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
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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 SUPPORTwhen 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.