14. Electrolytedeterminations:Thesetestsarenecessaryforpatientswith

respiratoryparalysisandsystemicsymptoms.15. ArterialbloodgasesandpHmayshowevidenceofrespiratoryfailure(neurotoxic

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envenoming)andacidaemia(respiratoryormetabolicacidosis).16. X-Ray/CT/Ultrasound(TheuseofX-Rayandultrasoundareofunprovenbenefit,

apartfromidentificationofbleedinginViperinebites).

4.5ANTISNAKEVENOM(ASV)THERAPY

– IfASV is indicated i.e.signsandsymptomsofenvenomationwithorwithoutevidenceoflaboratorytests,administerfulldose.

– TherearenoabsolutecontraindicationstoASV.– Do not routinely administer ASV to any patient claiming to have bitten by a

snakeasASVexposessuchpatientstotherisksofASVreactionsunnecessarily;besideswastageof valuableand scarce stocksofASV. However,at the sametimedonotdelayorwithholdASVonthegroundsofanaphylacticreactiontoadeservingcase.DoNOTgiveincompletedose.

– Purely local swelling, even if accompanied by a bitemark from an apparentlyvenomoussnake, isnotagroundforadministeringASV.Swelling,anumberofhoursold isalsonotagroundforgivingASV.However, rapiddevelopmentofswellingindicatesbitewithenvenomingrequiringASV.

4.5.1Antisnakevenom(ASV)– Antisnake venom treatment is the only specific treatment, should be given as

soonasitisindicated.Itmayreversesystemicenvenomationabnormalityevenwhen this has persisted for several days or, in the case of haemostaticabnormalities, persisting for two or more weeks. The dosage required varieswiththedegreeofenvenomation.

– Inthepresenceofcoagulopathy,PolyvalentASVfreeze-dried(heatstable;tobe

stored at cool temperature; shelf life 5 years) or neat liquid ASV (heat labile;requires reliable cold chain (2-8oC) with a refrigeration shelf life of 2 years)whichever is available may be used. If integrity of the cold chain is notguaranteedthenuselyophilizedASV.

– ASVsuppliedindrypowderformhastobereconstitutedbydilutingin10mlof

distilledwater/normal saline (Figure 8).Mixing is done by swirling and not byvigorousshaking.Caution:Donotuse,ifreconstitutedsolutionisopaquetoanyextent.

4.5.2PrecautionsduringASVAdministration-– ASVshouldbegivenonlybytheIVroute,andshouldbegivenslowly,withthe

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physicianatthebedsideduringtheinitialperiodtointerveneimmediatelyatthefirstsignofanyreaction.Therateofinfusioncanbeincreasedgraduallyinthe absence of a reaction until the full starting dose has been administered(overaperiodof~1hour).

– Epinephrine(adrenaline)shouldalwaysbedrawnupinreadinessbeforeASVisadministered.

– ASVmustNEVERbegivenbytheIMroutebecauseofpoorbioavailabilitybythisroute.AlsodoNOTinjecttheASVlocallyatthebitesitesinceitisnoteffective,isextremelypainfulandmayincreaseintra-compartmentalpressure.

– Take all aseptic precautions before starting ASV to prevent any pyrogenicreactionstoASV.

4.5.3-DoseofASVforneuroparalyticsnakebite–ASV10vialsstatasinfusionover30minutesfollowedby2nddoseof10vialsafter1hourifnoimprovementwithin1sthour.

4.5.4-DoseofASVforvasculotoxicsnakebite-Tworegimenslowdoseinfusiontherapyandhighdoseintermittentbolustherapycanbeused.LowdoseinfusiontherapyisaseffectiveashighdoseintermittentbolustherapyandalsosavesscarceASVdoses(ExpertConsensus).

– LowDoseinfusiontherapy–10vialsforRussel’sviperor6vialsforSawscaledviperasstatasinfusionover30minutesfollowedby2vialsevery6hoursasinfusionin100mlofnormalsalinetillclottingtimenormalizesorfor3dayswhicheverisearlier.OR

– Highdoseintermittentbolustherapy -10vialsofpolyvalentASVstatover30minutes as infusion, followed by 6 vials 6 hourly as bolus therapy till clottingtimenormalizesand/orlocalswellingsubsides.

– NoASV forSea snakebiteorpit viperbiteasavailableASVdoesnot containantibodiesagainstthem.

– The range of venom injected is 5mg-147mg. The total required dose rangebetween10and30vialsaseachvialneutralizes6mgofRussell’sVipervenom.Dependingonthepatientcondition,additionalvialscanbeconsidered.

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10vialsofAVSdissolvedin100mlofdistilledwaterandaddedto400mlofnormalsaline

ASVinsyringe

Administer10vialsofASVinfirsthour.Maintainslowdripfor24hours

Mentiondateandtimeofstartinginfusion

Figure8.ASVinfusionanddosagescheduleEachvialofAVSbedissolvedin10mlof distilledwater andadded to an infusionmedium suchasnormal saline (i.e. 10vials of AVS dissolved in 100ml of distilledwater and added to 400ml of normalsaline).Thevolumeofinfusionisreducedaccordingtothebodysizeandthestateofhydrationofthepatient.InoliguricpatientsrestrictfluidsanduseinfusionpumptogivefulldoseofASVover30minutes.

4.5.5ASVdoseinpregnancy

Pregnantwomenare treated in exactly the sameway as other victims. The samedosage of ASV is given. Refer the victim to a gynecologist for assessment of anyimpactonthefoetus.

4.5.6ASVdoseinchildren

ChildrenalsoaregivenexactlythesamedoseofASVasadultsassnakesinjectthesameamountofvenomintochildrenandadult.Infusion:liquidorreconstitutedASVisdilutedin5-10ml/kgbodyweightofnormalsaline.However, reduceamountof fluid in runningbottle to200ml toavoid fluidoverload.

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4.5.7ASVdosageinvictimsrequiringlifesavingsurgery

Rarely patientmay develop intracranial bleeding forwhich a life saving surgery isrequired. In such cases before surgery coagulation must be restored to avoidcatastrophic bleeding and higher initial dose of ASV (up to 30 vials) can beadministered.

4.5.8RepeatdoseofASV

– Repeatdose:inVasculotoxicorhaemotoxicenvenomation

Repeat clotting test every 6 hours until coagulation is restored. Administer ASVevery6huntilcoagulationisrestored.EnvenomationbytheHump-nosedPitviperdoesnotrespondtonormalIndianpolyvalentASVandcoagulopathymaycontinuefor up to 3weeks. If 30 vials of ASV have been administered reconsiderwhethercontinuedadministrationofASVisservinganypurpose,particularlyintheabsenceofprovensystemicbleeding.

– Repeatdose:neuroparalyticorneurotoxicenvenomation

RepeatASVwhenthere isworseningneurotoxicorcardiovascularsignsevenafter1–2 h. Maximum dose 20 vials of ASV for neurotoxically envenomed patients. Iflargedoseshavebeenadministeredandthecoagulationabnormalitypersists,givefresh frozen plasma (FFP) or cryoprecipitate (fibrinogen, factor VIII), fresh wholeblood,ifFFPnotavailableorplateletconcentrate.

4.5.9Victimswhoarrivelate

Sometimes victims arrive late after thebite, often after several days, usuallywithacute kidney injury.Determine current venomactivity such as bleeding in caseofviperine envenomation. Perform 20WBCT and determine if any coagulopathy ispresent thenadministerASV. Ifnocoagulopathy isevident, treatkidney injury, ifany.Inpatientswithneuroparalyticenvenomation(ptosis,respiratoryfailureetc.)

• Continuerespiratorysupportuntilrecovery• Give10vialsofASVonarrivalandifnoimprovementwithinonehourrepeat

10vialsofASV(Nomorethan20vialsofASV).• NofurtherASVandAtropineNeostigmine(AN)infusionisrequiredONLYto

reverse the Ptosis. Ptosis in Common Krait bite is due to presynapticblockage,furtherASVandNeostigminedosebeyond3dosescannotreverse

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it,sinceregeneration isanaturalprocessandmaytake4-5days.BothASVandANinjectionshouldbestoppedwhentheinitialsyndromeofpharyngealmusclepalsyisover.

4.5.10MonitoringofPatientsonASVtherapy

– Allpatientsshouldbewatchedcarefullyevery5minforfirst30min,thenat

15minfor2hoursformanifestationofareaction.Attheearliestsignofanadversereactionsuspendtemporarily.

– Maintainastrictintakeoutputchartandnotecolourofurinetodetectacutekidneyinjuryearly.

4.6.ASVreaction

– NOASVTESTDOSEMUSTBEADMINISTERED.

– SKIN/CONJUNCTIVALHYPERSENSITIVITYTESTINGDOESNOTRELIABLYPREDICTEARLYORLATEANTISNAKEVENOMREACTIONSANDISNOTRECOMMENDED.

– Rarelypatientsmaydevelopseverelife-threateninganaphylaxischaracterizedbyhypotension, bronchospasm, and angioedema. However, 20%-60% patientstreatedwithASVdevelopeitherearlyorlatemildreactions.

– Earlyanaphylacticreactionsoccurswithin10–180minofstartoftherapyandischaracterizedby itching, urticaria, dry cough, nausea and vomiting, abdominalcolic,diarrhoea,tachycardia,andfever.

– Pyrogenic reactionsusually develop 1–2 h after treatment. Symptoms includechills and rigors, fever, and hypotension. These reactions are caused bycontaminationoftheASVwithpyrogensduringthemanufacturingprocess.

– AnynewsignorsymptomafterstartingtheASVindripshouldbesuspectedasareactiontoASV.

– Late (serum sickness–type) reactionsdevelop 1–12 (mean 7) days aftertreatment. Clinical features include fever, nausea, vomiting, diarrhoea, itching,recurrent urticaria, arthralgia, myalgia, lymphadenopathy, immune complexnephritisand,rarely,encephalopathy.

