snake bite
TRANSCRIPT
SNAKE ENVENOMATION
SNAKESSSSS…
FIRST AID
REASSURANCE
IMMOBILISATION
APPLY TORNIQUET
MINIMAL WOUND HANDLING
SALINE CLEANING, STERILE DRESSING
? INCISION ? SUCTION
? LOCAL ANTIVENOM
WHEN A VICTIM ARRIVES
ASSESS VITAL SIGNS
START AN IV LINE
MONITOR – CARDIAC RHYTHM, BP, [O2]
SEND BASELINE INVESTIGATIONS
CONFIRMING THE DIAGNOSIS
IS IT A SNAKE BITE ?
LOOK FOR FANG MARKS
COULD IT BE ANYTHING ELSE ?
BITES OF OTHER INSECTS
SCRATCHES / PENETRATION BY THORNS
CONFIRMING THE DIAGNOSIS
IS IT A POISONOUS SNAKE ?
WATCH FOR LOCAL / SYSTEMIC TOXICITY
WHICH SPECIES IS INVOLVED ?
SNAKE BITE - PROFILE
2500 - 3000 SPECIES WORLDWIDE
500 VENOMOUS SPECIES
52 POISONOUS SPECIES IN INDIA
INCIDENCE > 5 MILLION PER YEAR
DEATH IN TRANSIT, ? TRUE INCIDENCE
INDIAN SNAKESELAPIDAE - COMMON / KING COBRAS,
- KRAIT
INDIAN SNAKESVIPERIDAE - RUSSELS, SAW SCALED,
PIT VIPERS
INDIAN SNAKES• HYDROPHIDAE - SEA SNAKES
SNAKE BITE - PREVALENCE IN INDIA
60 -65% - SAW- SCALED VIPER
20 -25% - RUSSELS VIPER
10 -15% - COBRAS / SEA SNAKES
POISONOUS VS
NON-POISONOUS SNAKES
HAZARDOUS BITES
ACCIDENTAL
LOWER LIMB BITES
DEVELOPING COUNTRIES
ILLEGITIMATE BITES
SNAKE HANDLING
UPPER LIMB BITES
DEVELOPED COUNTRIES
SNAKE BITE -PATHOPHYSIOLOGY
CONSTITUENTS OF SNAKE VENOM
ENZYMES
NON - ENZYMATIC COMPOUNDS
NON - TOXIC PROTEINS
SNAKE VENOM ENZYMES
PHOSPHALIPASES HYDROLASES PHOSPHATASES PROTEASES, ESTRASESACETYLOCHOLINESTERASESTRANSAMINASES HYALURONIDASESATP ASE, NUCLEOSIDASES
SNAKE VENOM NON ENZYMATIC COMPOUNDS
NEUROTOXINS
MYOTOXINS
CARDIOTOXINS
HAEMORRHAGENS
SNAKE VENOMNON TOXIC PROTEINS
CARBOHYDRATES
METALS
INFECTIVE ORGANISMS
VENOM ACTIONS
DISRUPT CELLULAR FUNCTIONS
BREAK DOWN OF ENDOTHELIUM
INCREASE VASCULAR PERMEABILITY
ACTIVATE COAGULATION SYSTEM
DIRECT CYTOLYTIC ACTION
BREAK TISSUE BARRIERS
PRODUCE ORGAN DAMAGE
SPECIES VENOM PER BITE FATAL DOSE
COBRA 60 MG 12 MG
RUSSELS 63 MG 15 MG
KRAIT 20 MG 6 MG
SAW SCALED VIPER 13 MG 8 MG
FATAL DOSE
SNAKE BITE - MANIFESTATIONS
FRIGHT & FLIGHT RESPONSES
FEAR OF DEATH
PALLOR, SWEATING, VOMITING
SHOCK & DEATH
NO SYMPTOMS / SIGNS
LOCAL EFFECTS
SYSTEMIC EFFECTS
SNAKE BITE MANIFESTATIONS
SNAKEBITE NO MANIFESTATIONS
NON POISONOUS SNAKES
SUPERFICIAL, DRY BITES
PROTECTION BY CLOTHING, FOOT WEAR
SNAKE BITELOCAL MANIFESTATIONS
