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64 August 2016 11
editorial
as adults. The ASV is targeted at final occasion but in the vast of ASV should continue on a 6 hourly
neutralizing the venom. Snakes majority of reactions, 2 doses of pattern until coagulation is restored
inject the same amount of venom adrenaline will be sufficient in or unless a species is identified as
into adults and children. children. one against whichpolyvalent ASV
ASV can be Administered in Two Ways If there is hypotension or is not effective.
Infusion: liquid or reconstituted hemodynamic instability, IV The repeat dose should be 10 vials
ASV in isotonic saline or fluids should be given. of ASV i.e. one full dose of the original
glucose, may be started without Once the patient has recovered, the amount. The most logical approach
any diluent fluid in volume ASV can be restarted slowly for 10-15 is to administer the same dose again,
overload patients. minutes, keeping the patient under as was administered initially. Some
close observation. Then the normal drip Indian doctors however, argue that
All ASV to be administered
rate should be resumed. since the amount of unbound venom
o ve r 1 h o u r a t c o n s t a n t s p e e d .
is declining, due to its continued
Local administration of ASV, near Late Serum sickness reactions can be
binding to tissue, and due to the
the bite site, has been proven to easily treated with an oral steroid such
wish to conserve scarce supplies
be ineffective, painful and raises as prednisolone, adults 5mg 6 hourly,
of ASV, there may be a case for
the intracompartmental pressure, paediatric dose 0.7mg/kg/day. Oral
administering a smaller second dose.
particularly in the digits, it should Antihistaminic provide additional
In the absence of good trial evidence
not be used . symptomatic relief.
to determine the objective position,
Snakebite in Pregnancy Neurotxic Envenomation a range of vials in the second dose
Pregnant women are treated in Neostigmine is an has been adopted.
exactly the same way as other victims. anticholinesterase that prolongs Repeat Dose: Haematotoxic
The same dosage of ASV is given. the life of acetylcholine and can
The normal guidelines are to
The victim should be referred to a therefore reverse respiratory
administer ASV every 6 hours until
gynecologist for assessment of any failure and neurotoxic symptoms.
coagulation has been restored.
impact on the foetus. It is particularly effective for post
However, what should the clinician
ASV Reactions synaptic neurotoxins such as those
do after say, 30 vials have been
Anaphylaxis can be rapid onset of the Cobra (Watt et al, 1986).
administered and the coagulation
and can deteriorate into a life- In the case of neurotoxic abnormality persists. A large study
threatening emergency very rapidly. envenomation where edrophonium recently done from south India
A d r e n a l i n e s h o u l d a l wa y s b e is not available Neostigmine Test ( K e r a l a ) s h o we d t h a t u p t o 5 0
immediately available. can bedone. The neostigmine dose vials (500 ml) has been given for
The patient should be monitored is 0.04 mg/kg IV and atropine/ Haemotoxic poisoning.
closely (Peshin et al, 1997) and glycopyrolate may be given by
It has been established that
at the first sign of any of the continuous infusion.
envenomation by the Hump-
following: The patient should be closely nosed Pitviper(Hypnalehypnale)
Urticaria, itching, fever, chills, observed for l hour to determine if does not respond to normal ASV.
nausea, vomiting, diarrhea, the neostigmine is effective. This may be a cause as, in the
abdominal cramps, tachycardia, Repeat Doses: Anti Haemostatic case of Hypnale, coagulopathy
hypotension, bronchospasm and In case of anti haemostatic can continue for up to 3 weeks.
angio-oedema envenomation, the ASV strategy Surgical Intervention
ASV to be discontinued will be based around a six hour time Whilst there is undoubtedly a
period. When the initial blood test place for a surgical debridement
Children are given 0.01mg/kg
reveals a coagulation abnormality, of necrotic tissue, the use of
body weight of adrenaline iv.
the initial ASV amount will be fasciotomy is highly questionable.
In elderly noradrenalin and given over 1 hour. The appearance of (Joseph, 2003):
nitroglycerin infusion when
No additional ASV will be given Fasciotomy is required if the
hypotension is corrected can
u n t i l t h e n e x t C l o t t i n g Te s t i s intracompartmental pressure is
be given to avoid adrenalin
carried out. This is due to the sufficiently high to cause blood
induced arrhythmia which is
inability of the liver to replace vessels to collapse and lead to
common in elderly.
clotting factors in under 6 hrs. ischemia.Now a days we are using
If after 10 to 15 minutes the
After 6 hours a further coagulation multiple puncture technique using
patients condition has not
test should be performed and a large bore needle.