4.6.1TreatmentofEarlyASVreaction

– StopASVtemporarily.

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– Oxygen– StartfreshIVnormalsalineinfusionwithanewIVset– AdministerEpinephrine (adrenaline) (1 in1,000solution,0.5mg (ie0.5ml) in

adults intramuscular over deltoid or over thigh; In children 0.01mg/kg bodyweight)forearlyanaphylacticandpyrogenicASVreactions.

– AdministerChlorpheniraminemaleate(adultdose10mg,inchildren0.2mg/kg)intravenously.

– RoleofHydrocortisoneinmanagingASVreactionisnotproved.– Oncethepatienthasrecovered, re-startASVslowly for10-15minuteskeeping

thepatientundercloseobservation.Thenresumenormaldriprate.– Forhighriskpatients

InpatientswithhistoryofhypersensitivityorexposuretoanimalserumsuchasequineASV,tetanus-immuneglobulinorrabies-immuneglobulininpast,severeatopicconditions:

• GiveASVonlyiftheyhavesignsofsystemicenvenoming.• GiveInj.Hydrocortisone200mgandChlorpheniraminemaleate22.75mg

priortotheadministrationofASV.– Epinephrinepremedication isnotgivenasroutineas itcancausehypertension

andinpatientswithbleedingtendencycanleadtointracranialbleeding(ExpertConsensus). However, epinephrine should be kept handy for adults. No trialshavebeendoneinchildrenandoldpeople.Inj.Adrenaline0.25mlof1:1000(asavailableinoneampouleof1ml)SubcutaneouslyjustbeforeaddingASVtotherunningIVfluid.

4.6.2TreatmentofLate(serumsickness–type)reactions

– Inj.Chlorpheniramine2mginadults(Inchildren0.25mg/kg/day)6hourlyfor5days.

– In patients who fail to respond within 24–48 h give a 5-day course ofPrednisolone (5 mg 6 hourly in adults and 0.7 mg/kg/day in divided doses inchildren.

4.6.3 Desensitization procedure only in case of severe anaphylaxis reaction toASV

– Pre-medication:Administer Inj.Hydrocortisone100mg I.V. and Inj.Adrenaline0.5mlsubcutaneously/intramuscularly(+/-Promethazine)

Table.StepsofdilutionofASV

Stepsofdilution

Instructions TotalVolume

Solution Dilution

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1. Dilute1mlofASVinavialwith10mlofnormalsaline

10ml A

2. 1ml of solution A + 9 ml ofsaline

10ml B 1:10

3. 1ml of solution B+ 9 ml ofsaline

10ml C 1:100

4. 1ml of solution C + 9 ml ofsaline

10ml D 1:1000

5. 1ml of solution D + 9 ml ofsaline

10ml E 1:10,000

AfterdilutionandpreparationofSolutionE,

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4.7MANAGEMENTNEUROTOXIC(NEUROPARALYTIC)ENVENOMATION

Antisnake venom treatment alone cannot be relied upon to save the life of apatientwithbulbarandrespiratoryparalysis.Administerfollowinginaddition:– Oxygen– Assistedventilation.Thedurationofmechanicalventilationinsnakebitevictims

isusuallyshortsinceneuroparalysisreversesquicklywithpromptadministrationofASV.Manualventilation (selfventilatinganaestheticbag)hasbeeneffectivewhere no mechanical ventilator was available. In case of Guillain-Barresyndromeand delayed neuropathyfollowing snakebite prolonged assistedventilationwithroomairoroxygenisfollowedbycompleterecovery.

– Administer‘AtropineNeostigmine(AN)’scheduledescribedasbelow.– RefertoahigherfacilitywhereASVisavailable,incaseofnoimprovement.4.7.1Atropineneostigmine(AN)dosageschedule

– Atropine0.6mgfollowedbyneostigmine(1.5mg)tobegivenIVstatandrepeatdose of neostigmine 0.5 mg with atropine every 30 minutes for 5 doses (Inchildren, Inj. Atropine 0.05 mg/kg followed by Inj. Neostigmine 0.04 mg/kgIntravenousandrepeatdose0.01mg/kgevery30minutesfor5doses).AfixeddosecombinationofNeostigmineandglycopyrolateIVcanalsobeused.

– Thereaftertobegivenastaperingdoseat1hour,2hour,6hoursand12hour.Majority of patients improvewithin first 5 doses. Observe thepatient closelyobserved for 1 hour to determine if the neostigmine is effective. After 30minutes, any improvement should be visible by an improvement in ptosis.Positive response to “AN” trial is measured as 50% or more recovery of theptosisinonehour.

– StopAtropineneostigmine(AN)dosagescheduleif:• Patienthascompleterecoveryfromneuroparalysis.Rarelypatientcanhave

recurrence,carefullywatchpatientsforrecurrence.• Patientshowssideeffectsintheformoffasciculationsorbradycardia.• Ifthereisnoimprovementafter3doses.

– ImprovementbyatropineneostigmineindicatesCobrabite.AfewNilgiriRussel’sviperbitesvictimsalsoimprovewiththisregimen.

– Giveonedoseof“AN”injectionbeforetransferringtothehighercentre.RapiddeteriorationofCobrabiteneurotoxicsyndromemaykillthepatientonthewaytotransfer.

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– If there isno improvementafter3dosesofatropineneostigmine (within1h), this indicatesprobableKraitbite.Kraitaffectspre-synaptic fibreswherecalciumionactsasneurotransmitter.GiveInj.Calciumgluconate10mlIV(inchildren 1-2 ml/kg (1:1 dilution) slowly over 5-10 min every 6 hourly andcontinuetillneuroparalysisrecoverswhichmaylastfor5-7days.

4.8MANAGEMENTOFVASCULOTOXICSNAKEBITE:

– Strictbedresttoavoidevenminortrauma.– Screen for hematuria, hemoglobinuria, myoglobinuria by Dipstick method.

Dipsticktestispositiveinallthreepresentationslistedabove.Centrifugedurineshowing pink color indicates hemoglobinuria, clear supernatant (RBCs settledownasdeposit)indicatesmyoglobinuria.

– Closelymonitorurineoutputandmaintain1ml/kg/hurineoutput.

4.8.1 VolumeReplacementinsnakebite:– If the patient has intravascular volume depletion, indicated by supine or

posturalhypotension,oremptyneckveins,proceedasfollows:– Establishintravenousaccess.– Givefluidchallenge:Anadultpatientcanbegiventwolitresofisotonicsaline

overonehouroruntilthejugularvenouspressure/centralvenouspressurehasrisento8-10cmabovethesternaangle(withthepatientproppedupat450).

– Observethepatientcloselywhilethisisbeingdone.Thefluidchallengemustbestoppedimmediatelyifpulmonaryoedemadevelops.

4.8.2ForcedAlkalineDiuresis– Ifthepatienthasoliguriaordipstickpositiveforbloodgiveatrialof

forcedalkalinediuresis(FAD)withinfirst24hoursofthebitetoavoidpigmentnephropathyleadingtoacutetubularnecrosis(ATN).

– DelayedFADhasnorole.– SequenceofFADinadultsisasfollows:• Inj.Frusemide40mgIVstat• Inj.Normalsaline500ml+20mlofNaHCO3over20minutes• Inj.Ringer’slactate500ml+20mlofNaHCO3over20minutes• Inj.5%dextrose500ml+10mlofPotassiumChlorideover90minutes• Inj.Mannitol150mlover20min– Whole cycle completes in 2 h 30min and urine output of 3ml/min is

expected.

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– If patient responds to first cycle continue for 3 cycles. FAD convertsoliguria into polyuria and avoid ATN and acute kidney injury needingdialysisinmorethan75%patients.

– IfthereisnoresponsetofurosemidediscontinueFADandreferpatientimmediatelytoahighercenterfordialysis.

– Indicationsfordialysisare:

• AbsolutevalueofBloodurea>130mg/dl(27mmol/L)(BUN100mg/dl),Sr.Creatinine>4mg/dl(500μmol/L)ORevidenceofhypercatabolismintheformofdailyriseinbloodurea30mg/dL(BUN>15),Sr.Creatinine>1mg/dL,Sr.Potassium>1mEq/Landfallinbicarbonate>2mmol/L

• Fluidoverloadleadingtopulmonaryoedema• Hyperkalaemia(>7mmol/l(orhyperkalaemicECGchanges)• unresponsivetoconservativemanagement.• Uremiccomplications–encephalopathy,pericarditis.

– Haemodialysis is preferable in cases of hypotension or hyperkalaemia.Peritoneal dialysis can be performed at a secondary health care center.Continuous renal replacement therapies and intermittent hemodialysis areequivalentinpatientswithseveresepsisandacuterenalfailurebecausetheyachievesimilarshort-termsurvivalrates.

– Continuous therapies are recommended to facilitate management of fluidbalance in hemodynamically unstable patients. An efficient dose forcontinuousrenalreplacementtherapywouldbe20to25mL/kg/hofeffluentgeneration.

4.8.3 IncaseofShock,myocardialdamage:

– Correct hypovolaemiawith colloid/crystalloids, controlled by observationofthecentralvenouspressure.

– Infusionofisotoniccrystalloidsoralbumin,withbolusesofupto20ml/kgforcrystalloids (or albumin equivalent) over 5 to 10mins titrated to reversinghypotension, increasing urine output, and attaining normal capillary refill,peripheral pulses and level of consciousness without inducing lungcrepitationsorhepatomegaly.

– If hepatomegalyor ralesdevelop, initiate inotropic supportwithdopamineor dobutamine. If patient doesn’t respond to fluid resuscitation, inotropicsupportmustbegiven.

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– In sepsis,noadrenaline is the inotropicagentofchoice.Treatpatientswithhypotensionassociatedwithbradycardiawithatropine.