ONSET WITHIN MINUTES
SWELLING , ERYTHEMA , BULLAE,
HEAMORRHAGE
TISSUE NECROSIS, GANGRENE
RAPID AND EXTENSIVE SPREAD
REGIONAL LYMPADHENOPATHY
SECONDARY INFECTION
SNAKE BITE- SYSTEMIC MANIFESTATIONS
ONSET FROM FEW MINUTES - DAYS
DEPENDS ON VENOM COMPOSITION
NEUROTOXIC - COBRA / KRAIT
HEAMORRHAGIC - VIPERS
MYOTOXIC - SEA SNAKES
SNAKE BITENEUROTOXICITY
PRODUCES NEUROMUSCULAR BLOCKADE
FLACCID NEUROMUSCULAR PARALYSIS
PTOSIS, OPTHALMOPLEGIA
FACIAL INVOLVEMENT - EARLY
REFLEXES SPARED
INTERCOSTALS / DIAPHRAGM / PUPILLARY
COMA - TERMINAL
SNAKE BITECARDIO VASCULAR MANIFESTATIONS
HYPOTENSION COMMON
DISTURBANCES IN RATE / RHYTHM
PANCARDITIS
ELECTROLYTE DISTURBANCES
SNAKE BITEHAEMATOLOGICAL MANIFESTATIONS
ENDOTHELIAL DAMAGE
INTRAVASCULAR COAGULATION
FIBRINOLYTIC SYSTEM ACTIVATION
INTRAVASCULAR HEMOLYSIS
PLATELET DYS FUNCTION
LOCAL / SYSTEMIC BLEEDING
SNAKE BITERENAL DAMAGE
FEW MINUTES TO DAYS
OLIGURIC OR NON OLIGURIC R.F
ATN, GN, INT-NEPH,
CORTICAL NECROSIS, VASCULITIS
SNAKE BITEUNUSUAL MANIFESTATIONS
DELAYED TOXICITY
RECURRENT TOXICITY
TOXEMIA WITHOUT BITES
LONG TERM EFFECTS
UNUSUAL MANIFESTATIONS
DELAYED TOXICITY
LOCAL BLEBS AS VENOM DEPOT
INACCESSIBLE TO ANTI - VENOM
UNUSUAL MANIFESTATIONS
RECURRENT TOXICITY
VENOM RELEASE FROM BLEBS
PARTIAL THERAPY
UNUSUAL MANIFESTATIONSTOXEMIA WITHOUT BITES
SPITTING COBRAAIMED AT VICTIMS EYE
CONJUNCTIVITIS,
CORNEAL ULCERS
UNUSUAL MANIFESTATIONS
LONGTERM EFFECTS
PERSISTANT EDEMA
SERUM SICKNESS
CORTICAL NECROSIS
FACTORS AFFECTING OUTCOMEHOST FACTORS
BITES IN CHILDREN
PROXIMAL BITES
EXERTION POST BITE
PROTECTION BY CLOTHING /FOOT WEAR
SECONDARY INFECTION
FACTORS AFFECTING OUTCOMEAGENT FACTORS
NUMBER & DEPTH OF BITES
CONDITION OF FANGS
SPECIES OF SNAKES
DURATION OF BITE
? SIZE OF SNAKES
FACTORS AFFECTING OUTCOMEENVIRONMENTAL FACTORS
NATURE OF FIRST AID
TIME TAKEN TO TREAT THE VICTIM
CIRCUMSTANCES THAT PROVOKED
THE BITE
SNAKE BITELAB DATA
HEMOGRAM, PERIPHERAL SMEAR
COAGULATION PROFILE-BT,CT,FDP
URINE ANALYSIS
UREA, CREATININE, E.LYTES, SUGAR
CXR, ECG
PERIODIC MONITORING
SNAKE BITESPECIFIC THERAPY
MONO / POLYVALENT ANTIVENOM
INDICATIONS –
SEVERE LOCAL/SYSTEMIC SYMPTOMS
NO STANDARD PROTOCOL
WATCH FOR HYPERSENSTIVITY
SNAKE BITEANTIVENOM
SENSITIVITY TESTING
0.02 ML OF 1:10 SOLUTION I.D
