Dr Megongusie Meru Christian Fellowship Hospital Oddanchatram. - PowerPoint PPT Presentation

Dr Megongusie Meru Christian Fellowship Hospital Oddanchatram.

Number of snake bites and syndromes  Number of snake bites/ year (or in the last year):87  Number of venomous bites/ year (or in the last year):61  Number of non-venomous bites/ year (or in the last year):26

Snake Bite in 2012 14 12 10 8 6 4 2 0

Snake Species Cobra Viper Krait Unidentified

Number of snake bites due to main syndromes  Neurotoxic-7  Haemotoxic-40  Combination of neurotoxic and Haemotoxic-3

Outcome of snake bites in our hospital  Number requiring mechanical ventilation-4  Number requiring haemodialysis-3  Deaths Number-1

Facilities available in our hospital  ICU  Mechanical ventilators  Coagulation parameters: Prothrombin time and partial thromboplastin time  Blood transfusion facilities: Whole blood  Haemo-Dialysis facilities- X

Indications for ASV  Signs of local, regional or systemic envenomation  Coagulopathy-bleeding,elevated clotting time (> 22 minutes)  Features of neurotoxicity-ptosis,weakness of limbs, respiratory paralysis

Monitoring response to therapy for Haemotoxic bite  Whole blood clotting time  Time of measurement of coagulation parameters - Q4- 6 hrs or according to doctor’s order.  Repeat dose of ASV- after completion of the initial ASV dose.

Neostigmine?  Any neurotoxic bite with evidence of envenomation.

antibiotics  Indications – -evidence of cellulitis/infection. -underlying coexisting infection.  Common antibiotic choice - Cap cloxacillin + Tab Metronidazole -Cap cloxacillin -IV Metronidazole +Ceftriaxone

Admission and referral  ICU or Ward? ICU-All snake bite or suspected snake bite or unknown bite  Referral? Acute renal failure for hemodialysis When patient/relatives request for referral to a tertiary centre When ventilators /required facilities are unavailable

Antisnake venom  Polyvalent Anti Snake Venom(SII)  Stock of ASV approx 200 vials.  46 snake bite patients received ASV.  Reactions to ASV-9 (itching, chills)

Department of medicine Christian fellowship hospital.

 Receive the client & inform to the duty Dr.  Provide comfortable bed.  Identify the snake.  Blood to be sent for C.T.  Inj.T.T. to be given-before that, when lost dose was taken.  Identify the bite mark & clean the site with betadine if needed.  Elevate the part with pillow sling.( if swelling).  Check any respiratory distress.(R.Rate, Single breath count every half an hour,Neck lifting time.Ptosis,Swelling.).  Check hourly urine out-put.  Advise plenty of oral fluids.

 Strict in-take & out-put chart.  If C.T. > 18….C.F.H. ASV protocol.  Explain to the client & relative the cost of 1 vial of Inj.ASV and its side effects.  Before starting ASV injection as an infusion, administer Inj.Avil 1 amp and Inj.Hydrocort 100 mg I.V.stat .Followed by give test dose of Inj.ASV as 10 drops through infusion set or by blood set.  Watch for any allergic reaction  Inj.ASV should be administered in one pint of NS or DNS as per Dr’s order.  ASV infusion should be administered in blood set.  According to Dr’s order Repeat Clotting -Time has to be done.

 If urine out-put is low inform Dr.  Check urine albumin once in a day.  Check vital signs Q 1 H.  Watch for swelling and ptosis.

On DISCHARGE………………………….  Review P.R.N. If any complaints.  Take more oral fluids.

Is it Viper, Cobra or Krait ??? Viper Look for the following :- 1.Local swelling -Mark it. Every 2 nd hourly assess the swelling increase part. 2.Bleeding from anywhere- Gums. Haematuria etc. 3.Renal Involvement- Haematuria, Proteinuria, Renal failure, Hypertension.

COBRA Look for neurological manifestation:- 1. Ptosis -and other evidence of Opthalmoplegia. 2.Respiratory weakness -ability to cough, single breath count. 3.Weakness of limbs -Assessment at admission with regular intervals for any worsening- Document.

KRAIT 1.Local swelling -Mark it. Every 2 nd hourly assess the swelling increase part. 2.Bleeding from anywhere- Gums. Haematuria etc. 3.Renal Involvement- Haematuria, Proteinuria, Renal failure, Hypertension 4.Ptosis -any evidence of Opthalmoplegia. 5.Respiratory weakness -ability to cough, single breath count. 6.Weakness of limbs -Assessment at admission with regular intervals for any worsening- Document.

Investigation to be done…..  Viper ----BT; CT; Platelets; Creatinine and other investigation according to clinical condition.  Cobra ----ONLY clinical assessment.

Viper bite  Injection ASV 2 vials IV fast in 500 ml Normal Saline to be given for 4 hours as an infusion after skin sensitivity test if not cover with Injection Hydrocort.  If there are signs of envenomation namely increase in BT,CT & swelling increased ---administered IV ASV 2 vials for next 6 hours to be continued q 6 h till signs are absent.  When BT,CT becomes normal and no increase swelling --- Administer ASV one vial in 12 Hours, followed by ASV one vial in 24 Hours. Ordinarily ASV may stopped after 48-72 Hours.

COBRA BITE  If Ptosis is present to give ASV 4 vials IV in half an hour followed by Inj ASV two vials as IV drip for next 4 hours.  If there is weakness of LIMBS / RESPIRATION to give ASV 6 vials in half an hour followed by ASV 4 vials in 4 hours. RESPIRATORY SUPPORT- when needed….. 1.To assess Oxygenation by Pulse oxy meter/ Blood gas. 2.To keep ET tube , Ambu bag, Laryngescope ready. 3.To keep VENTILATOR ready.