snake bite

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2 : Ophitoxaemia” Snake bite envenomation 2500-3000 species worldwide 500 venomous 52 poisonous snakes in India
3 : Indian Scenario 200,000 bites /year 35,000 - 50,000 deaths / year
4 : Poisonous non-poisonous Triangular head Round head Fangs, upper jaw No fangs Grooved Hollow Venom channel Pupil elliptical rounded Pit present (viperidae - crotalidae)
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6 : Compressor glandulae muscle Venom gland Accessory venom gland Secondary venom duct Venom duct
7 : Common snakes Common snakes in India (A) Elapidae Common cobra (Naja naja ) King cobra (Ophiophagus hannah) Krait (Bungarus caeruleus )
8 : (B) Viperidae Russell’s viper (Daboia rusellii) Pit viper Saw scaled (C) Hydrophidae Sea snake (Achrocardus granulatus)
9 : ELAPIDAE short permanently erect fangs
10 : Cobra ( Naja Naja) Indian name NAG Yellowish/ dark brown/ black Hood- spreads when disturbed 5-6 feets Inject as well as spit the venom
11 : Krait (B. caeruleus) Indian name SURYAKANDAR SAWLI MANYAR Black, smooth , glossy Hexagonal scales White/yellow circular bands Nocturnal 3- 5 feets
12 : VIPERIDAE Long fangs Folded,erected when the snake strikes. Two subgroups Typical vipers (Viperinae) Pit vipers (Crotalinae).
13 : Russel viper Indian name RAKTYA GHONAS KAMBLYA Flat triangular head small scales Body stout round Short tail Long hissing sound
14 : Pit viper Indian name HARA NAG, HIRWA GHONAS Greenish Yellow lip scales Pit like Sensory organ
15 : Sea snake SAMUDRI SARP, SAGARI SARP Blunt head Tiny knobby scales Grey/white body White bands
16 : Snake venoms >20 constituents Proteins Enzymes Polypeptide toxins
17 : Snake venoms EPILADAE VIPERIDAE Phospolipase a2 Phospolipase a2 Polypeptide Procoagulants Hydrolases Hemorrhagins
18 : Phospholipases Haemolytic Myolytic Damage : Cell membranes Endothelium Skeletal muscle Nerve RBC
19 : Polypeptides compete with acetylcholine at NM junction curare-like paralysis
20 : Procoagulant enzymes activate different steps of the clotting cascade Formation of fibrin in the blood stream immediately broken down by the fibrinolytic system Disseminated Intravascular Coagulopathy
21 : Haemorrhagins Zinc Metalloproteinases endothelial damageof blood spontaneous systemic hemorrhage
22 : Cytolytic/Necrotic toxins Hydrolases Phospholipases A Polypeptide toxins Increase permeability Destroy cell membranes and tissue Local swelling
23 : Lethal Dose For Venom Krait- 6 mg Cobra- 12 mg Saw-scaled Viper- 8 mg Russel’s viper- 15 mg Average Yield Per Bite 20 mg 60 mg 13 mg 63 mg
24 : Dry bites… DO NOT RESULT IN INJECTION OF VENOM 30% Cobras 50% Malayan pit vipers Russell’s viper 5-10% saw-scaled vipers
25 : Early Symptoms and Signs Local pain Burning/bursting/ throbbing Extends proximally up the bitten limb Tender painful enlargement of the Regional Lymph nodes..
26 : Local Symptoms and Signs Local pain Local bleeding Bruising Lymphangitis LN Enlargement Blistering Local infection & Abscess formation Necrosis Fang marks
27 : Systemic Symptoms General Nausea Vomiting Malaise Abdominal pain Weakness Drowsiness Prostration
28 : Cardiovascular (Viperidae) Visual disturbances Dizziness Faintness Collapse Shock Hypotension Cardiac arrhythmias Pulmonary oedema Conjunctival oedema
29 : Bleeding and clotting disorders (Viperidae) Recent wounds Fang marks venepunctures Old partly-healed wounds Spontaneous systemic bleeding
30 : Neurological (Elapidae, Russell’s viper) Drowsiness Paraesthesiae Abnormal taste and smell Ptosis Ext. ophthalmoplegia Facial paralysis Aphonia Difficulty in swallowing secretion Respiratory paralysis generalised flaccid paralysis
31 : Cobra split ophthalmia Corneal ulceration Corneal scarring Endophthalmitis
32 : Rhabdomyolysis Sea snakes, Russell’s viper Generalised pain stiffness ,tenderness of muscles Trismus Myoglobinuria Hyperkalemia, Cardiac arrest Acute renal failure
33 : Renal (Viperidae, sea snakes) Loin (lower back) pain Haematuria Haemoglobinuria Myoglobinuria Oliguria / Anuria Uraemia
34 : Endocrine Acute pituitary/adrenal insuff. with Russell’s viper Acute phase: Shock Hypoglycaemia Chronic phase (mnths to yrs after): Loss of 2ry sexual hair Amenorrhoea Testicular atrophy Hypothyroidism
35 : Grades of envenomation Grade 0 No envenomation No local signs by six hours No systemic signs by 24 hours Grade 1 Minimal envenomation Local swelling Pain without progression No systemic or lab abnormalities Rx- Pain control Careful observation
36 : Grade 2 Moderate envenomation Swelling Pain Ecchymosis progressing beyond site of injury Mild systemic signs nausea ,vomitting Perioral and scalp parasthesias Fasciculations OR Lab manifestations e/o Coagulopathy Rx- Antivenom