– For coagulopathy – in case of prolonged CT, PT, aPTT administer freshfrozenplasma(FFP)infusion.Associatedlowplateletsindicatesconsumptivecoagulopathyanddisseminatedintravascularcoagulopathy(DIC).Toconfirmfibrinogen levelFDPshouldbeestimated.LowfibrinogenandhighFDPwillrequire fibrinogen/FFPsupplementation.Bleeding leadstoanaemia,PCVof30% must be maintained, therefore, measure serial PCV every 4 – 6 hdependinguponbleedingseverityofpatients.IfPCVislowerthan30needsbloodtransfusion/PCVtransfusion.

– Avoidintramuscularinjections.– FFPadministrationafterASVadministrationresultsinmorerapidrestoration

ofclottingfunctioninmostpatients,butnodecreaseindischargetime.EarlyFFPadministration(<6-8h)post-biteislesslikelytobeeffective.Administer10-15 ml/kg of FFP within over 30–60 min within 4 hours of ASVadministration. The aim should be a return of coagulation function, asdefinedbyanINRof<2.0,at6hafterASVadministrationwascommenced.Non–responsetoFFPcanoccurwithuseofFFPthathas lowactivityofFVandFVIII,becauseofeitherpoorstorageorprematurethawing(>24hours)priortoadministration.

– Heparin is ineffective against venom-induced thrombosis andmay causebleedingonitsownaccount.Itshouldneverbeusedincasesofsnakebite.Antifibrinolyticagentsarenoteffectiveandshouldnotbeusedinvictimsofsnakebite.

4.9MANAGEMENTOFSEVERELOCALENVENOMING

– Local necrosis, intracompartmental syndromes and even thrombosis ofmajorvesselsismorelikelyinpatientswhocannotbetreatedwithASV.

– Surgicalinterventionmaybeneededbuttherisksofsurgeryinapatientwithconsumption coagulopathy, thrombocytopenia and enhanced fibrinolysismust be balanced against the life -threatening complications of localenvenoming.

– Giveprophylacticbroad-spectrumantimicrobialtreatmentforcellulitisaftercompletionoffirst10vialsofASV)isasfollowing.• Inj.Amoxiciilin+clavulanicacid1.2g IV thricedaily for first7days then

switch to oral therapy Tab. Amoxiciilin+clavulanic acid 625 mg threetimesadayforfurther3-7days;Inchildren,thedoseis100mg/Kg/dayinthree divided doses intravenously; for oral therapy, the dose is 50

33


mg/kg/dayinthreedivideddoses.• Inj.Metronidazole400mgIVinfusionthricedailyfor7days;inchildren-

30mg/kg/dayin3-4divideddoses.

• AlternativelyInjCeftriaxone1gIVtwicedaily(inchildrenthedoseis100mg/kg/dayintwodivideddoses)for7daysifAmoxiciilin+clavulanicacidisnot available. Both Amoxiciilin+ clavulanic acid and Ceftriaxone aremainly excreted through Kidney. Therefore, in case of acute kidneyinjuryinViperbitesdoseofboththeseantibioticsshouldbereducedandadjustedaccordingtorenalfunction.

4.10Recoveryphaseorobservationoftheresponsetoadequatedoseofantisnake

venom

– Response to infusionofASV ismarkedbynormalizationofbloodpressure.Within15–30minbleedingstops,thoughcoagulationdisturbancesmaytakeupto6htonormalize.

– Neurotoxic envenoming of the postsynaptic type (Cobra bites) begins toimprovewithin the first 30min, but patientsmay require 24–48 h for fullrecovery.Envenomingwithpresynaptictoxins(Kraitsandseasnakes)donotrespondinthiswayusuallytakesaconsiderabletimetoimprove.

– Nausea, headache and generalised aches and pains may disappear very

quickly.– Inshockpatients,bloodpressuremayincreasewithinthefirst30-60minutes

andarrhythmiassuchassinusbradycardiamayresolve.

– Activehaemolysisandrhabdomyolysismayceasewithinafewhoursandtheurinereturnstoitsnormalcolour.However,redcoloururinemaypersistforseveral days in spite of adequate ASV treatment due to damage of renalpapillae,nofurtherASVcanhelp.

4.11Othermeasures

– Clean the bitten site with povidone-iodine solution, but do not apply any

dressings.– Leaveblistersalone.Allowthemtobreakspontaneouslyandheal.Ifthereis

localnecrosis,exciseandapplysalinedressings.Surgicaldecompressionmaybenecessaryinsomecases.

– AdministerboosterdoseofTetanustoxoidinjection,ifnotvaccinatedearlierorvaccinationhistoryisnotreliableaftercorrectionofcoagulopathy.

34


– Formildpain,inadultsParacetamol500-1000mg(inchildren10-15mg/kg)every 4-6 hourly orally. Do not use aspirin or other non steroidal anti-inflammatorydrugs(NSAIDs).Incaseofseverepaininadults,Tab.Tramadol50mgor Inj. Tramadol50mg IVand in children Ibuprofen cautiously5-10mg/kg/doseevery8hourly.

– Maintainhydrationandnutrition.– If there is local pain and spreading oedema, elevate the affected limb and

allowittorestonasandbag.

– Morbidity and mortality depends on the age and size of victim (childrenreceive larger envenomation relative to body size), co morbid conditions(elderlypatientssuccumbmoreeasilytosnakevenom)aswellasnatureoffirstaidgiven.Factorsnotcontributingtooutcomearesizeofthesnakeandtimeofbite(day/night)

4.12SURGICALPROCEDURESINSNAKEBITE

4.12.1Debridementofnecrotictissue

– Refer the victim to a facility that can perform surgery and is equippedwith asurgeon. It is worth waiting 5-7 days before commencing a debridement ofnecrotic tissue inorder to specify the lineof demarcationbetween viable andnon-viabletissue.

– Skingraftingandamputationofanecroticdigitmayberequiredinsomecasesofsnakebite. Refer these cases to the Surgeons after completion of Antisnakevenom treatment. Surgical interventions in these cases are in the generalprinciplesofsurgery,notmuchrelatedwithAntisnakevenomtherapy.

4.12.2Compartmentalsyndrome

Clinicalfeaturesofacompartmentalsyndrome

Compartmentsyndromeisdiagnosedwith5‘P’–• Pain(severe)• Pallor• Paraesthesia• Pulselessness• Paralysisorweaknessofcompartmentmuscle.

4.12.3Criteriaforfasciotomyinsnakebitelimb

• Haemostaticabnormalitieshavebeencorrected

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• Clinicalevidenceofanintracompartmentalsyndrome• Intra-compartmental pressure >40 mmHg of normal saline (in adults).

Compartmentpressurecanbemeasuredbedsideusing3waycannula–16Gneedle attached to one end, BP apparatus attached to 2nd end and salineinfusionon3rdside(Figure9).

• ThiscanbeconfirmedbyvascularDopplerandrisingCPK inthousands.Timelyfasciotomydecreasestheneedforrepeateddialysis.

Earlytreatmentwithantisnakevenom(ASV)remainsthebestwayofpreventingirreversiblemuscle damage. In any case, fasciotomy should not be contemplateduntilhaemostaticabnormalitieshavebeencorrected(withASVorwithoutclottingfactors),otherwise thepatientmaybleed todeath.Antisnakevenommayalsobehelpful in reducing severe limboedema (Rojnuckarin et al., 2006). Corticosteroidsshould not be used as they are not effective in ameliorating local effects ofenvenomingandcarrytheriskofside-effects(Reidetal.,1963;Nuchprayoonetal.,2008).CompartmentpressuremeasurementprocedureisshowninFigure10.

Figure10.Compartmentpressuremeasurementprocedure.

– Asimple instrument canbeused formeasurementof intra-compartmentalpressure.Inserta16no.needleinthesuspectedcompartmentatadepthof

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1cmandconnect toasimple tubing irrigatedwithnormalsaline.Measurerise in the saline column in the tubing. A rise more than 40 cm of salinecorrespondsto30mmHgofLymphatic/capillarypressureandissuggestiveofcompartmentpressure.Thisnecessitatesfasciotomyprocedure.

– Referthepatienttoasurgicalspecialistbutit isworththetreatingclinicianensuring that objective criteria are used to assess the actualintracompartmentalpressureinthelimb(A2).

– The limb can be raised in the initial stages to see if swelling is reduced.However, this is controversial as there is no trial evidence to support itseffectiveness.

– Persistentmoderateswellingofthelimbafterviperbitecanbesuccessfullymanagedbysystemicbroadspectrumantibioticsand repeatedMagnesiumSulphatecompresses(inthelayersofwetbandage,changed2-3timesaday)for5-7days.

4.13Discharge

Ifnosymptomsandsignsdevelopafter24hoursthepatientcanbedischarged.Keepthepatientunderobservationfor48hoursifASVwasinfused.

4.14Follow-up

Asnakebitevictimdischargedfromthehospitalshouldcontinuetobefollowedup.At the timeofdischargepatient shouldbeadvised to return to theemergency, ifthereisworseningofsymptomsorsignssuchasevidenceofbleeding,worseningofpain and swelling at the site of bite, difficulty in breathing, altered sensorium,reducedorincreasedurineoutputetc.Thepatientsshouldalsobeexplainedaboutthe signs and symptomsof serum sickness (fever, joint pain, joint swelling)whichmaymanifestafter5-10days.

4.15Rehabilitation

In patients with severe local envenoming, the limb should be maintained in afunctionalposition.Forexample,intheleg,equinusdeformityoftheankleshouldbepreventedbyapplicationofabackslab.

