First Aid for Animal Bites

Ricky Wibowo, dr,. Sp.B,. FINACS

20th June 2021
 Bites
• Animal Bites
– Insect bites
– Reptilian bites
– Mammalia bites
• Human Bites
 Bites (2)
• Toxins
– Localized
– Systemic (Especially viper) :
• Neuroparalytic
• Vasculotoxic
• Secondary Infection : Sepsis
– Common bacteria
– Spesific infection
• Rabies
• Tetanus
• Hypersensitivity ; Anaphylactic reactions
 Refferences
• Marik PE, Taeb AM, SIRS, qSOFA and New sepsis definition,
J Thoracic Dis 2017 April. 9(4):943-45.
• Management of Snake Bites; Standard Treatment
Guidelines, Quick Reference Guide 2016 January, Ministry
of Health & Family Welfare, government of India
• Surya R, Skoring Prognosis Tetanus Generalisata pada
pasien dewasa, laporan kasus, CDK-238/vol.43 no 3,2016.
• Buku Saku Petunjuk Teknis Penatalaksanaan Kasus Gigitan
Hewan penular Rabies di Indonesia, Kemenkes RI, Dirjen
P3, Direktorat Pencegahan dan pengendalian Penyakit tular
vektor dan Zoonotik, 2016
• Management of Snake Bite (WHO) 2017.
 Toxins (viper)
• Life threatening condition
• Preventable
• Cureable
• Has limited golden period
• 2000 species (viper) : 30% venomous
• 300 species (India) : 52 species venomous
• 349 species ( Indonesia) : 77 species venomous
• Can live at all habitats around us
 When to suspect/Recognize
• Clinical presentation (gradation) depends upon :
– Species
– Amount of venom
– Season of bite
– Snake is fed /unfed
– Area covered/uncovered
– Dry or incomplete bite
– Multiple bites
– Venom inj in vessel
– Victim weights
– Time elapsed between the bite and administration ASV
(SABU)
• Four clinical syndromes / combination :
– Proggresive weakness (neuroparaytic/toxin)
– Bleeding ( vasculotoxic/hematotoxic)
– Myotoxic and painfull progressive swelling
 Caution!
• Dont attempt to kill or catch the snakes
• Discard traditional first aid methods which dont
have the EBM principals
• Dont wash, incision, suction, rubbing, massage,
vigorous cleaning, appy herbs or unsertified
chemical substance (for wounds).
• Dont inject SABU locally or Intra muscular
• Dont apply torniquette!
• Elastic bandage applied at the bite is allowed as
long as do by qualified medical personels.
 management
• Recognize first(clinical examination)
• Symptomatic or asymptomatic?
• Confirmed or doubtfull : keep under observation within 1-2
x 24 hours
• Still asymptomatic within 2x 24 hours : ambulatory status (
communicate about the other incidences could happen any
moment for at least 3-4 weeks since the viper bites)
• The other sign and symptoms (not toxin matters) are
happened within 2x24 hours: do the appropriate and
suitable managements
• Beware secondary infections and hypersensitivity matters
 Management
• Pain management
– Immobilization : elastic bandaging, splinting, back slab splinting,
tredelenburg position
– Analgetic medication
• SABU administration necessity
• Doubtfull if need SABU or not? Observation at hospital at
least 2x24 hours
• Secondary infection? Considered antibiotics, anti tetanus or
anti rabies serum, or may be combination of three if
needed.
• Worsen become abcess forming or gangrene as late
complication : consult the surgeon for further management
 Serum Anti Bisa Ular (SABU)
• Indicated by signs and symptoms, with or without
laboratory findings
• Administer full dose
• There are no absolute contraindications to SABU
• Do not delay or withhold SABU on the grounds of
anaphylactic reaction to a deserving case. Do not give
incomplete dose!
• Purely localized swelling with/without bite mark/s or
swelling, a number of hours old : not indicating for
SABU administration
• Rapid development of swelling indicates bite with
