BANGALORE BAPTIST HOSPITAL Snakebite Study Workshop Vellore, Mar - - PowerPoint PPT Presentation

BANGALORE BAPTIST HOSPITAL

Snakebite Study Workshop Vellore, Mar 2013 Dr Tarun/ Dr Indira Menon

Questionnaire.

• Name of centre—BBH
• No. of snake bites per year-- 55—60
• No. of snake bites in last year-- -65
• No. of venomous bites last year --50 approx.
• No. of non venomous bites in last year—15
• Snake bites due to main syndromes %
• Haematotoxic—90% Neuro—10%
• Combination 1-2 %
• No.of cases where dead snakes are brought—5

Questionnaire (contd.)

• Indications for ASV—systemic or local envenomation
• No prophylactic adrenaline is given prior to ASV
• Initial dose of ASV—8—10 vials both haematotoxic and

neurotoxic.

• Time duration of administration –1 hour
• Response to ASV is monitored by 20 WBCT every 6

hourly

• When to repeat dose of ASV?
• Haematotoxic every 6 hours—10 vials
• Neurotoxic every 1 hour –10 vials
• Is continuous low dose of ASV administered after

normalization of coagulation –NO

Questionnaire (contd.)

• Ceiling dose—Haematotoxic—30 vials( exceeded very

rarely)

• Neurotoxic— 20 vials
• Do you use Neostigmine in neurotoxic bites –Yes
• Indication for antibiotics—local swelling/ cellulitisChoice
• f antibiotic—Crystalline penicillin + ciprofloxacin +

metronidazole.

• When to admit to ICU ?—all patients are observed in

ICU initially.

• When do you refer –we do not refer.
• Which ASV do we use—Bharath serum
• Stock in pharmacy at any given time—20—30 vials

Questionnaire (contd.)

• Last year cases of allergy to ASV—
• minor -10
• angioedema—swelling mouth/ bronchospasm—2
• anaphylaxis fall in BP---2
• death –nil

Questionnaire (contd.)

• Outcomes :
• Mechanical ventilation –10—15 %
• Haemodialysis—2-3 %
• Deaths—2 %
• Facilities available:
• Coagulation parameters –yes
• Blood transfusion—yes
• Haemodialysis –yes
• Mechanical ventilation –yes
• ICU yes
• Protocol for snake bite management –yes
• Blood tests routinely done—20WBCT, CBC,PT
• PTT ,creatinine, ,ECG Electrolytes, Urine RE

Snake bite management protocol

• Check airway breathing circulation
• Inj TT 0.5ml IM to all patients
• OBSERVE ALL PATIENTS for minimum 24 hrs
• Determine time of bite
• What was the patient doing at that time ?
• Release any tourniquet very slowly
• Assess envenomation –local / systemic

Snake bite management protocol (contd.)

• Local
• swelling > ½ bitten limb
• swollen digits
• rapid extension of swelling.
• Systemic
• Haematotoxic-deranged 20 WBCT / bleeding gums
• Neurotoxic - ptosis/ external ophthalmoplegia/

neck muscle weakness

• CVS—hypotension/arrythmias
• Persistent vomiting/ abdominal pain.

Investigations

• 20 WBCT
• CBC
• S Creatinine
• Electrolytes
• CPK/PT /APTT
• Urine RE
• ECG

Protocol (contd.)

• IF CLOT forms

 repeat 20 WBCT every ½ hourly x 3 hours If still normal repeat every 1 hourly for 3 hours  Then every 6 hourly for 24 hours. ( done at bedside in glass test tube )

• If NO CLOT at 20 mins

 repeat 20WBCT every 6 hours till normal.

Snakebite Protocol (contd.)

• Local /systemic envenomation present ?
• Premedication –hydrocortisone 100mg + Avil 1

ampoule

• ASV -- 8—10 vials in 500ml N.Saline over 1 hour
• No test dose .
• Haematotoxic---assess 20WBCT 6 hrly and give

further doses of 5 vials if needed.

• Max- 30 vials ( usually)

Snakebite Protocol (contd.)

• Neurotoxic- Try neostigmine 1.5mg -2mg IM plus 0.6mg

Atropine IV stat.—if response repeat neostigmine every 30 mins and give atropine 0.6mg infusion over 8 hours.

• If no response to Neostigmine – discontinue.
• Support with mechanical ventilation till weakness

improves

• ASV—initial 8—10 vials. Reassess every 1 hour and

repeat ½ dose of initial ASV till a maximum 20 vials.

• ASV is costly and not freely available therefore do not

waste.

• ASV only acts on unbound venom.

Snakebite Protocol (contd.)

• If anaphylaxis to ASV occurs —stop the infusion,

administer 0.5ml(1:1000) adrenaline IM stat +avil + hydrocortisone + ranitidine.

• 200ml NS bolus.
• Repeat adrenaline dose after 10 mins if required.
• Restart ASV as soon as patient stabilizes

Snakebite Protocol (contd.)

• Pain ---give paracetamol IV 1000mg +/- inj

tramadol 25—50mg IV

• Antibiotics—Crystalline

penicillin+Ciprofloxacin+Metronidazole

• Surgical consult only if severe swelling seen.
• Ensure adequate hydration to maintain an

hourly urine output of 0.5ml/kg

• Monitor creatinine and K+ daily
• Haemodialysis if needed.

BANGALORE BAPTIST HOSPITAL

Thank you!