37 : Grade 3 Severe envenomation Marked local response Vesicles and Bullae Systemic findings as in moderate plus Hypotension Shock Bleeding diathesis Respiratory distress e/o Coagulopathy Anaemia, Metabolic acidosis Rx- Antivenom
38 : Long term complications At the site of the bite : Chronic ulceration Infection Osteomyelitis Arthritis Malignant transformation may occur in skin ulcers after a number of years
39 : Management of snake bite First aid treatment Transport to hospital Rapid clinical assessment and resuscitation Detailed clinical assessment and species diagnosis Investigations/laboratory tests
40 : Antivenom treatment Observation of the response to antivenom: decision about the need for further dose(s) of antivenom Supportive/ancillary treatment Treatment of the bitten part Rehabilitation Treatment of chronic complications
41 : Recommended first aid methods Reassurance Immobilise Pressure-Immobilisation for elapids -Not for vipers -
42 : Pressure immobilisation method Ideally, an elasticated, stretchy, crepe bandage, approximately 10 cm wide and at least 4.5 metres long should be used The bandage is bound firmly around the entire bitten limb, starting distally around the fingers or toes and moving proximally, to include a rigid splint
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45 : Caution Release of a tight tourniquet or compression bandage may result in the dramatic development of severe systemic envenoming Ideally, compression bandages should not be released until the patient is in hospital, resuscitation facilities are available and antivenom treatment has been started NO TIGHT ARTERIAL TORNIQUETS
46 : Useless or Dangerous Methods Local incisions Pricks at the site of the bite or in the bitten limb Attempts to suck the venom Snake stones Electric shock Topical instillation or application of chemicals, herbs or ice packs.
47 : Avoid any interference with the bite wound THIS MAY LEAD TO Infection Increase absorption of the venom Increase local bleeding
48 : Snake Do not attempt to kill it If killed it should be taken to the hospital Do not handle the snake with bare hands as even a severed head can bite !!!
49 : Rapid clinical assessment resuscitation Oxygen administration IV access. ABC The level of consciousness CPR may be needed
50 : Detailed Clinical Assessment and Species Diagnosis History progression of symptoms and signs Site of bite & Time of bite Snake identification
51 : Physical Examination Examination of the bitten part Extent of swelling Tenderness to palpation LN enlargement and lymphangitis Tense oedema Arterial pulses Compartmental syndrome
52 : General Examination Blood pressure Postural drop hypotension indicative of hypovolemia Heart rate Petechiae, Purpura & Echymoses Chemosis Epistaxis
53 : Abdominal tenderness s/o Gastrointestinal Retroperitoneal bleeding Loin pain,tenderness s/o Acute renal ischaemia (Russell’s viper bites) Intracranial haemorrhage is suggested by lateralising neurological signs, asymmetrical pupils, convulsions or impaired consciousness
54 : Neurotoxic Features Ptosis Ophthalmoplegia Trismus Check facial muscles, tongue, gag reflex Flexors of the neck may be Paralysed ? Broken neck sign
55 :
56 : Bulbar and Respiratory Paralysis Inability to swallow secretions “Paradoxical respiration” Objective measurement of ventilatory capacity is useful. Use a peak flow meter/spirometer Single breath count
57 : Generalised Rhabdomyolysis Muscles,of the neck, trunk and proximal limbs,become tender and painful on movement and may become paralysed Sea snake bite pseudotrismus Myoglobinuria may be evident 3 hrs after bite.
58 : Examination of pregnant women Fetal distress ( fetal bradycardia) Vaginal bleeding and threatened abortion. Monitor uterine contractions and FHR Lactating women who have been bitten by snakes should be encouraged to continue breast feeding.
59 : Investigations/laboratory tests 20 minute whole blood clotting test (20WBCT) Haemoglobin concentration/haematocrit: Increased d/t transient increase capillary permeability ex. Russell’s viper Decrease Blood loss Intravascular haemolysis ex. Russell’s viper
60 : Platelet count : Decreased viper WBC cell count : Leucocytosis Blood film : Fragmented RBC “ Helmet cell” Schistocytes Plasma/serum : Haemoglobinaemia Myoglobinaemia.
61 : Biochemical Abnormalities ELEVATED Aminotransferases , Creatine kinase Aldolase - Severe local damage Generalised muscle damage Bilirubin - massive extravasation of blood Creatinine, urea or blood urea nitrogen -renal failure.