Functionaleffectsoflocalenvenomingrangefrompersistentstiffnessandindurationduetosclerosisofveins,lymphaticsandtissueplanesthroughwhichthevenomhasspread,toseveredeformity,tissueloss,especiallydermonecrosis,andrequiringskingraftingandgangrenerequiringdebridementandamputation.Restorationofnormalfunctioninthebittenpartshouldbestartedbysimpleexerciseswhilethepatientis

37


stillinhospital.Afterthepatienthasbeendischargedfromhospitalrehabilitationisrarely supervised but relatives can be instructed and given a time table ofrehabilitation activities. Conventional physiotherapy may accelerate functionalrecoveryofthebittenlimb.

5.LEVELSPECIFICMANAGEMENTOFSNAKEBITE

5.1REFERRALCRITERIA

5.1.1Vasculotoxicenvenomation

– If no ASV is available, transfer to a hospital (where ASV availability isconfirmedoverthephone).

– If20WBCTis“notclotted”afterloadingdoseof10vialsofASVasincaseofViperbite.

– If patient is continuing to bleed even after full dose of ASV transfer to atertiarycaremedicalcollegeorhigherlevelofhealthfacility.

– Progressivesepticaemia– Signsofkidneyinjuryorabnormalkidneyfunctiontesttransfertoatertiary

caremedicalcollegeorhigherlevelofhealthfacility.

5.1.2ReferralCriteria:NeurotoxicEnvenomation

– Progressive neuroparalysis - transfer with life support in ambulance formechanical ventilation. Whilst it is entirely possible to maintain aneurotoxicvictimbysimplyusingaresuscitationbag,thisshouldalwaysbeused as a last resort; the ideal means of support remains a mechanicalventilator (Battery operated Transport Ventilator) operated by qualifiedstaff.

– PHC and even many referral hospitals are not equipped with mechanicalventilators.Themostimportantfactor,therefore,iswhentoreferapatienttoahospitalwithaventilator.

– The key criteria to determine whether respiratory failure, requiringmechanical ventilation is likely, is the ‘neck lift’ to elicit broken neck sign.Neurotoxicpatientsshouldbefrequentlycheckedontheirabilitytoperforma neck lift. If they are able to carry out the action then treatment shouldcontinueuntil recovery in thePHC.Neck lift test isalsouseful for childrenexceptveryyoungchildrenwhomaynotbeabletofollowcommands.Othertestswhich indicatedescendingparalysisaredecliningsinglebreathcount,

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poolingofsaliva.– Ifthepatientreachesthestagewhenpatientcannotdoneckliftimmediately

referthepatienttoahospitalwithamechanicalventilator.– Maintain oxygen saturation using Pulse oximetry.Oxygen saturation <90%

patientindicatesrequirementforventilatorsupport.

Figure 11. ‘‘Broken neck’’ sign observed in a 14-year-old girl bitten by aRussell’sviperinIndia.Envenomingbycobras,kraitsand—insomeareas—byRussell’s viper frequently leads to progressive descending paralysis. In thiscase,neuroparalysispersistedfor fivedaysdespiteantivenomtreatment,butwithout progression toward respiratory failure. H. S. Bawaskar.doi:10.1371/journal.pntd.0000603.g002

5.1.3Instructionswhilereferring

– Informtheneedforreferraltothepatientand/caregiver(familymemberortheaccompanyingattendant).

– Givepriorintimationtothereceivingcentreusingavailablecommunicationfacilities.

– Arrangeforanambulance. CallEmergencyhelpline102/108etc.Transportin an ambulance equipped with transport ventilator. If ventilator is notavailable tight-fitting face mask connected to an anaesthetic (Ambu) bag

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shouldbeavailable.However,donotwastetimetogetanidealambulance.Motorbikeisapracticalalternativeinruralareasforrapidtransportbutthirdpersonmustsitbehindthepatienttosupportonbike.

– IfASV isnotavailableatFirstcontactcentretransfertothenearesthealthfacilitywhereASVisavailableconfirmedbytelephone.

– Transfertoahigherhealthfacility(SecondaryCareHospitalorTertiaryCareHospital)wheremechanicalventilatoranddialysisfacilitiesareavailablefordialysisandventilation,ifrequiredaftercompletionofASVinfusiononly.

– During transfer, continue life-supportingmeasures, insert nasogastric tubeand provide airway support with the help of an accompanying staff, ifrequired.

– Sendthereferralnotewithdetailsoftreatmentgivenclearlymentioningtheclinicalstatusatthetimeofreferral.

5.2SNAKEBITEMANGEMENTATAPRIMARYHEALTHCARECENTER(PHC)

PatientArrival&Assessment

1. Assess circulation, airway and breathing and deal with any life threateningsymptomsonpresentation.

2. Establishlargeboreintravenousaccessandstartnormalsalineslowinfusion.3. Before removal of the tourniquet/ligatures, test for the presence of a pulse

distaltothetourniquet.Ifthepulseisabsentensureadoctorispresentbeforeremovalorligatures.

4. In caseof clinically confirmedvenomousbite, tourniquet shouldbe removedonly after starting of loading dose of ASV and keep Atropine Neostigmineinjectionready.Incaseofmultipleligatures,alltheligaturescanbereleasedinEmergencyRoomEXCEPTthemostproximalone;whichshouldonlybereleasedafteradmissionandallpreparations.

5. Carry out a simple medical assessment including history and simple physicalexamination – local swelling, painful tender and enlarged local lymph glands,persistent bleeding from the bitewound, blood pressure, pulse rate, bleeding(gums, nose, vomit, stool or urine), level of consciousness, drooping eyelids(ptosis)andothersignsofparalysis.TheGlasgowComascalecannotbeusedtoassessthelevelofconsciousnessofpatientsparalyzedbyneurotoxicvenoms.

6. Thesnake, ifbrought,shouldbecarefullyexaminedandidentified, ifpossible.(Onesmartphonephotographof thesnake,deadoralive, ifavailable,shouldbetakenforconfirmationbyanexpert).

7. Clottingtest‘20WBCT’inclean,new,dry,glasstesttubesshouldbecarriedouttodiagnose vasculotoxic envenomation. Report should be given as ClottedorNotClotted.NeverwritePositive/negative. Ifclottedcontinueevery1hourforthe

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1st3hours fromthetimeofhospitalizationandthen6hourly for24hours. Ifaneurotoxicsnakebiteisconfirmed,clottingtestcanberepeatedafter6hours.Ifnotclottedadministerantisnakevenom(ASV).

8. Give analgesia bymouth if required: Paracetamol (acetaminophen) (adult dose500mgto1gmaximum4g in24hours;children10-15mg/kg/dose(maximum100mg/kg/day). Do NOT give aspirin or non-steroidal anti-inflammatory drugswhichcancausebleedingandrenaldysfunction.

9. Assess theneedand feasibilityof transporting thepatient toahigher levelofthehealthservice(seeAabove).

10. Ifthenecessaryskills,equipment,antivenomandotherdrugsareavailable,giveintravenous fluid to correcthypovolaemic shock.These skills includeability todiagnose local and systemic envenoming, set up intravenous infusion orintravenousinjection,identifytheearlysignsofanaphylaxis.

11. If the patient fulfils criteria for antivenom treatment, give ASV. If no ASV isavailable,transfertoahealthfacilitywhereASVisavailable.

12. Adrenaline is made ready in two syringes of 0.5mg (1:1000) for IMadministration if symptoms of any adverse reaction appear. If symptoms doappear,ASVistemporarilysuspendedwhilethereactionisdealtwithandthenrecommenced(fordetailsseetreatmentofearlyASVreactions).

13. If the patient has evidence of respiratory paralysis, give oxygen by mask orlaryngealmaskairway(LMA),andintubatethepatientandmakearrangementsfor transfer to a higher facility accompanied by aMedical Officer carrying anAmbu bag, additional endotracheal tubes, oxygen, facemasks and basic drugsfor resuscitation.Duringthe journeytheendotracheal tubemayslip intorightbronchus leading to left lung collapse and right side pneumothoraxmay alsooccur.Toprevent the tubebeingbitten,amouthgagshouldbe inserted.Thetubemay get obstructeddue to secretionsor kinking leading to cyanosis andresistancetoAmbu-ventilation.Thenthetubeshouldbepulledoutimmediatelyand Ambu- ventilation could be continued with a face mask.

Administer Atropine and Neostigmine before transferring to a hospital asrecommendedabove.

14. It is assumed that assisted ventilation other than by a tight-fitting facemaskconnectedtoananaesthetic(Ambu)bagwillnotbepossibleatthislevel.

15. Whileadmittedforobservation,IVfluidwithaslowplaindripofNormalsalineshouldbestarted,andaTetanusToxoidgivenafterrulingoutorcorrectionofcoagulopathy.

16. Patient should be placed under observation for 24 hours (even if the victimgives a history of a nonvenomous snakebite. The bite victim becomes sofrightened and confused immediately after a bite, many a time gives false

41


identificationhistory). Ifnosymptomsdevelopafter24hoursthepatientcanbedischarged.

17. Discourage the use of ineffective and potentially harmful drugs such ascorticosteroids,antihistamines,andheparin.

5.3SNAKEBITEMANGEMENTATTHEDISTRICTHOSPITAL

ProceedasinBaboveinadditiontothefollowings:

1. IfASVindicatedandhadnotbeengivenalreadystartwithoutanydelay,donotwaitforanytestreport.

2. Carry out a more detailed clinical and laboratory assessment includingbiochemical and haematological measurements, ECG or radiography, asindicatedtogetabaselinedata.

3. If thepatient isbleeding severely irrespectiveof full doseofASVor is alreadyseriously anaemic give transfusion of blood or fresh frozen plasmaor transferwherefacilityisavailable.

4. Reassessanalgesia (seeBabove)and, if required, considergivingTramadol50mg orally. In case of severe pain administer Inj. Tramadol 50 mg IV. Avoidpethidineormorphine inneurotoxicenvenomation.Adeeplysedatedpatientmaycreateconfusionregardinglevelofneuro-paralysis.

