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Management of snake bite

Management of snake bite. Dr Arya Jith. Best way to a manage Is to prevent a snake bite…..!. How to prevent snake bites. A WORLD WITHOUT SNAKES NEARLY A QUARTER OF US WOULD GO HUNGRY THEY ARE IMPORTANT ELEMENTS IN FOOD CHAIN THAT CONTROL RODENT POPULATION. INDIAN SCENARIO.

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Management of snake bite

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  1. Management of snake bite Dr Arya Jith

  2. Best way to a manage Is to prevent a snake bite…..!

  3. How to prevent snake bites • A WORLD WITHOUT SNAKES • NEARLY A QUARTER OF US WOULD GO HUNGRY • THEY ARE IMPORTANT ELEMENTS IN FOOD CHAIN THAT CONTROL RODENT POPULATION

  4. INDIAN SCENARIO • 5 DANGEROUSLY POISONOUS SNAKES KING COBRA COMMON COBRA COMMON KRAIT RUSSELL’S VIPER SAWSCALED VIPER MOST COMMON POISONOUS SNAKE IS COMMON KRAIT For more presentations www.medicalppt.blogspot.com

  5. FIRST STEP • TO IDENTIFY WHETHER IT WAS A POISONOUS SNAKE. • 216 SPECIES- 52 VENOMOUS • IF THE PAIN NUMBNESS AND OEDEMA IS SPREADING THEN IT IS A VENOMOUS SNAKE. • SUSPECTED SNAKE BITE OBSERVATION 24 HOURS

  6. SYMPTOMATOLOGY OF NON VENOMOUS SNAKES • Universal fear - a state of shock • Bite site -multiple teeth impressions • significant local pain or swelling -ABSENT • Adequate reassurance and symptomatic treatment . For more presentations www.medicalppt.blogspot.com

  7. eXAMINATION • To rule out ptosis Evidence of early external ophthalmoplegia . • size and reaction of the pupils. • Early paralysis of pterygoid muscles. • “broken neck sign

  8. Local examination Oedema petechiae bullae oozing from the wound should be noted Extent of swelling circumference of the bitten limb should be noted every 15 minutes- spreading

  9. Evidence of systemic envenomation • CT> 10 MINUTES • Bleeding manifestations • Oliguria /haematuria • Hypotension • Ptosis • Circumoral paraesthesia • Aphonia/Dysarthria

  10. classification • GRADE0 – NO ENVENOMATION • GRADE 1- MINIMAL ENVENOMATION (local pain and swelling) • GRADE2-MODERATE ENVENOMATION (Pain ,swelling,ecchymosis spreading +mild systemic/ lab manifestations) GRADE 3-SEVERE ENVENOMATION (Marked local response+severe systemic findings+significant lab findings)

  11. INVESTIGATIONS • Blood grouping • Hb, elevated PCV • TC-leucocytosis • Platelet count- thrombocytopenia • Peripheral smear – Haemolysis • BT,CT(20 min) • prolonged PT ,aPTT • Urea Serum Electrolytes- hyperkalemia • Urine Routine-haematuria • Metabolic /resp acidosis

  12. monitoring • Level of consiousness • Pulse, BP, Resp rate,Capillary refill time • Clotting time 1/2hr -1hourly • Urine output • Muscle weakness

  13. TREATMENT • GRADE 0-NO ENVENOMATION Local wound care Injn TT Observation -24 hrs

  14. GRADE 1 • MINIMAL ENVENOMATION Injn TT Antibiotics (inj CP/Ampicillin) Observe for 24 hours

  15. Grade 2 and 3 • Moderate and Severe Envenomation Injn TT Antibiotics(Ampicillin /CP/ 3 rd genertn cephalosporins+ metronidazole) local anti oedema measures

  16. NEVER APPLY A TOURNIQUET ABOVE THE SITE • IF THE PATIENT COMES WITH A TOURNIQUET alwaysCHECK FOR VASCULARITY • Do not suck out venom • Do not incise the bite wound nor apply any chemicals

  17. Anti snake venom (Asv)

  18. Asv- anti snake venom • Antivenom is immunoglobulin (usually the enzyme refined F(ab)2 fragment of IgG) purified from the serum or plasma of a horse or sheep that has been immunized with the venoms of one or more species of snake. • Monovalent or monospecific antivenom • Polyvalent • India –polyvalent is available which act against the venom of commonly found snakes in india

  19. Indications of asv • Neurotoxicity • Bleeding/coagulopathy • Myoglobinuria/haemoglobinuria • Cardiac toxicity • Local swelling involving more than half of the bitten limb • Rapid extension of swelling • Development of an enlarged tender Lymph node draining the bitten limb • ARF

  20. dosage • 10 vials polyvalent asv(irrespective of body weight and age) • 2nd dose - overt bleeding is present 10 vials OR Do 20 minute clotting time and give 2 vials Q6H till the coagulation parameters are normal

  21. How to give asv ? • No test dose is required • One vial is added with 100 ml of normal saline. After 10 -15 minutes 9 vials can be added in the same fluid over one hour

  22. Asv reaction • Urticaria ,itching ,fever , shaking chills ,nausea ,vomiting ,diarrhoea abdominal cramps ,tachycardia hypotension , bronchospasm and angioedema • ASV is discontinued • 0.01mg/kg of Adrenaline is given (1:1000)as IM should be given

  23. Long term reaction • 100mg of Hydocortisone(2mg/kg) and 10mg of H1 antihistamine (children- 0.2mg/kg) IV 2nd dose of Adrenaline 0.5 mg (1:1000) IM can be repeated Patient is recovered ASV can be restarted slowly within 10 – 15 minutes

  24. Timing of asv • Best effect – used within 4 hours • Can be administered upto 48 hours • Efficacy is seen upto 6- 7 days

  25. Response to asv • Normalization of BP • Bleeding stops within 15 – 30 mts • Normalization of coagulation parameters within 6 hours • Neurological sign will be resolving within 30-48 hours

  26. Neuroparalytic symptoms • Neostigmine -0.05mg to 0.1mg/kg every 4 hours • Atropine 0.02mg/kg (5minutes prior to neostigmine) Watch for ptosis

  27. complications • Shock • Renal failure • Myocardial failure • Shock lung • Bleeding

  28. Capillary leak syndrome • PUFFINESS • CHEMOSIS • PAROTID SWELLING • Rx - methyl prednisolone (10mg/kgQ8H) x 3days

  29. shock

  30. If renal function is normal Start with volume expanders(20ml/kg of isotonic soln) Corrected? Symptoms of other shock hypovolemic shock

  31. Cardiogenic shock • Raised JVP • Oedema • Signs of pulmonary oedema • Feeble heart sounds • Changes in ecg • Start Dobutamine Drip (5-10microg/min) Uncorrected-Neurogenic shock

  32. Neurogenic shock • Dopamine drip(10-12microg /min) • BP is coming up Nor adrenaline (0.1- 0.5 microgram/kg)

  33. Renal failure • Early dialysis

  34. Myocardial failure • Treat cardigenic shock • Treat ccf • Avoid fluid overload • Oxygen inhalation

  35. Shock lung • Tacypnea • Hypoxemia • Unexplained drowsiness • Mild acidosis • treatment-o2inhalation cpap ventillation

  36. bleeding • Correct coagulation failure • FFP-10ml/kg • Correct platelet deficiency • Whole blood– frank bleeding

  37. Thank you

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