Dr Megongusie Meru Christian Fellowship Hospital Oddanchatram. - - PowerPoint PPT Presentation

Dr Megongusie Meru Christian Fellowship Hospital Oddanchatram.

Number of snake bites and syndromes

 Number of snake bites/ year (or in the last year):87  Number of venomous bites/ year (or in the last

year):61

 Number of non-venomous bites/ year (or in the last

year):26

Snake Bite in 2012

2 4 6 8 10 12 14

Snake Species

Cobra Viper Krait Unidentified

Number of snake bites due to main syndromes

 Neurotoxic-7  Haemotoxic-40  Combination of neurotoxic and Haemotoxic-3

Outcome of snake bites in our hospital

 Number requiring mechanical ventilation-4  Number requiring haemodialysis-3  Deaths Number-1

Facilities available in our hospital

 ICU  Mechanical ventilators  Coagulation parameters: Prothrombin time and partial

thromboplastin time

 Blood transfusion facilities: Whole blood  Haemo-Dialysis facilities- X

Indications for ASV

 Signs of local, regional or systemic envenomation  Coagulopathy-bleeding,elevated clotting time (> 22

minutes)

 Features of neurotoxicity-ptosis,weakness of limbs,

respiratory paralysis

Monitoring response to therapy for Haemotoxic bite

 Whole blood clotting time  Time of measurement of coagulation parameters - Q4-

6 hrs or according to doctor’s order.

 Repeat dose of ASV- after completion of the initial

ASV dose.

Neostigmine?

 Any neurotoxic bite with evidence of envenomation.

antibiotics

 Indications –

• evidence of cellulitis/infection.
• underlying coexisting infection.

 Common antibiotic choice

• Cap cloxacillin + Tab Metronidazole
• Cap cloxacillin
• IV Metronidazole +Ceftriaxone

Admission and referral

 ICU or Ward?

ICU-All snake bite or suspected snake bite or unknown bite

 Referral?

Acute renal failure for hemodialysis When patient/relatives request for referral to a tertiary centre When ventilators /required facilities are unavailable

Antisnake venom

 Polyvalent Anti Snake Venom(SII)  Stock of ASV approx 200 vials.  46 snake bite patients received ASV.  Reactions to ASV-9 (itching, chills)

Department of medicine Christian fellowship hospital.

 Receive the client & inform to the duty Dr.  Provide comfortable bed.  Identify the snake.  Blood to be sent for C.T.  Inj.T.T. to be given-before that, when lost dose was taken.  Identify the bite mark & clean the site with betadine if needed.  Elevate the part with pillow sling.( if swelling).  Check any respiratory distress.(R.Rate, Single breath count every half an

hour,Neck lifting time.Ptosis,Swelling.).

 Check hourly urine out-put.  Advise plenty of oral fluids.

 Strict in-take & out-put chart.  If C.T. > 18….C.F.H. ASV protocol.  Explain to the client & relative the cost of 1 vial of Inj.ASV and its side

effects.

 Before starting ASV injection as an infusion, administer Inj.Avil 1 amp and

Inj.Hydrocort 100 mg I.V.stat .Followed by give test dose of Inj.ASV as 10 drops through infusion set or by blood set.

 Watch for any allergic reaction  Inj.ASV should be administered in one pint of NS or DNS as per Dr’s order.  ASV infusion should be administered in blood set.  According to Dr’s order Repeat Clotting-Time has to be done.

 If urine out-put is low inform Dr.  Check urine albumin once in a day.  Check vital signs Q 1 H.  Watch for swelling and ptosis.

On DISCHARGE………………………….

 Review P.R.N. If any complaints.  Take more oral fluids.

Is it Viper, Cobra or Krait ???

Viper Look for the following :- 1.Local swelling-Mark it. Every 2 nd hourly assess the swelling increase part. 2.Bleeding from anywhere- Gums. Haematuria etc. 3.Renal Involvement- Haematuria, Proteinuria, Renal failure, Hypertension.

COBRA

Look for neurological manifestation:- 1.Ptosis-and other evidence of Opthalmoplegia. 2.Respiratory weakness-ability to cough, single breath count. 3.Weakness of limbs-Assessment at admission with regular intervals for any worsening- Document.

KRAIT

1.Local swelling-Mark it. Every 2 nd hourly assess the swelling increase part. 2.Bleeding from anywhere- Gums. Haematuria etc. 3.Renal Involvement- Haematuria, Proteinuria, Renal failure, Hypertension 4.Ptosis-any evidence of Opthalmoplegia. 5.Respiratory weakness-ability to cough, single breath count. 6.Weakness of limbs-Assessment at admission with regular intervals for any worsening- Document.

Investigation to be done…..

 Viper ----BT; CT; Platelets; Creatinine and other investigation according

to clinical condition.

 Cobra ----ONLY clinical assessment.

Viper bite

 Injection ASV 2 vials IV fast in 500 ml Normal Saline to be given for 4

hours as an infusion after skin sensitivity test if not cover with Injection Hydrocort.

 If there are signs of envenomation namely increase in BT,CT &

swelling increased ---administered IV ASV 2 vials for next 6 hours to be continued q 6 h till signs are absent.

 When BT,CT becomes normal and no increase swelling --- Administer

ASV one vial in 12 Hours, followed by ASV one vial in 24 Hours. Ordinarily ASV may stopped after 48-72 Hours.

COBRA BITE

 If Ptosis is present to give ASV 4 vials IV in half an hour followed by

Inj ASV two vials as IV drip for next 4 hours.

 If there is weakness of LIMBS / RESPIRATION to give ASV 6 vials in

half an hour followed by ASV 4 vials in 4 hours. RESPIRATORY SUPPORT- when needed….. 1.To assess Oxygenation by Pulse oxy meter/ Blood gas. 2.To keep ET tube , Ambu bag, Laryngescope ready. 3.To keep VENTILATOR ready.