5. Give tetanus toxoid booster (if not given already), to all snakebite victimsprovidedcoagulationisrestored.

6. In case of cellulitis consider antibiotics, and consider surgical debridement ofdeadtissue.

7. Ifthepatienthasevidenceofacutekidneyinjury(AKI),treatwithdialysis.Ifthisisnotavailable,transfertoaspecializedhospital.FordetailsseeAnnexure.

8. If the patient has evidence of bulbar or respiratory paralysis, insertendotracheal tube with the help of the anesthesiologist if available or by a

42


trainedmedicalpersonnelorlaryngealmaskairway(LMA).Ifthereisevidenceof respiratory failure, assist ventilation manually by anaesthetic bag ormechanicalventilator.

9. InitialdoseofASVisadministeredover1hour.Thefirstblooddrawnfromthepatientshouldbetypedandcross-matched,astheeffectsofbothvenomandASVcaninterferewithlatercross-matching.

10. Atropine neostigmine “AN” challenge test is administered using 0.6mg ofatropine IV first followed by 1.5 mg of neostigmine IV (Schedule describedabove).Rarely,ifpatientrequiremorethan2nddoseofANtest.Stopafter3rddoseifthereisnoresponse. InKraitbitepracticeofcontinuingNeostigminedriptillptosispersistsbeyond24hisnotbeneficial.Pre-synapticblockagebyKraitvenomdoesnotrespondtoANinjection.

11. Ifafter2hoursfromtheendofthefirstdoseofASV,thepatient’ssymptomshaveworsenedi.e.paralysishasdescendedfurther,asecondfulldoseofASVisgivenover1hour.

5.4SNAKEBITEMANGEMENTATTHETERTIARYCAREORMEDICALCOLLEGE

ProceedasinBandCaboveinadditiontothefollowings:

1. Inthe ICU,thestandardprotocolshouldbefollowedduringassistedventilationand the patient should be monitored for all parameters including level ofconsciousness.Avoid drugs such as sedatives, morphine and neuromuscular blocking agents.Some patients go into a deep coma state but recover completely. Hence,diagnosisofbraindeathshouldnotbeconsidered.Recovery of respiratory muscles is reflected by improvement of neck flexorswhere flexing the neck against gravity indicates timing towean off ventilation.Prophylacticantibioticsareunnecessary.

2. Multiple organ failure. Management is supportive, and prevention of organdamage in those at risk are therefore crucial. Aggressive early resuscitation,adequate antivenom therapy, excision of devitalized tissue and treatment ofinfectionareimportant.Promptrecognitionoforgandysfunctionandimmediateinterventionmayreverseorganimpairmentandimprovetheoutcome.

3. Ifthepatienthasevidenceofacutekidneyinjuryperitonealorhaemodialysisorhaemofiltration.Indicationsfordialysisasdescribedabove.

4. Moreadvancedsurgicalmanagementoflocalnecrosis(e.g.splitskingrafting).5. Moreadvancedinvestigationsincludingbacterialculturesandimaging(CTscans)

asindicated.6. CNS complication and intracranial bleeding to be managed according to the

standard practice. Neurosurgical opinion may be requested according to

43


intracranialpathology.However,haemostaticabnormalitiesmustbecorrected.7. Coma, autonomic dysfunctions. Patient in deep coma recovers fully provided

there is no hypoxic brain damage. Autonomic dysfunctions are transient anddon’tneedtreatment.Sometimestreatmentmightbeharmfule.g.treatingwithantihypertensivedrugstolowertheincreasedbloodpressureduetosympathetichyperactivity.

8. Uncommon complications such as hepatic dysfunction, pancreatitis, endocrineinsufficiencyanddeepvenous thrombosis shouldbemanagedaccording to thestandardpractice.

9. Implementrehabilitationbyphysiotherapists.

6.PATIENTINFORMATIONSHEET• If discharged within 24 hours, advise the patient to return if there is any

worsening of symptoms such as bleeding, pain or swelling at the site of bite,difficultyinbreathingandalteredsensorium.

• Alsoexplaintothepatientaboutserumsicknesswhichmaymanifestafter5-10days.

PreventionofsnakebitesSnakebite is invariablyanaccident.As it isanaccident, it canbeavoided inmanycases.Somejudicious,timelyprecautionsareextremelyimportanttoavoidtheriskofsnake–bites.Peopleshouldbeawareofsuchpreventivemeasures.Education:Knowyour localsnakes,knowthesortofplaceswherethey liketo liveand hide, at what times of year, at what times of day/night or in what kinds ofweathertheyaremostlikelytobeactive.Learnwhenandwheresnakesmaybefound:

– Snakesrestincool,shadedareasduringhotweather.– Snakes are predatory carnivores, but they are also preyed upon by other

animals includingsnakes.For theirpreyinghabitsandsurvival tactics, theytendtobesecretive.Snakesavoidconfrontinglargeranimalsandhumans.

– Avoid snakes as far as possible, including snakes performing for snakecharmers.

– Never handle, threaten or attack a snake and never intentionally trap orcornerasnakeinanenclosedspace.

– DoNOTput yourhandsor fingersor feet intoholesornestorplaces youcannotseeoranyhiddenplace,wheresnakesmaylive.

44


– Most of the snakebites occur in the rainy season and after flood, becausesnakes are compelled to come out from their living and hiding places. Beespeciallyvigilantaboutsnakebitesduringtherainyseasonandafterflood,andtakeadequateprecautionswhilewalkingontheroadsandfields.

– Muchsnakebitesareencounteredduringploughing,plantingandharvesting.Leavesnakesalone:

– DoNOTtrytocatch,frighten,orattackasnake.– BackawayanddoNOTtrytotouchthesnake.Theydonotattackmanunless

they arehandled, threatened, trappedor corneredor their bodyparts aretouched unintentionally (such as pressed down or crushed with the footinadvertently).

– DoNOTpickupadeadsnakeorthatappearstobedead.Evenanaccidentalscratchingfromthefangofasnake'sseveredheadmayinflictdeadlypoison.

– Evendeadsnakescandelivervenomthroughtheirfangs.Rattlesnakesshakethe ends of their tails to make a rattle sound that warns that it feelsthreatened.Ifyouheararattlesnake,moveawayquickly.

Learnwhatpoisonoussnakeslooklike– People of a locality should knowwhat sort of snakes (both venomous and

non–venomous)areexisting there, thehabitsof thosesnakes, their livingandhidingplaces,atwhattimeofyearandatwhattimeofdayornighttheyaremostlikelytobeoutandactive.

– Snake charmers and snake handlers carry greater risk of snakebite. Avoidfreehandhandlingofvenomoussnakes;adequateequipmentmustbeusedforhandling.

– In snake restaurants, staff and customers may sometimes be bitten bysnakesaccidentally.

– Seasnakesmaysometimesbecaughtinnets.Fishermenareadvisednottotouchthosesnakes.

– Venomous snakes are born fully equipped with venom and fangs. Youngsnakes are more pugnacious and ready to defend themselves, so do notdiscountasnakegoingbyitssize.

Dresstoprotectyourself:

– Wearshoesorbootsandpantstoprotectyourfeetandlegs.– Alwayscheckfootwearbeforewearingthem.– Identify major situational sources of bites; walk at night with sturdy

footwear(preferablywithhighboots)anduseatorchwhilewalkingoutsidethehouseorvisitthelatrine(outdoor)atnight.

45


Outdoor– Light your path:Use a flashlight or lamp when you walk outside at night.

DoNOTwalkinareaswhereyoucannotseetheground.– Donotsteporreachintoanareawhereyoucannotseetheground.– Whenwalking,walkwith a heavy step as snakes can detect vibration and

willmoveaway.– Carryastickwhengrasscuttingorpickingfruitorvegetablesorclearingthe

baseoftrees.Usethesticktomovethegrassorleavesfirst.Givethesnakeachance tomove away. If collecting grass that has previously been cut andplacedinapile,disturbthegrasswiththestickbeforepickingthegrassup.

– Keep checking the ground aheadwhile cutting crops likemillet,which areoften harvested at head height and concentration is fixed away from theground.

– Pay closeattention to the leavesand stickson thegroundwhencollectingwood.

– Trytoavoidsleepingontheground.Usebamboocotandscrupuloususeofamosquito net can prevent snakebites, scorpion stings, andmosquito bitesalike.Ifyouhavetosleeponthegroundusemosquitonetthatiswelltuckedinunderthemattressorsleepingmat.

– Avoiddefecationinopenfield.Ifunavoidablecarrytorchorlamp.

– During trekking, etc. through forests ormountains, stay on clearlymarked

tracks.– Step on to rocks or logs rather than straight over them – snakes may be

sunningthemselvesonthesides.– Avoidhandlingdeadsnakes,orsnakesthatappeartobedead.Theycanstill

injectvenom!– Ifyouseeasnake,donothing; let itgo.Keepadistance, it isbettertorun

away.Snakescannotattackwhenitisabout25–30ftaway.– Donottrytopickituporkillit.Snakesprefernottoconfrontlargeanimals

suchashumanssogivethemthechancetoslitheraway.TheGardenorCompound

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– Clearheapsofrubbish,buildingmaterialsandtermitemounds.– Clearanybushorjungle.– Keepgrassshortorcleared.– Closeratholes.Indoor– In the house: Do not keep livestock, especially chickens, in the house, as

snakesmaycometohuntthem.– Regularly check houses for snakes and, if possible, avoid those types of

houseconstructionthatwillprovidesnakeswithhiding.– Storefoodinrat-proofcontainers.– Alsokeepanimalfeedandrubbishawayfromyourhouse.Theyattractrats

andsnakesfollow.– There is no chemical/onions which can effectively repel snakes. Bleaching

powder or gammaxanemaybe spreadwhichmay to someextent preventthe entry of snake in the house as they repel small creatures like rat andfrog;snakeswouldnotcomefollowingthem.

