BANGALORE BAPTIST HOSPITAL
Snakebite Study Workshop
Vellore, Mar 2013
Dr Tarun/ Dr Indira Menon
Questionnaire.
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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)
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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
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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
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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!