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Snake Bite: A Forgotten Problem: Case Report
Snake Bite: A Forgotten Problem: Case Report
INTRODUCTION
Snake bite is a worldwide environmental and
occupational hazard with significant morbidity
and mortality, found to occur more among
farmers, plantation workers and other people
who dwell outdoors especially in rural and poor
communities
Inadequately studied and published data (as
ICD 9 code E905.0, ICD 10 code T63.0 and X20)
two million snake bite envenoming, 100.000
deaths/year in Asia
Epidemics when flood or invaded habitat
Case Report
PATIENT IDENTITY
Mrs. K
Female
70 y.o
Farmer and Breeder
Muslim
From Magetan, East Java
Came to ER RSI
Madiun at May
11th, 2015
because of snake
bite
History taking
bite by snake 1 day before admission. Odem on
the left lower arm since around 1 hour after bitten
by snake in the grass field when the patient was
looking for grass.
The odem bigger and wider since then (until left
upper arm). Tenderness (+), redness (+)
Nausea (+), vomit (+), shortness of breath (-),
fever (-), faint (-), loss of sensation (-), abnormal in
urination (-)
Seek for the traditional treatment in advance
(sucking the blood), but didnt get better condition
History
past illnesses :
Unable to bring
the of
snake
No HT, no DM, no allergy
Physical Examinations
General Condition : Weak BP :
100/50
GCS : E4V5M6
HR : 96
x/m
RR : 20 x/m
T : 36.5 C
Head and Neck : Normal
Chest : symmetric, Chest percussion sonor, no tenderness,
auscultation vesicular. Regular heart sound, no additional
sound.
Abdominal : Flat, abdominal sound normal, percussion
thympani, abdominal tenderness on all area.
Extremities : redness (+), odem (+), tenderness (+) on
left arm and hand, bite mark (-), lateralization (-), Other
extremities normal
Initial Diagnosis
SNAKE
BITE
Initial Assessment in ER
Inf. PZ 20 dpm
Inj. Ceftriaxone 1 gr / 12 h
Inj. Antivenin serum (SABU)
Inj. Ranitidin 2x1 iv
Inj. Ondancetron 2x1 iv
Inj. Antrain 2x1 iv
Immobilization and splitting
Check the blood (DL,PT, APPT, OT/PT/SC, SE, BS)
ECG
Laboratory result
Blood
Leuco
(neutrophil
dominant)
18,9
0
ery
5,25
thrombo
15,9
Hb
207
Blood sugar
2hpp
184
BUN
22,8
Creatinine
1,60
Sodium
129
Potassium
3,2
Chloride
95
Calcium
1,09
ECG
Sinus rhythm
Normal ECG
INITIAL PLANNING
May, 11 2015
Diagnostic
Therapy
IVFD Futrolit 1500 mL/24h
Inj. Cefxon 2x1 gr
Inj. Acran 3x1 amp
Inj. Antrain 3x1 amp
Soft Diet
Wound care
Monitoring
Vital signs, sign of shock, sign of allergic reaction, breathing
failure
DISCUSSION
Venomous Snake of
South East Asia
Venom Apparatus
2 ways :
Injecting
Spitting
Elapidae
Viperidae
Colubridae
Rear fangs of a dangerously venomous Colubrid snake, the rednecked keelback (Rhabdophis subminiatus) (Copyright DA
Warrell)
SNAKE VENOMs
Venom Composition :
Quantity
Epidemiology in SEAR
Male > female, but depends on work force
Peak age : children and young adults
Fatality : young children and elderly
General (systemic)
a. Nausea
g. chemosis
b. Vomiting
h. arrhythmia
c. Abdominal pain i. spontaneous syst.
Bleeding
d. Weakness
j. paresthesia
e. Dizziness
k. paralysis
f. Shock
l. acute renal failure
Patientss condition
Management
1. Step of Management
3. Transport to hospital
as quickly, but as safely and comfortably, as
possible
Any movement especially movement of the
bitten limb, must be reduced
If possible, patients should be placed in the
recovery position
Treatment in hospital
4 important questions
Question
In what part of your
body have you been
bitten?
When and under
what circumstances
were you bitten?
Where is the snake
that bit you?
Patient condition
Left low arm
Note
To see the evidence,
signs of envenoming
Physical examination
Examination (bitten part)
extent of swelling, which is usually also
the extent of tenderness to palpation
(start proximally)
Lymph nodes draining the limb should be
palpated and overlying ecchymoses and
lymphangitic lines
A bitten limb may be tensely
oedematous, cold, immobile and with
impalpable arterial pulses
Early signs of necrosis may include
blistering, demarcated darkening (easily
confused with bruising)
paleness of the skin, loss of sensation
Patient
+
Examination (General)
Blood Pressure, HR, RR
skin and mucous membranes for evidence of
petechiae, purpura, discoid haemorrhages
ecchymoses, chemosis, and epistaxis for
haemorrhages
Abdominal tenderness may suggest
gastrointestinal or retroperitoneal bleeding.
Loin (low back) pain and tenderness
suggests acute renal ischaemia
Intracranial haemorrhage is suggested
by lateralising neurological signs,
asymmetrical pupils, convulsions
Impaired consciousness (in the absence of
respiratory or circulatory failure).
Patient
+ (all
abdominal
area)
-
Examination (Neurotoxic
envenoming)
Patie
nt
INVESTIGATION/LAB TEST
1. 20 minutes whole blood test (20WBCT)
ANTIVENOM TREATMENT
What is antivenom?
is immunoglobulin [usually pepsin-refined
F(ab)2 fragment of whole IgG]
Monovalent/Polyvalent
Indications?
Antivenin serum
Reactions?
Anaphylactic
Pyrogenic
Late
How to prevent it? prophylactic drug
& speed and dilution of antivenom
administration
Main Challenges
Improving
Improving
Improving
Improving
access
clinical management
diagnostic and treatment tools
knowledge
References
Kasturiratne, A et al. 2008. The Global Burden of
Snakebite: A Literature Analysis and Modelling
Based on Regional Estimates of Envenoming and
Deaths. PLoS Med 5(11):e218
Alirol, E et al. 2010. Snake Bite in South Asia: A
Review. PloS Med 4(1):e603
Warrel, D A. 2010. Guidelines for the management
of the snakebite. WHO SEARO
Gold, B S. 2002. Current concept of venomous
snake. N Engl J Med, Vol. 347, No. 5
Thank you