– Sealanyratholeinandaroundthehouses.– Meticulously observe heaps of fire woods, cow dung cakes and similar

materialsatfirstandthenhandle.– Keep plants away from doors and windows. Snakes like cover and plants

helpthemclimbupandintowindows.– DoNOT have treebranches touching thehouse. Keep grass short or clear

the ground around the house and clear low bushes in the vicinity so thatsnakescannothideclosetothehouse.

– Inspectmudmadeovensorchulhasatfirstbeforecleaning.–

Duringconstructionofnewhouse– Indoortoiletsshouldbemadecompulsoryatthetimeofissuingpermission

fornewhousingconstruction.AftersnakebiteoccursDo’sandDon’tsDo’s

– Seekmedicalhelprightaway.– Callambulanceandtransferpatienttoamedicalhealthfacility.Arrange

transportofthepatienttomedicalcareasquickly,safelyandpassivelyaspossiblebyvehicleambulance(tollfreeno.102/108/etc.),boat,bicycle,motorbike,stretcheretc.

– Keepthepersoncalm.Reassurethemthatbitescanbeeffectivelytreatedinanemergencyroom.Restrictmovement,andkeeptheaffectedareabelowheartleveltoreducetheflowofvenom.

47


– Removeanyringsorconstrictingitems,becausetheaffectedareamayswell.– Createaloosesplint(itshouldbecapableofinsertingonefingerbeneath)to

helprestrictmovementofthearea.– Ideallythepatientshouldlieintherecoveryposition(prone,ontheleftside)

withhis/herairwayprotectedtominimizetheriskofaspirationofvomitus.– Iftheareaofthebitebeginstoswellandchangecolour,thesnakewas

probablyvenomous.– Monitortheperson'svitalsigns--temperature,pulse,rateofbreathing,and

bloodpressure--ifpossible.Iftherearesignsofshock(suchaspaleness),laythepersonflat,raisethefeetaboutafoot,andcoverthepersonwithablanket.

Don’ts

– DoNOTwastetimeintraditionalfirstaidmethods– DoNOTallowthepersontobecomeover-exerted.Ifnecessary,carrythe

persontosafety.– DoNOTapplyatourniquet.DoNOTblockthebloodsupplyorapply

pressure.– DoNOTapplycoldcompressestosnakebite.– DoNOTcutintoasnakebitewithaknifeorrazor.– DoNOTtrytosuckoutthevenombymouthorwashthewound.– DoNOTgivethepersonstimulantsorpainmedicationsunlessadoctortells

youtodoso.– DoNOTgivethepersonanythingbymouth.– DoNOTraisethesiteofthebiteabovetheleveloftheperson'sheart.– DoNOTattempttokillorcatchthesnakeasthismaybedangerous.Bringin

thedeadsnakeonlyifthiscanbedonesafely.DoNOTwastetimehuntingforthesnake,anddoNOTriskanotherbiteifitisnoteasytokillthesnake.Becarefuloftheheadwhentransportingit-asnakecanactuallybiteforseveralhoursafteritisdead(fromareflex).

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VinodSDeshmukh,VijayMMotghare,DharmendraGajbhiye,BirajdarSV,RushikeshDeshpande,HarshalPise,SwapnilJaykare.StudyonacuteadversedrugreactionsofantisnakevenominaruraltertiarycarehospitalAsianJPharmClinRes,Vol7,Issue5,2014,13-15

WarrellandWHO11-Http://www.who.int/neglected_diseases.EB132_R7_en.pdf).

Warrell DA. Guideline for Management of Snakebite. World Health Organization2010.

Warrell DA. Redi award lecture: clinical studies of snake–bite in four tropicalcontinents. Toxicon 2013 Jul; 69:3-13. doi: 10.1016/j.toxicon.2012.11.013. Epub2012Nov29.

WarrellDA.WHO/SEAROGuidelinesfortheclinicalmanagementofsnakebiteintheSoutheastAsianRegion.SEAsianJTropMedPubHlth.1999;30:1–85.

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8.SNAKEBITEEXAMINATIONPERFORMAName…………………………………….. Age………………. SexM/FAddress……………………………………………………………………………………………………….. Date……………….timeofbite………………..Activityattimeofbite……………………Sleepingonfloorbed…Yes/No….Cot……Yes/No………MosquitonetYes/NoSnakeSeenYes/NoKilled Yes/NoSpecimenphotoinmobileYes/No Identificationofsnakeinphotosspecimenas………………………………..Confirmedspecimenofsnake…………………………………………………….LocalsiteFangsmarks……………...ActivebleedingfromfangsYes/NoBloodclotYes/NoTimeofdevelopmentofedema……………………………………………………..………… Extensionofedema…………………………………………………………………………….Regionallymphangitis…………………………………………………………..……………. Paininabdomen……………………………………………Vomiting……………………..Bloodpressure…………………………………. Pulserate…………………………ActivebleedingGum/fromabrasions/anyothersite20WBCTonarrival Clotted/Notclotted Time…………...Repeat20WBCT Clotted/Notclotted Time……………

Repeat20WBCT Clotted/Notclotted Time……………

ASVadministered………………………….Dosegiven…………………………Time……Repeat20WBCTafterASVClotted/Notclotted

52


ProgressafterASV

20WBCTat1h………….2h…………..3h……………6h…………12h……….18h……..24h…

ProgressINR……………………..APTT………………………………

Bloodurea………………………………

Serumcreatinine…………………..

UrineHaematuria/hemoglobinurea

Haemogram………………………..Plateletcount…………………………………

Bloodtransfusion,ifany

FreshFrozenPlasma(FFP),ifany

Dialysis,ifany

CompartmentsyndromePresent/NotpresentNeuroparalyticsymptomsBilatralPtosis……………….. Bulbarpalsy…………….

Opthalmoplegia

Respiratoryrate………………../min sPO2

Oneminutecount…………………..

MusclepoweronarrivalUpperlimb……………………lowerlimb……………………..ProgressPelvicgirdleReflexesPlanteronarrival…………………….Progress……………….

Voiceonarrival

DistancebetweenInterteethmargin…………Onarrival…………..Progress………….

53


Protrudeoftongueinrelationtoteethmargin…………Onarrival……….progress

Pupilsize………….reactingtolight……………Onarrival………………………….....

ProgressafterASVtotaldose……………….AfterRepeatdose…………………………..

Intubationtime………………..Ambubagventilation/MechanicalventilatorFollowup

Recoverytimeindays………………TotalASVdosegiven……………………....

Bloodtransfusion given/notgiven

FFP given/notgiven

Dialysisdays…………………..

Ventilationstotaldays……………….

Disability……………………………….

Hypoxicbraininjury………………..

Amputationoflimb…………………….

Plasticsurgery……………………………….

QualityStandardsandIndicators–ManagementofSnakeBiteVer1.0

STANDARD TREATMENT GUIDELINES

Management of Snake Bite

Quality Standards & Indicators January 2016

Ministry of Health & Family Welfare Government of India


QualityStandardsforManagementofSnakebite

Standard Statement

QualityStandard1

ObservationAllpatientsreportingtohealthfacilitywithhistoryofsnakebite/

suspectedsnakebitearekeptunderclinicalobservationforat

least24hoursirrespectiveofseverityofenvenomation

QualityStandard2

DiagnosisForallpatientswithsignofenvenomation,20-minutewhole

bloodclotting(20WBCT)testisdoneimmediatelyafter

admission,repeatedhourlyforfirst3hours.

QualityStandard3

InitiationofASVTherapy

AllpatientswithSnakebite,confirmedclinicallywith

neuroparalyticsymptomsornonclotting20WBCTare

immediatelyprovidedAntiSnakeVenomtherapy

QualityStandard4

CareofNeurotoxicenvenomation

Allsnakebitepatientspresentingwithneuroparlyticsymptoms

areimmediatelyadmittedtoICUorreferredtohigherfacility

withICU

QualityStandard5

ASVDoseAllpatientswithconfirmeddiagnosisofsnakebiteare

administered10vialsofpolyvalentASVwithin30minof

confirmationforindication/admission.

QualityStandard6

AtropineNeostigmineTherapy

AllpatientswithpresentationofNeurotoxic(neuroparalytic)

EnvenomationareprovidedAN(Atropine-Neostigmine)therapy

asperschedule

QualityStandard7

ASVAvailability24X7AvailabilityofAntisnakevenomisensuredindesignated

healthcarefacilities.

QualityStandard8

ManagementofASVReactions

ASVreactionsaremonitoredandtreatedandmanagedasper

protocol

QualityStandard9

CompetenceHealthcareprovideriscompetentandconfidenttomanage

snakebitecases

QualityStandard10

PromotionHealthfacilitypromotestheinformationandeducationregarding

scientificmanagementofsnakebiteincommunity


QualityStandard-1-AdmissionandObservationofSuspectedSnakebiteCases1.Statement Allpatientsreportingtohealthfacilitywithhistoryofsnakebite/

suspectedsnakebitearekeptunderclinicalobservationforat

least24hoursirrespectiveofseverityofenvenomation

2.Rationale PresentingSignandsymptomsofsnakebitemaybeconfusingthe

timeofarrivaltoahealthfacility.Somepatientwithdrybiteor

nobitemaymimiclikeasnakebitecasedueanxietyand

sympatheticoveractivity.Ontheotherhand,somecasestheir

maybenosignorsignsimilarothercommondisease(Acute

abdomenincaseonoccultsnakebite.Thedefinitivesignsand

symptomsofsnakebitemaymanifestlater.Soitisjudiciousto

keepallcasesofsuspectedsnakebitunderobservationatleast

for24hours.

3.QualityMeasure

3a.Structure Evidenceofavailabilityoffunctionindoorfacilitiesand24X7

nursingcareatthefacilitiesdesignatedtotreatsnakebite.

