Case presentation
snake bites
Grampians EMET training Hub
Case 1 - VICTORIA
56 year old male
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Arrived at 1140
- bitten by snake on right
hand
- whilst trying to scare it
away from his children
- in afternoon at nearby
picnic ground
- He had consumed alcohol
- snake killed by friends and
brought in
States feels weird and
nauseated
No bandage applied initially
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What could be done
differently here?
Past History
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Angina => angioplasty
5 yrs ago, nil since
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Drugs
Simvastatin, Aspirin
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Allergies
Morphine
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Any specific features on
history that you should
ask about?
Examination
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Anxious, mildly confused,
breathalyser 0.32
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Bite to 1st web space right
hand
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puncture wounds dorsum
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Observations stable
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Otherwise NAD
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Any specific features that
should be documented?
Management- Initial
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Swab taken from bite
site, then compression
bandage applied
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IV line
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Blood for FBE, U+E,
CK, Coagulation profile
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ADT given
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What further action is
appropriate now?
30 minutes later…
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Venom detection kit positive
for tiger and black snake
Patient feels better, alert,
orientated,
neuro exam normal
APTT 33, INR 0.9
FBE, U+E, CK normal
Bandage removed
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20 minutes later…
A staff member has called the
local wildlife park
Snake seen by herpetologist,
identified as copperhead
What do we learn from this
case?
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Pre hospital issues
include public
education, and first aid
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In Victoria, Australia
The only antivenom
required is tiger and
brown snake
Exceptions include
snake handlers, the
wildlife park/zoos, and
people with other
snakes as pets
25 minutes after the snake
identification…
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Patient disorientated, slurred speech c/o
weak arms and legs, and blurred vision
Slight ptosis
What action is needed?
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Do you put the bandage back on?
Do give antivenom?
If yes, which antivenom?
Who can you ask for help?
Further management
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One vial tiger snake
antivenom given in
Hartmans solution over
30 minutes
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IV hydrocortisone given
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Adrenalin and
phenergan drawn up
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Putting the bandage back on
while getting the antivenom
ready is a good idea
But then the antivenom must
come in contact with the
venom, so after infusion
commenced and patient is
stable, take off bandage
Tiger antivenom is given for
black or tiger snake
HELP - seek senior help, and
POISONS centre 131126 is
available PRN
40 minutes later (10 mins post
infusion complete)
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Patient feels a bit
better, with clinical
evidence of
improvement
No respiratory
compromise
Admitted and
transferred to ICU
overnight
for observation
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Following morning
Feels well, no
neurological
signs/symptoms, no
bleeding
Repeated blood tests
all normal
Discharged
Case 2 - WESTERN AUST.
38 year old male
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Snake bite to middle finger
of left hand
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Whilst trying to catch snake
in house
Placed a single layer
compression bandage on
his own arm from fingers to
elbow
Drove to his GP in 10
minutes
No symptoms or signs of
envenomation
Decision to transfer to
Tertiary referral Hospital by
ambulance (60 minutes)
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In transit, the patient
complained of feeling unwell
with chest tightness and
rapidly became unresponsive.
Decision to seek medical
attention at Urban Hospital
en route (still 30 minutes
approx from tertiary referral
hospital)
Initial Management 02.15
hours following the bite
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Unresponsive with no
cardiac output
ECG: pulseless electrical
activity, narrow complexes
CPR commenced
Intubation
1mg adrenalin
1000ml normal saline
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Antivenom IV bolus;
1 ampoule polyvalent
2 ampoules brown snake
2 ampoules tiger snake
Subsequent course
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Spontaneous circulation
resumed within 1 minute of this
antivenom, total 11 minutes
CPR
Platelets 33, INR >10, APTT
>180, Fibrinogen < 0.3, FDP >
20
Discussed with on-call
toxicologist
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Further antivenom:
1 ampoule polyvalent
3 ampoules brown snake
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Creatinine 108, ALT 113, CK
143, Troponin I < 0.4,
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Stabilised and transferred to
tertiary centre, developed
bleeding lips and gums en
route
3 hours following the bite
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Pulse 105, BP 135/60,
pupils 4mm equal and
reactive
Bleeding gingivae and
venepuncture sites,
petechiae around eyes,
haematuria
ECG: sinus tachycardia,
RBBB, mild ST-segment
depression
Venom detection kit from
bite site positive for brown
snake
Compression bandage
reinforced and extended
to include the whole limb
Subsequent course
10 ampoules brown snake
antivenom given in 100 ml
0.9% saline over 15 minutes
Platelets 111, INR > 10, APTT
> 180, Fibrinogen < 0.3, FDP
>20
Creatinine108, ALT 201, CK
164, Troponin I < 0.4
CT head normal
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No further oozing noted and
compression bandage
removed
Patient’s condition remained
stable
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5 hours following the bite
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Transferred to ICU, where remained
stable
Platelets 214, INR >10, APTT > 180,
Fibrinogen < O.3, FDP > 20
Creatinine 133, ALT 277, CK 259,
Troponin I 2.8
Further 5 ampoules brown snake
antivenom infused
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9.30 hours following bite
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Platelets 161, INR > 10, APTT > 180,
Fibrinogen <0.3, FDP > 20,
Creatinine 127, ALT 243, CK 366,
Troponin I 10.8
15 hours following bite
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Platelets 148, INR 1.8, APTT 44.7, Fibrinogen 0.5, FDP > 20,
Creatinine 134, ALT 223, CK 462, Troponin I 6.8
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Extubated, neurologically normal.
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Commenced on 5 days oral prednisolone 50 mg
1 month later
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Follow up, well
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Flu like illness with rash and sore joints
between days 17 and 21 after envenomation
Learn from this case?
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A correctly applied
pressure immobilisation
bandage should allow
stable transfer of
patients long distances
E.g Flying doctor
service
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Expert advice is
needed
In WA, there is a
different profile of
snake bites
The recommendations
for antivenom have
changed since this
case, and will continue
to change, hence seek
advice
Scenario 3
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A 23 yr old man present to your emergency
department complaining of dizziness, blurred
vision, nausea and vomiting. He was well
until about 1 hour ago. Today he has been
chopping wood and re organising the wood
heap, he sustained a scratch to his R thumb,
but did not see what did it.
What is your assessment & management?
Assessment/examination
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cubicle
ABC
consider risk of snake bite
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swab wound for VDK
pressure/immobilization
full hx & ex
bloods fbe, uec, clotting, glucose
Investigation
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VDK + for brown snake
FBE 12.3, 12(10), 120
UEC NAD
Clot INR 4 APTT 65 Fibrinogen 0.5
what now?
Management
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Resus
prepare antivenom & give
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1unit now recommended starting dose
dilute as described
consider premedication
when do you remove the Pressure immobilisation
neuro obs
what next
continued
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recheck coags
do you correct the coags?
Where to?
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There are recent updates in
recommendations re
treatment of coagulopathy
http://www.australianprescri
ber.com/magazine/35/5/152
/5
Replaces 2006 article
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http://www.australianprescri
ber.com/magazine/29/5/125
/9/