envenoming : requiring SABU.
• SABU treatment : spesific treatment
• May reverse systemic envenomation abnormality even
when this had persisted for several days, or in the case of
haemostatic abnormalities which persisting for two or
more weeks.
• Required dosage are varies
• SABU should be given by IV routes, slowly, and highly
observed by physician to anticipate immediately about the
first sign of reaction (eg. Anaphylactic rx)
• Do not administered by IM route nor local site of the bite/s.
• SABU works just at the spesific local area/country/content
 SABU dose
• Dose of SABU for neuroparalytic snakebite
– 10 vials SABU as infusion (deluted by NS) over 30 minutes
followed by 2nd dose of 10 vials after 1 hour if no
improvement within 1 hour.
• Dose of SABU for vasculotoxic snake bite
– Low Dose infusion therapy
• 6-10 vials over 30 minutes followed by 2 vials every 6 hours as
infusion (deluted by NS) till clotting time normalize
OR
– High Dose intermittent bolus therapy
• 10 vials over 30 minutes , followed by 6 vials every 6 hours as
bolus therapy till clotting time normalize and/or local swelling
subsides
 Repeating the dose
• Repeat clotting test every 6 hours until
coagulation is restored
• Repeat SABU administration if worsening
neurotoxic or cardiovascular sign even after 1-2
hours
• If large dose (>20 vials) does not improve the
coagulation abnormality, FFP, Cryoprecipitate (
fibrinogen, factor VIII), or fresh Whole blood it
self if FFP or platelet concentrate not available.
 Anaphylactic events after SABU
administration
• Stop SABU temporary
• Do the anaphylactic protocols (airway patency,
oxygen, epinephrine, anti-histamine, etc)
• Role of hydrocortisone is not proved
• Once patient recovered, restart SABU adm
slowly under high observation before resume
it at normal drop rate.
• No epinephrine premedication is needed
before SABU adm.
 Instead snake bite
• Insect bite, mammal bite , reptilian bite instead snake :
has the similar problems beside the venom.
– Bacterial infection, candida furthermore
– Rabies
– Tetanus
• Human bites
– Has many comensal and varieties of flora normal
muchmore than other species
– It becomes the impact is worse than the others : beware!
– Worse wounds, worse infection, and ressistant to many
antibiotics.
Rabies Anti serum dosage
Rabies Vaccine dosage
Tetanus, prognostic factors
 Anti tetanus Serum
• Conventional ( Anti tetanus Serum)
– Horse immunoglobulin
– Allergic reaction is common
– Cheaper
– Easy to afford
– Need skin test premedically
• Tetanus immunoglobulin (TIG)
– Human based immunoglobulin
– Allergic reaction is rare
– More expensive
– Relative easy to get
– No need skin test premedically
 Sepsis definition (1991)
• SIRS (two or more)
– Tachycardia
– Tachypnea
– Fever or hypothermia
– Leucocytosis or leucopenia or bandemia
• Source of infection (+)
• Complicated: severe sepsis, septic shock, MODS
• Problem :
– prognostic accuracy is low (hard to define when getting
worse or not)
– SIRS (+) at some hospital never incur adverse outcomes
(sepsis) : SIRS, negative -sepsis
Sequential Organ Failure Assesment
(SOFA)
2016
 SOFA
• Improve accuracy of sepsis epidemiology and
hospital coding, ICU preparation, etc
• Among critically ill patients with suspected sepsis,
the predictive validity of the SOFA score for in
hospital mortality was more better than SIRS
criteria
• Other studies : SIRS criteria is not ideal marker for
sepsis
• Lack : complexity method, late results, late
requisite data for many patients >> impractical
Quick SOFA ; qSOFA
 qSOFA
• Low sensitivity
• Need more research
• Screening tools for patients need of ICU using
or not (in debate)

18/06/2021
THANK YOU