3b.Process Proportionofsuspectedsnakebitecasesreportedtohealth

facilitythatwerekeptunderobservationforatleast24hours.

Numerator-Totalnopatientswithsuspectedsnakebitekeptunderobservationfor24hours

Denominator-Totalno.ofsuspectedsnakebitecasesreportedtothefacility.

3c.Outcome ProportionofSnakebitecasesre-admittedforsignand

symptomsafterearlydischarge(Before24hours)

Numerator-TotalNo.ofPatientsreadmittedafterearly

discharge(before24hoursofreporting)

Denominator–TotalNo.ofsuspectedPatientsdischargedbefore24hrsofreporting)

4.WhatQualityMeasuremeansforeachaudience

ServiceProvider–Ensurethatallthesuspectedcasesofsnakebitearekeptunderobservationatleastfor24hours

HealthAdministrator-Ensurethatadequateindoorfacilityandnursingcareisavailableatthedesignatedfacility.

PatientandCommunity–Patientortheirattendantshouldnotnotrequesthospitalsstaffforearlydischargeevenifsnakebiteis

notconfirmed.

5.DataSource EmergencyRegister

IndoorRegister

6.Definitions HealthFacility-AnyPublichealthfacilitywithprovisionof24X7indoorcare(PHC,CHC,DistrictHospitals,TertiarycareCenters/

TeachingHospitals)ortheirequivalentinprivatesector


QualityStandard-2-LabDiagnosisforSnakebite1.Statement Forallpatientswithsignofenvenomation,20-minutewhole

bloodclotting(20WBCT)testisdoneimmediatelyafter

admission,repeatedhourlyforfirst3hours.

2.Rationale 20MinuteWBCtestisthemostdefinitivetesttoidentifyany

venom-inducedconsumptioncoagulopathy.Thetestwillhelp

careproviderinconfirmingthediagnosisanddifferentiating

betweenneurotoxicandvasculotoxicsnakebite.Thetest

requiresminimalresources(Asyringeandaglasstesttube)and

skillssocanbeperformedinatallleveloffacilities.

3.QualityMeasure

3a.Structure Evidenceofnecessaryconsumableseg.Syringeandglasstest

tubeisavailableandserviceprovidersareskilledforperforming

thetest.

3b.Process ProportionofsuspectedsnakebitecasesImmediatelyprovided

the20WBCTestafteradmissionoutoftotalsuspectedsnake

bitecasesadmitted

Numerator-Totalnopatientsprovidedimmediate20WBCtest

afteradmission

Denominator-Totalno.ofsuspectedsnakebitecasesadmitted

inthefacility.


ServiceProvider–Ensurethat20WBCtestisconductedasearly

aspossibleafteradmittingthesnakebitepatientandthen

repeatedhourlyfornextthreehourstoruleoutcoagulopathy.

Ensurenursing/paramedicstaffareskilledtoperformthetest.

Aworkinstructionregardingthiscanbedisplayedatnursing

station

HealthAdministrators/QAOfficials-Monitortherelated

indicators.Periodicreviewofcaserecords(ClinicalAudit)

PatientandCommunity–Cooperatewithserviceprovidersandunderstandtheneedofreparativedrawingofbloodand

conductingthetest.

5.DataSource ClinicalCaserecords/BedHeadTicketsofthesakebitecases

6.Definitions 20WBCT-(20Minutewholebloodclottingtest)performedby

placing2mlfreshlydrawnvenousbloodinasmallglasstubeat

ambienttemperatureandobservingforcoagulationafter20

minutesbytiltingthetesttube.“NotClotted”bloodis

confirmationofvenominducedconsumptioncoagulopathy.


QualityStandard-3-InitiationofAntiSnakeVenomTherapy1.Statement AllpatientswithSnakebite,confirmedclinicallywith

neuroparalyticsymptomsornonclotting20WBCTare

immediatelyprovidedAntiSnakeVenomtherapy

2.Rationale AntiSnakeVenomtherapyistheonlyspecifictreatmentfor

snakebitecases.Oncesnakebitecaseconfirmedbasedonclinical

signandsymptomofenvenomationorbylabtest(20WBCT),

ASVtherapyshouldbestartedimmediatelywithoutanyother

consideration.TherearenocontradictionstoASV.Early

administrationofASVwillstopthefurtherprogressof

envenomationandevenmayreversesystemicenvenomation

abnormalities.

3.QualityMeasure

3a.Structure EvidenceofadequatestockofASVisreadilyavailableforuseand

clinicalstaffisASVtherapy

3b.Process Proportionconfirmedsnakebitecasesinitiatedtheantisnake

venomtherapyimmediatelyoutoftotalconfirmedcasesof

snakebitecasesattended

Numerator-Totalnoofpatientsinitiatedantisnakebitetherapyimmediately(notmorethan10Minutes)afterconfirmationof

envenomation.

Denominator-Totalno.ofconfirmedsnakebitecasesattended

3c.Outcome Proportionofsnakebitecasedwheremortalityorsevere

morbidityoccurredduetodelayininitiationofAntisnakeVenom

therapy

Numerator-Totalno.ofcaseswheremortalityorsevere

morbidityoccurredduetodelayininitiationofAntisnakevenom

Denominator–Totalno.ofsnakebitecasestreated4.WhatQualityMeasuremeansforeachaudience

ServiceProvider–EnsurethatadequatestockofASVisreadilyaccessibleforuse,includinginnighthourswhenpharmacyor

drugstoremaybeclosed.Protocolregardingtheimmediate

initiationofiseffectivelycommunicatedandmonitored.



PatientandCommunity–InsistoninitiationofASVtherapyoncediagnosisisconfirmed.Communityrepresentativeinrogikalyan

samitiescanperiodicallymonitortheavailabilityofantisnake

venominthehospital.


ClinicalAuditRecords

6.Definitions AntisnakeVenomTherapy–IntravenousinfusionofPolyvalent/SnakespecificAntisnakevenomwithminimumdoseof100ml.


QualityStandard-4-CareofPatientswithNeurotoxicEnvenomation1.Statement Allsnakebitepatientspresentingwithneuroparalyticsymptoms

areimmediatelyadmittedtoICUorreferredtohigherfacility

withICUafterANInjection

2.Rationale NeuroparalyticSnakebitecasespresentingcannotonlybe

managedwithAntisnakeVenomtherapy.Theywillrequire

intensivemonitoringandmayrequiresassistedlifesupportIf

healthfacilityishaveningIntensivecareunitwithventilatorsthe

patientshouldbeimmediatelyshiftedICU.Primaryand

secondaryhealthcarecentersnothaveningICUshouldreferthe

patientinanadvancelifesupportambulancetothehigher

centerimmediatelyaftergivingAtropine–Neostigmine

injection.

3.QualityMeasure

3a.Structure EvidenceoffunctionalIntensiveCareunitwithfacilityof

mechanicalventilatorsareavailableatDistrictHospitalsand

aboveleveloffacilities

Evidencethatemergencydepartmentoffacilitiesareequipped

withlifesavingequipmentlikeOxygen,LaryngoscopeandBag&

Maskareavailable

Evidenceoflifesavingemergencydrugse.g.Atropineand

Neostigmineareavailableinfacility

3b.Process • Proportionofneuroparalyticsnakebitecasesreferredto

ICU/Higherfacilityoutoftotalneuroparalyticcasesreceived

Numerator-Totalnoofneuroparalyticcasesreferredimmediately(notmorethan30minutes)ofreceivingthe

patients

Denominator-Totalno.ofneuroparalyticsnakebitecasesattended

• ProportionofneuroparalyticsnakebitecasesgivenAN

injectionbeforerefereeingtohighercenter

Numerator-Totalno.ofcasesAN(Atropine-Neostigmine)

injectionwasadministeredbeforereferringthepatient

Denominator–Totalno.ofneuroparalyticsnakebitecasesattended


ServiceProvider–Ensuretimelyshifting/referralofcases

requiresintensivecare.EnsurethatANinjectionisgivenbefore

referral

HealthAdministrators/QAOfficials–InsurethatICUsarefunctionalatdistrictandabovelevelfacilitieswithmechanical

ventilators.Emergencydrugsandreferraltransportisavailable.

PatientandCommunity–Cooperateandsupportthecareprovidersinarrangingtheambulanceandreferralofpatient.


Handoverregisters,Ambulancerecords


6.Definitions ANinjection–Atropine0.6mgfollowedbyneostigmine(1.5mg)

tobegivenIVstatbeforereferralQualityStandard-5-Adequatedoseofantisnakevenom

1. Statement Allpatientswithconfirmeddiagnosisofsnakebiteare

administered10vialsofpolyvalentASVover30min

2. Rationale AdequateandtimelyadministrationofASViskeytopsuccessful

managementofsnakebite.Irrespectiveoftypeofsnakeorsign

andsymptoms,10vialsofASVmustgivenover30minutes

throughIVinfusion.Laterdoseswilldependupontypeofvenom

(VasculotoxicorNeurotoxic)andextendofenvenomation.

Incompletedoseshouldbeneverbegiven

3. QualityMeasure

3a.Structure EvidenceofadequatestockofASVisreadilyavailableforuseand

clinicalstaffistrainedfordosagesofASVtherapy

3b.Process Proportionconfirmedsnakebitecasesgivenatleast10vialsof

ASVover30minutesoutoftotalsnakebitecasestreated.

Numerator-Totalnoofconfirmedsnakebitepatientsinitially

givenatleast10vialofantisnakevenomover30minutes

Denominator-Totalno.ofconfirmedsnakebitecasesattended

3c.Outcome Proportionofsnakebitecasedsuccessfullytreatedoutoftotal

snakebitecasesattended

Numerator-Totalno.confirmedsnakebitecasessuccessfully

treated

Denominator–Totalno.ofconfirmedsnakebitecasesattended

4. WhatQualityMeasuremeansforeachaudience

ServiceProvider–EnsurethatadequatestockofASVisreadilyavailable.ProtocolregardingtheinitialdosagesofASVis

communicatedandpracticed.