62 : Early hyperkalaemia -sea snake bites Bicarbonate low - metabolic acidosis (ARF) Arterial blood gases ,pH -respiratory failure -respiratory or metabolic acidosis
63 : Urine Examination Dipsticks Blood/ Hb/myoglobin Microscopy - RBC Red cell casts - glomerular bleeding Massive proteinuria - Russell’s viper
64 : Antivenom Treatment Immunoglobulin enzyme refined F(ab)2 fragment of IgG) serum or plasma of a horse or sheep Monovalent or monospecific antivenom Polyvalent or polyspecific antivenom
65 : INCLUDES Indian Cobra Indian Krait Russell’s viper Saw-scaled viper
66 : Neutralisation of Venom 1 cc of ASV neutralises Cobra venom Russel’s Viper venom Saw scaled viper venom Krait venom 0.6 mg 0.45 mg
67 : Indications for Antivenom Systemic Envenoming Haemostatic abnormalities: Spontaneous systemic bleeding Coagulopathy Thrombocytopenia (<100 x 109/L) Neurotoxic signs: Ptosis, external ophthalmoplegia, paralysis…
68 : Cardiovascular abnormalities: Hypotension, shock, cardiac arrhythmia, abnormal ECG Acute renal failure: Oliguria/anuria, rising blood creatinine/urea Haemoglobinuria/myoglobinuria: dark brown urine, evidence of intravascular haemolysis or generalised rhabdomyolysis (muscle aches and pains)
69 : Supporting laboratory evidence of systemic envenoming Local Envenoming Local swelling involving more than half of the bitten limb (in the absence of a tourniquet) Swelling after bites on the digits (toes and especially fingers)
70 : Rapid extension of swelling (for example beyond the wrist or ankle within a few hours of bites on the hands or feet) Development of an enlarged tender lymph node draining the bitten limb
71 : Antivenom treatment should be given as soon as it is indicated.It may reverse systemic envenoming even when this has persisted for several days In the case of haemostatic abnormalities, for 2 or more weeks. local envenoming effective within first few hours after the bite.
72 : Route i.v. 100-200 mL = 10 vials Dilute in NS /D5% 250-500 ml Slowly over 1-2 hrs Observe for reactions i/c/o reactions increase dilution over long duration I.M route should not be used
73 : Antivenom reactions Early 10 min- 3 hrs Itch (often over the scalp) Urticaria Dry cough Fever Nausea Vomiting Abdominal colic Diarrhoea
74 : Severe life-threatening anaphylaxis: Hypotension bronchospasm angio-oedema
75 : FOR HYPERSENSITIVITY REACTIONS s/c Adrenaline i/v Antihistamines Corticosteroid
76 : Late (serum sickness type) reactions 1 - 12 (mean 7) days Fever Arthralgia Nausea Myalgia Vomiting Lymphadenopathy Diarrhoea Itching RX 5-7 DAYS Recurrent urticaria PREDNISOLONE Mononeuritis multiplex
77 : Pyrogenic (endotoxin) reactions Contamination 1-2 hours after treatment Chills (rigors) Fever Vasodilatation Hypotension Febrile convulsions may be precipitated
78 : Observation of the response to antivenom Nausea, headache and generalised aches and pains - very quickly Spontaneous systemic bleeding (eg from the gums) - within 15-30 minutes. Blood pressure - 30-60 minutes
79 : Criteria for giving more antivenom Persistence or recurrence of blood incoagulability Deteriorating neurotoxic or cardiovascular signs
80 : If the blood remains incoagulable (as measured by 20WBCT) six hours after the initial dose of antivenom, the same dose should be repeated In patients who continue to bleed briskly, the dose of antivenom should be repeated within 1-2 hours
81 : Conservative treatment when no antivenom is available When antivenom is unavailable Bite by a species against whose venom there is no available specific antivenom (for example coral snakes - genera, sea snakes)
82 : Neurotoxic envenoming with respiratory paralysis Assisted ventilation Mechanical ventilation or Ambu bag Anticholinesterases Neostigmine 0.5 mg slow IV push or SC q20min (pretreat with atropine)
83 : Edrophonium chloride 0.25 mg/kg BW IV over 3-4 min Observe 10- 20 min OTHERS Prostigmine Distigmine Pyridostigmine Ambenonium
84 : Hemostatic abnormalities Strict bed rest Clotting factors and platelets Fresh frozen plasma with platelet concentrates if these are not available, fresh whole blood Avoid Intramuscular injections
85 : Shock,Myocardial damage Hypovolaemia : ivf Pressor drugs (dopamine or epinephrine-adrenaline) Hypotension associated with bradycardia : Atropine
86 : Renal failure : conservative treatment or dialysis
87 : Bacterial infections Prophylactic course of penicillin (erythromycin for penicillin-hypersensitive patients) single dose of gentamicin Booster dose of tetanus toxoid is recommended
89 : Clinical features of compartmental syndrome Disproportionately severe pain Weakness of intracompartmental muscles Pain on passive stretching Hypoaesthesia of areas of skin supplied by nerves running through the compartment Obvious tenseness of the compartment
90 : Criteria for fasciotomy Clinical evidence of an intra compartmental syndrome Intra compartmental pressure >40 mmHg
91 : HOW TO AVOID Use torch in night While going near water sources use stick and torch Use of cap while going through forest Do not through food near houses RATS - SNAKE Take precautions on sea shore
92 : Thank you


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snake bite
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