ERYTHEMIA&WHEAL >10mm IN 30M
SNAKE BITEANTIVENOM
DESENSITATION
0.01 ml of 1:100 SOLUTION SC
INCREASE VOLUME EVERY 15 M TILL 1ml
1 ML SC EVERY 2 HOURS
SNAKEBITE - SEVERITY
MILDMODERATE
SEVERE
MILD ENVENOMATION
CELLULITIS < 2CM/HR
PT, APTT - NORMAL
FDP < 5 , BT, CT - NORMAL
CARDIOTOXICITY - NIL
NEUROTOXICITY - NIL
HYPOTENSION - NIL
MYOTOXICITY - NIL
MODERATE ENVENOMATION
CELLULITIS 2-5 CM/HR
PLATELET > 20,000
FDP > 5 , BT, CT - NORMAL
CARDIOTOXICITY–LV DYSFUNCTION(MILD-MOD)
NEUROTOXICITY - MILD PTOSIS
WEAKNESS OF LIMBS
NO RESPIRATORY FAILURE
HYPOTENSION - SYSTOLIC > 90
SEVERE ENVENOMATIONCELLULITIS > 5CM/HR
PLATELET COUNT < 20,000
FDP > 200, BT, CT - PROLONGED
CARDIOTOXICITY - SEVERE LV DYSFUNCTION
NEUROTOXICITY - SEVERE PTOSIS,
RESPIRATORY INSUFFICIENCY
HYPOTENSION - SYSTOLIC < 90
MYOTOXICITY - RHABDOMYOLYSIS,MYOGLOBINURIA
SNAKE BITEANTIVENOM DOSAGE
MILD ENVENOMATION - 15 VIALS PER DAY
MODERATE ,, - 30 VIALS PER DAY
SEVERE ,, - 60 VIALS PER DAY
SUPPORTIVE THERAPY
DIC - BLOOD & BLOOD PRODUCTS
SHOCK - VOLUME SUPPLEMENTS /INOTROPHS
ARF - CONSERVATIVE / DIALYSIS
CNS - NEOSTIGMINE + ATROPINE
CVS - ANTI ARRYTHMICS / INOTROPHS
ANTIBIOTICS - TETANUS PROPHYLAXIS
IMMEDIATE MEASURES
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RECORD
�TYPE OF SNAKE�TIME OF BITE�SITE OF BITE�NUMBER OF FANG MARKS�TYPE OF FIRST AID GIVEN
ON EXAMINATION
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PAININDURATION
CREPITUSCELLULITIS
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• PETECHIAE• PURPURA• LOCAL BLEED• ENT BLEED• TACHYCARDIA• HYPOTENSION• PROLONGED CLOTTING TIME• HEMOCONCENTRATION
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• WEAKNESS,PTOSIS,OPTHALMOPLEGIA• PALATAL,PHARYNGEAL PARALYSIS• RESP MUSCLE PARALYSIS-HYPOXIA,ACIDOSIS• CONVULSIONS,COMA
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• CARDIOTOXICITY,ARRHYTHMIAS• RENAL FAILURE-OLIGURIA,UREMIA,VOMITING• COMPARTMENT SYND,GANGRENE,NECROSIS
INVESTIGATIONS•BT,CT,PT,APTT,FDP,•PLATLET COUNT,HB,TC,DC,•S.CREATITNE,S.ELECTROLYTES•ABG,ECG,CPK(WHEN REQUIRED)
TREATMENT
•ANTISNAKE VENOM•OTHER MEASURES
PROTOCOL FOR MANAGEMENT OF SNAKE ENVENOMATION
CONCLUSION
SNAKE BITE - UNIVERSAL PROBLEM
EARLY INTERVENTION - LIFE SAVING
NEED FOR UNIVERSAL PROTOCOL
THANK YOU