PatientandCommunity–InsistoninitiationofASVtherapyoncediagnosisisconfirmed.Communityrepresentativeinrogikalyan

samitiescanperiodicallymonitortheavailabilityofantisnake

venominthehospital.

5. DataSource ClinicalCaserecords/BedHeadTicketsofthesakebitecases

ClinicalAuditRecords

6. Definitions AntisnakeVenomTherapy–IntravenousinfusionofPolyvalent/SnakespecificAntisnakevenomwithminimumdoseof100ml.


QualityStandard-6-AtropineNeostigmineTherapyforNeurotoxicEnvenomation1.Statement AllpatientswithpresentationofNeurotoxic(neuroparalytic)

EnvenomationareprovidedAN(Atropine-Neostigmine)therapy

asperschedule

2.Rationale NeuroparalyticSnakebitemustbemanagedwithANtherapy

alongwithASV.ThedosagesofANtherapyshouldbegivenas

perguidelinesforrecoveryofpatients.

3.QualityMeasure

3a.Structure EvidenceofavailabilityofAtropineandNeostigmineandclinical

staffisskilledforANtherapy

3b.Process ProportionofneuroparalyticsnakebitecasesgivencompleteAN

therapyasperprotocol

Numerator-Totalno.ofneuroparalyticsnakebitecasesgivencompleteANtherapy

Denominator–Totalno.ofneuroparalyticsnakebitecasesattended


ServiceProvider–EnsureANtherapyisgivenasperprotocol.HealthAdministrators/QAOfficials–Ensuredrugsandconsumableareavailableandprotocolsfollowed.


Handoverregisters,Ambulancerecords

6.Definitions ANTherapy-Atropine0.6mgfollowedbyneostigmine(1.5mg)

tobegivenIVstatandrepeatdoseofneostigmine0.5mgevery

30minutesfor5doses.Thereaftertobegivenastaperingdose

at1hour,2hour,6hoursand12hour


QualityStandard-7-AntisnakeVenomAvailability1.Statement 24X7AvailabilityofAntisnakevenomisensuredindesignated

healthcarefacilities.

2.Rationale AntisnakeVenomistheonlyspecifictreatmentforsnakebite

andsavinglifesnakepatientsisdirectlylinkedforswiftand

adequateaccesstoASV.IndianPublicHealthStandards

mandatesavailabilityofLyophilyzedPolyvalentAntisnakeVenom

atPrimaryHealthCentersandaboveleveloffacilities.

3.QualityMeasure

3a.Structure Totalno.ofStockoutDaysforAntisnakeVenom

(No.ofdayswhenASVwasnotavailableaddedformonth)

3b.Outcome Proportionofpatientsdeniedtreatmentduetononavailability

ofASV

Numerator-No.ofPatientsweredeniedtreatment/referredto

higherfacilitybecauseofnonavailability/inadequatequantity

ofAntisnakevenom

Denominator-Totalno.ofsuspectedsnakebitecasesreceivedinthefacility


ServiceProvider–Ensurethatadequatestockofantisnakevenomisalwaysmaintainedatthefacility.Theoptimalstock

shouldtakeinaccountofusualcaseloadandtimetakento

replenishthestock.

HealthAdministrators/QAOfficials–EnsurethatASVispartofessentialdruglist.AvailabilityofASVisregularlymonitored.

Patient/Community-BeawareofthefacilitiesthosehaveprovisionforAntiSnakeVenom.Communityrepresentativesin

RogiKaylanSamitiesshouldmonitortheavailabilityofASVin

concernedfacility.

5.DataSource EmergencyRegister,CaseRecords

DrugStockRegister

6.Definitions PrimaryHealthCenter-Ahealthfacilityprimarylevelof

preventive,promotiveandcurativecaretoapopulationof

around25000.24X7PHCsusuallyhave6bedindoorfacilityand

canperformminorprocedures.


QualityStandard-8-ASVReaction1.Statement ASVreactionsareprevented/managedasperprotocol.

2.Rationale 20-60%ofpatientsonASVtherapymaydevelopearlyorlate

reactionandrarelymaymanifestintolifethreatening

anaphylaxisreaction.Someofthesereactionsmaybeprevented

byavoidingunnecessaryadministrationofASVanduseofaseptic

precautions.Someofthereactionwillstilldueingredientand

impurityintheASV.Thesereactionsshouldbemanagedby

administrationofdrugslikeEpinephrineandChlorpheniramine

Maleate

3.QualityMeasure

3a.Structure EvidencethatDrugsfortreatingASVReactionsareavailableat

designatedfacilityforASVtherapy.

Evidencethatclinicalstaffhasbeentrainedforpreventingand

managingASVreactions.

3b.Process ProportionofASVreactionstreatedwithEpinephrine/

ChlorpheniramineoutoftotalASVReaction

Numerator–No.ofpatientswithASVReactions(EarlyorLate)treatedwithEpinephrine(0.5mg)andChlorpheniramine(10mg)

Denominator–Totalno.ofsnakebitecasespresentedearlyorlateASVreaction

3c.Outcome ProportionofpatientsdevelopedASVreactionsoutoftotalno.

oftotalno.ofpatientsprovidedASVtherapy

Numerator-Totalno.ofsnakebitecasesdevelopedASVreaction

Denominator-Totalno.ofpatientsprovidedASVtherapy4.WhatQualityMeasuremeansforeachaudience

ServiceProvider–EnsurethatrequireddrugsareavailableandclinicalstaffhavebeentrainedformanagingASVreactions

HealthAdministrators/QAOfficials–Monitorthereactionand

findouttherootcause.GivefeedbacktoASVmanufacturers

andserviceproviders

Patient/Community-DonotinsistforASVtherapyifsignandsymptomsofenvenomationarenotconfirmedbyclinician

5.DataSource Patientsclinicalrecords

AdverseDrugReactions(ADR)records

6.Definitions ASVReaction–Anymajororminorreactionoccurreddueto

hypersensitivitytooneoftheingredientofASV,impurityinthe

drug,contaminationorduetounnecessaryadministrationof

ASV.


QualityStandard-9-StaffSkills&CompetenceforManagementofSnakebite1.Statement Healthcareprovideriscompetentandconfidenttomanage

snakebitecases

2.Rationale Snakebiteisamedicalemergencyrequirespromptandskilled

clinicalinterventiontosavethelifeofvictim.Asmostofthe

snakebitecaseshappeninruralareatheskillsrequiredto

managesuchcasesshouldbeavailableatfirstpointofcaremay

beaPrimaryorCommunityHealthCenter.

3.QualityMeasure

3a.Structure Evidencethatformaltraininghasbeenprovidedtothemedical

officersformanagementofsnakebitecases

EvidencethatupdatedStandardTreatmentGuidelines/Protocols

areavailablewithclinicalcarestaff

3b.Outcome Proportionofpatientsreferredtohigherfacilitiesbecauseof

lackskills/confidenceintreatingsnakebitecases.

Numerator-Totalno.ofsnakebitereferredtohigherfacilitiesbecauseoflackskills/confidenceintreatingsnakebitecases.

Denominator-Totalno.ofsuspectedsnakereceivedinfacility.4.WhatQualityMeasuremeansforeachaudience

ServiceProvider–EnsurethatclinicalcarestaffistrainingandSTGonmanagementofsnakebiteisreadilyavailable

HealthAdministrators/QAOfficials–ConductperiodicskillassessmentoftheMedicalofficersandarrangefortheirtrainings

PublishandDistributetheguidelinesonsnakebitetoall

stakeholders

5.DataSource TrainingRecords

ReferralRegister

6.Definitions


QualityStandard-10-PromotionofScientificManagementofSnakebiteincommunity

1.Statement Healthfacilitypromotestheinformationandeducationregarding

scientificmanagementofsnakebiteincommunity

2.Rationale Thereareseveralmythsandtraditionalmethodsofmanaging

snakebiteprevalentindifferentpartofIndiaeg.Tying

tourniquets,scarification,Ojhaetc.Noneofthismethodare

clinicallyproveneffective.Duemisbelievesandlackof

informationmanyofthevictimstillindulgetheseremedies

whichleadswastageofprecioustimeandpoorprognosis.Public

Healthsystemandserviceprovidersshouldeducatethe

communityregardinghowtopreventsnakebitesaswellasdo’s

anddon’tsincaseofsnakebite.

3.QualityMeasure

3a.Structure EvidencethatIECmaterialhasbeendisplayedathealthfacilities

andpublicplacesregardingpreventionandfirstaidincaseof

snakebitespeciallyinendemicareas.

3b.Outcome Proportionofsnakebitepatientsattended,thosehavealready

gonethroughsometraditionaltherapyormalpracticeliketrying

tourniquetsbeforereachinghealthcarefacility

Numerator-Totalno.snakebitepatientsreceivedtraditionalremedybeforereachingthehealthcarefacility

Denominator-Totalno.ofSnakebitepatientsattendedatFacility


ServiceProvider–Promotehealtheducationonsnakebiteto

patientsandvisitorsinhospitalthroughIECdisplayand

counseling.

HealthAdministrators/QAOfficials–Planandimplement

healthcampaignsonpreventionofsnakebiteandfirstaid.

Patients&Community–Understanddo’sanddon’tsincaseofsnakebite.

Followthepreventivemeasurestoavoidsnakebitessuch

avoidingsleepingonfloor,opendefecation,confrontingwith

snakeetc.

5.DataSource CommunityandHealthCarefacilitysurvey

6.Definitions IEC–Information,EducationandCommunication

management of snake bite - nhm · although total number of bites may be more than 5-6 lakhs but...

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