BANGALORE BAPTIST HOSPITAL Snakebite Study Workshop Vellore, Mar - PowerPoint PPT Presentation

BANGALORE BAPTIST HOSPITAL Snakebite Study Workshop Vellore, Mar 2013 Dr Tarun/ Dr Indira Menon

Questionnaire. • Name of centre — BBH • No. of snake bites per year-- 55 — 60 • No. of snake bites in last year-- -65 • No. of venomous bites last year --50 approx. • No. of non venomous bites in last year — 15 • Snake bites due to main syndromes % • Haematotoxic — 90% Neuro — 10% • Combination 1-2 % • No.of cases where dead snakes are brought — 5

Questionnaire (contd.) • Indications for ASV — systemic or local envenomation • No prophylactic adrenaline is given prior to ASV • Initial dose of ASV — 8 — 10 vials both haematotoxic and neurotoxic. • Time duration of administration – 1 hour • Response to ASV is monitored by 20 WBCT every 6 hourly • When to repeat dose of ASV? • Haematotoxic every 6 hours — 10 vials • Neurotoxic every 1 hour – 10 vials • Is continuous low dose of ASV administered after normalization of coagulation – NO

Questionnaire (contd.) • Ceiling dose — Haematotoxic — 30 vials( exceeded very rarely) • Neurotoxic — 20 vials • Do you use Neostigmine in neurotoxic bites – Yes • Indication for antibiotics — local swelling/ cellulitisChoice of antibiotic — Crystalline penicillin + ciprofloxacin + metronidazole. • When to admit to ICU ? — all patients are observed in ICU initially. • When do you refer – we do not refer. • Which ASV do we use — Bharath serum • Stock in pharmacy at any given time — 20 — 30 vials

Questionnaire (contd.) • Last year cases of allergy to ASV — - minor -10 - angioedema — swelling mouth/ bronchospasm — 2 - anaphylaxis fall in BP---2 - death – nil

Questionnaire (contd.) • Outcomes : - Mechanical ventilation – 10 — 15 % - Haemodialysis — 2-3 % - Deaths — 2 % • Facilities available: - Coagulation parameters – yes - Blood transfusion — yes - Haemodialysis – yes - Mechanical ventilation – yes - ICU yes • Protocol for snake bite management – yes • Blood tests routinely done — 20WBCT, CBC,PT - PTT ,creatinine, ,ECG Electrolytes, Urine RE

Snake bite management protocol • Check airway breathing circulation • Inj TT 0.5ml IM to all patients • OBSERVE ALL PATIENTS for minimum 24 hrs • Determine time of bite • What was the patient doing at that time ? • Release any tourniquet very slowly • Assess envenomation – local / systemic

Snake bite management protocol (contd.) • Local - swelling > ½ bitten limb - swollen digits - rapid extension of swelling. • Systemic - Haematotoxic-deranged 20 WBCT / bleeding gums - Neurotoxic - ptosis/ external ophthalmoplegia/ neck muscle weakness - CVS — hypotension/arrythmias - Persistent vomiting/ abdominal pain.

Investigations • 20 WBCT • CBC • S Creatinine • Electrolytes • CPK/PT /APTT • Urine RE • ECG

Protocol (contd.) • IF CLOT forms  repeat 20 WBCT every ½ hourly x 3 hours  If still normal repeat every 1 hourly for 3 hours  Then every 6 hourly for 24 hours. ( done at bedside in glass test tube ) • If NO CLOT at 20 mins  repeat 20WBCT every 6 hours till normal.

Snakebite Protocol (contd.) • Local /systemic envenomation present ? • Premedication – hydrocortisone 100mg + Avil 1 ampoule • ASV -- 8 — 10 vials in 500ml N.Saline over 1 hour • No test dose . • Haematotoxic---assess 20WBCT 6 hrly and give further doses of 5 vials if needed. • Max- 30 vials ( usually)

Snakebite Protocol (contd.) • Neurotoxic- Try neostigmine 1.5mg -2mg IM plus 0.6mg Atropine IV stat. — if response repeat neostigmine every 30 mins and give atropine 0.6mg infusion over 8 hours. • If no response to Neostigmine – discontinue. • Support with mechanical ventilation till weakness improves • ASV — initial 8 — 10 vials. Reassess every 1 hour and repeat ½ dose of initial ASV till a maximum 20 vials . • ASV is costly and not freely available therefore do not waste. • ASV only acts on unbound venom.

Snakebite Protocol (contd.) • If anaphylaxis to ASV occurs — stop the infusion, administer 0.5ml(1:1000) adrenaline IM stat +avil + hydrocortisone + ranitidine. • 200ml NS bolus. • Repeat adrenaline dose after 10 mins if required. • Restart ASV as soon as patient stabilizes

Snakebite Protocol (contd.) • Pain ---give paracetamol IV 1000mg +/- inj tramadol 25 — 50mg IV • Antibiotics — Crystalline penicillin+Ciprofloxacin+Metronidazole • Surgical consult only if severe swelling seen. • Ensure adequate hydration to maintain an hourly urine output of 0.5ml/kg • Monitor creatinine and K+ daily • Haemodialysis if needed.

BANGALORE BAPTIST HOSPITAL Thank you!