SNAKE BITE

Dr.B.Sureshkumar

Mr. Mohan 30 years

Presented with

Snake bite to L/s ankle 1hour back Snake identified as Viper

PMHx Mental retarded pt Examination

BP-110/70 mmHg PR- 80/min Lungs clear Abdomen soft No ptosis, No opthalmoplegia, No bleeding manifestations Local No swelling, No fang marks.

IX

Whole blood clotting time < 20min on admission Rx

IM tetanus toxoid 0.5mg stat WBCT in 2hours KUO for ptosis, Bleeding manifestations Monitor UOP, BP, RR

After 2 Hours of Admission.

Pt developed Ptosis WBCT >20min Rx IV Anti-venom Serum 10 vials given

Day 2

8 hours later

Rx

WBCT > 20min B/L ptosis BP-75/60 mmHg Hyperthermia+

Ix CBS 171 mg/dl

IV AVS 5 vials stat (2nd Dose) IV Dopamine 5 g/Kg/min started and titrated according to BP IV Cloxacillin 500mg 6hrly IV Hydrocortisone 400mg stat

Day 3

Loose stools Bp- 100/70 mmHg 80/50mmHg ECG ST in Inferior leads Fever+ S. Cr 1.6

Rx

IV Metronidazole 500mg 8hrly IV Ciprofloxacin 400mg BD IV Dobutamine 10 g/Kg/min

Day 4

BP 100/70mmHg HR 110/ Min Resp B/L crepts SpO2 <90% with O2 CXR Features of Pulmonary Oedema

Rx

IV Frusemide 40 mg stat + 15mg/Hr infusion

Pt Transferred to THBatticaloa as he had developed impending respiratory failure.

At TH-Batticaloa

Pt went into respiratory failure and Intubated.

Signs and Symptoms of Envenomation.

Symptoms:

Local pain at bite site80% Pain in regional lymph nodes55% Vomiting26% Bleeding from distant sites24% Drowsiness14% Epigastric pain8% Lower back pain7% Dizziness/impaired consciousness2%

Signs
Local Local swelling 68% Tender, enlarged lymph nodes 54% Bleeding at bite site 31% Local blistering and necrosis 2%

Systemic envenomation Spontaneous systemic bleeding46% Hypotension35% Conjunctival edema24% Bleeding from gums20% Bleeding from venipuncture sites15% Hematemesis11%

Urinary Symptoms and Renal Failure

Hematuria 72% BUN range 14 - 68% Proteinuria (>1 gm/liter) 55% RBC casts55% Oliguria 44% Renal-angle tenderness 39%

Indication for Anti venom.

Incoagulable blood with 20 mins of WBCT. Systemic envenomation. Spontaneous bleeding. Neurotoxicity (Russels viper). Impaired LOC.

WBCT

Few ml of blood in clean glass tube. Leave it for 20 mins undisturbed. Do it before and after the administration AVS. Can be repeated in 6 hours time until become normal (< 20 min) WBCT.

AVS Administration

1 Vial AVS dissolve in 10 ml of water for injection. Add 100 ml of N/S. Total 200 ml over one hour infusion. Watch for reaction. Children also should be given same dose.

RESPONSE TO AVS

Hypotension & Bradycardia will improve in 10-20 mins. Spontaneous systemic bleeding stops in 15 30 mins. CNS effects will improve in 30 mins Blood coagualability is restored about 6 hours.

THANK YOU