improved or is worsening,
further dose should be administered What is important is that the
A second dose of 0.5 mg of in the event of continued coagulation intracompartmental pressure
adrenalin 1:1000 iv is given. This defect and in that case ASV to be given should be measured objectively
can be repeated for a third and over 1 hr. CT tests and repeat doses using saline manometers or newer
14 Journal of The Association of Physicians of India Vol. 64 August 2016
specialised equipment such as the snake bite pose an important can be avoided. Most of the patients
Stryker Intracompartmental Pressure problem for transportation from a r e c o n s c i o u s t h o u g h t h e y r e
Monitoring Equipment. the site of bite to the hospital. A speechless and if theres no upper
Renal Failure in Snakebite well designed study from PGI airways paralysis, nasopharyngeal
Chandigarh shows that just putting (may be modified one) along with
The acute renal failure which
an airway tube and an AMBU bag non-invasive ventilation is a better
occurs due to snake bite are
decrease the morbidity to a great choice. However, if early intubation
multifactorial 1) Severe and
ex ten t. Mechanical vent ilat ion and early weaning principle is
persistent hypotension leading to
to be avoided as far as possible, m a i n t a i n e d , t h e n VA P c a n b e
acute tubular necrosis, 2) Hb and
as because most of the death in minimised, which may be the major
other cellular parts of RBC and others
ventilated snake bite patient is cause of mortality and morbidity
(myoglobin and rhabdomylysis 3)
Ventilator associated pneumonia. for altered mentation with or
part of DIC 4)vasculitis 5) acute
Early initiation and early weaning without bulbar paralysis. Theres
diffuse intersticial nephritis^)
from ventilator is the strategy, some physicians who think that
extra capillary proliferative
n o n i n va s i ve ve n t i l a t o r w i t h a ve n t i l a t o r y s u p p o r t s h o u l d b e
glomerulonephritis.
patent upper air way is better op the primary with very little or no
Most of the patients of acute tion. ASV particularly who came late (6
tubular necrosisrecovers by few hours or more), though this is not
Heparin and Botropase: No role
weeks, with the help of occational recommended still today
need of haemodialysis, but who Referral Criteria
develops cortical necrosis requires The primary consideration, in the References
reanal replacement therapy case of neurotoxic bites, is respiratory
on along term basis. It is the failure.Capasity of neck lifting is 1. Simpson ID. Management of Snakebite-
The National, API WB branch. Update in
hyperkalemia rather than elevated good predictor of requirement of
Medicine 2006; 88-93.
Urea, creatinine requires dialysis. ventilator support. Refer suchpatient
2. Narvencar K. Correlation between Timing
The hyperkalemia of snakebite AKI to the center equipped with invasive
of ASV Administration and Complication
is a hypermetabolichyperkalemia, ventilation. in Snake Bite. J Assoc Physicians India 2006;
which may kill the patient within In this issue of JAPI a study 54:717-719.
few minutes and Calcium gluconate from south India 9 involving more 3. Gudilines for the Clinical Management
and glucose insulin is mostly than 1000 patients has thrown of Snake Bites in South- East Asia Region
ineffective.Early urgent adequate light in the controversies in Written and edited by David AWarrell
treatment with ASV can reverse the m anag ement of snak e b it e published by WHO, 2005.
the whole process of deterioration victims. The study shows that early 4. Srimannaryan J, Dutta TK, Sahai Aet al.
of renal function which is far from diagnosis of envenomation by way Rational Use of Anti-Snake Venom(ASV):
our expectation in our country. Trial of Various Regimens in Hemotoxic
of clinical (history, bleeding and snake Envenomation. J Assoc Physicians
Renal failure is a common regional lymphadenopathy) along India 2004; 52:788-792.
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and Hump-nosed Pitviper bites WBCT and early institution Antivenoms: Critical Supply Issues. J Assoc
(Tin-Nu-Swe et a1,1993, Joseph et of anti-snake venom in adequate Physicians India 2004; 52:11-13.
al, 2006). The contributory factors dose,can reduce the development 6. Paul V, Pratibha S, Prahaald KA, et al.
a r e i n t r a va s c u l a r h a e m o l y s i s , of SAKI (snake bite induced acute High-Dose Anti- Snake Venom Versus Low-
DIC, direct nephrotoxicity and kidney injury).The study also used Dose Anti Snake Venom in the treatment
hypotension (Chugh et a1, 1975) ASV more than 50 vials or 500 ml of Poisonous Snake Bites- A Critical Study.
and rhabdomyolysis. (maximum) for haematological J Assoc Physicians India 2004; 52:14-17.
Renal damage can develop very and 30 vials for neurotoxic 7. Indian National snake bite Protocol 2008
early in cases of Russells Viper bite poisoning (maximum) and which 8. Guideline for management of snake bite in
and even when the patient arrives I fully endorse from my personal south east Asia countries by David Warrel
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Profile and Laboratory Parameters in 1051
damage may already have been Another study from North
Victims of Snakebite from a Single Centre in
done. Studies have shown that India 10 in this issue of JAPI has Kerala, South India. J Assoc Physicians India
even when ASV is administered shown that usual or low dose ASV 2016; 63:22-29.
within 1-2 hours after the bite, it (100 ml of two doses) is sufficient 10. Pandey PC, Bajaj S, Srivastava A. A Clinico-
was incapable of preventing ARF along with early ventilatory Epidemiological Profile of Neuroparalytic
(Myint-Iewin et al, 1985). support. However, I personally Snake Bite: Using Low Dose ASV in a
Neurological Manifestation in think that if invasive ventilation Tertiary Care Centre from North India. J
Snakebite can be avoided, incidence of Assoc Physicians India 2016; 63:16-20.