Dr Arya Jith
Best
way to a manage
Is to prevent a snake
bite…..!
A
WORLD WITHOUT SNAKES
 NEARLY
A QUARTER OF US WOULD GO
HUNGRY
 THEY
ARE IMPORTANT ELEMENTS IN FOOD
CHAIN THAT CONTROL RODENT POPULATION
5
DANGEROUSLY POISONOUS SNAKES
KING COBRA
COMMON COBRA
COMMON KRAIT
RUSSELL’S VIPER
SAWSCALED VIPER
MOST COMMON POISONOUS SNAKE IS
COMMON KRAIT
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 TO
IDENTIFY WHETHER IT WAS A POISONOUS
SNAKE.
 216 SPECIES- 52 VENOMOUS
 IF THE PAIN NUMBNESS AND OEDEMA IS
SPREADING THEN IT IS A VENOMOUS SNAKE.
 SUSPECTED SNAKE BITE
OBSERVATION 24 HOURS
 Universal
fear - a state of shock
 Bite site -multiple teeth impressions
 significant local pain or swelling -ABSENT
 Adequate reassurance and symptomatic
treatment .
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•
To rule out ptosis
Evidence of early external
ophthalmoplegia .
•
•
•
size and reaction of the pupils.
Early paralysis of pterygoid muscles.
“broken neck sign
Oedema petechiae bullae oozing from the wound
should be noted
Extent of swelling
circumference of the bitten limb should be noted
every 15 minutes- spreading
 CT>
10 MINUTES
 Bleeding manifestations
 Oliguria /haematuria
 Hypotension
 Ptosis
 Circumoral paraesthesia
 Aphonia/Dysarthria
 GRADE0
– NO ENVENOMATION
 GRADE 1- MINIMAL ENVENOMATION
(local pain and swelling)
 GRADE2-MODERATE ENVENOMATION
(Pain ,swelling,ecchymosis spreading
+mild systemic/ lab manifestations)
GRADE 3-SEVERE ENVENOMATION
(Marked local response+severe
systemic findings+significant lab findings)
 Blood
grouping
 Hb, elevated PCV
 TC-leucocytosis
 Platelet count- thrombocytopenia
 Peripheral smear – Haemolysis
 BT,CT(20 min)
 prolonged PT ,aPTT
 Urea Serum Electrolytes- hyperkalemia
 Urine Routine-haematuria
 Metabolic /resp acidosis
 Level
of consiousness
 Pulse, BP, Resp rate,Capillary refill time
 Clotting time 1/2hr -1hourly
 Urine output
 Muscle weakness
 GRADE
0-NO ENVENOMATION
Local wound care
Injn TT
Observation -24 hrs
 MINIMAL
ENVENOMATION
Injn TT
Antibiotics (inj CP/Ampicillin)
Observe for 24 hours
 Moderate
and Severe Envenomation
Injn TT
Antibiotics(Ampicillin /CP/
3 rd genertn cephalosporins+
metronidazole)
local anti oedema measures
 NEVER
APPLY A TOURNIQUET ABOVE THE
SITE
 IF THE PATIENT COMES WITH A TOURNIQUET
always CHECK FOR VASCULARITY
 Do not suck out venom
 Do not incise the bite wound nor apply any
chemicals
 Antivenom
is immunoglobulin (usually the
enzyme refined F(ab)2 fragment of IgG)
purified from the serum or plasma of a horse
or sheep that has been immunized with the
venoms of one or more species of snake.
 Monovalent or monospecific antivenom
 Polyvalent
 India –polyvalent is available which act
against the venom of commonly found
snakes in india
 Neurotoxicity
 Bleeding/coagulopathy
 Myoglobinuria/haemoglobinuria
 Cardiac
toxicity
 Local swelling involving more than half of the
bitten limb
 Rapid extension of swelling
 Development of an enlarged tender
Lymph node draining the bitten limb
 ARF
 10
vials polyvalent asv(irrespective of body
weight and age)
 2nd dose - overt bleeding is present
10 vials
OR
Do 20 minute clotting time and give
2 vials Q6H till the coagulation
parameters are normal
 No
test dose is required
 One
vial is added with 100 ml of normal
saline. After 10 -15 minutes 9 vials can be
added in the same fluid over one hour
 Urticaria
,itching ,fever , shaking chills
,nausea ,vomiting ,diarrhoea abdominal
cramps ,tachycardia hypotension ,
bronchospasm and angioedema


ASV is discontinued
0.01mg/kg of Adrenaline is given
(1:1000)as IM should be given

100mg of Hydocortisone(2mg/kg) and
10mg of H1 antihistamine
(children- 0.2mg/kg) IV
2nd dose of Adrenaline 0.5 mg (1:1000) IM
can be repeated
Patient is recovered ASV can be restarted
slowly within 10 – 15 minutes
 Best
effect – used within 4 hours
 Can be administered upto 48 hours
 Efficacy is seen upto 6- 7 days
 Normalization
of BP
 Bleeding stops within 15 – 30 mts
 Normalization of coagulation parameters
within 6 hours
 Neurological sign will be resolving within 3048 hours
 Neostigmine
-0.05mg to 0.1mg/kg every 4
hours
 Atropine
0.02mg/kg (5minutes prior to
neostigmine)
Watch for
ptosis
 Shock
 Renal
failure
 Myocardial failure
 Shock lung
 Bleeding
 PUFFINESS
 CHEMOSIS
 PAROTID
 Rx
-
SWELLING
methyl prednisolone
(10mg/kgQ8H) x 3days
cardiogenic
hypovolemic
neurogenic

If renal function is normal
Start with volume expanders(20ml/kg of isotonic
soln)
Corrected?
hypovolemic shock
Symptoms of other
shock
 Raised
JVP
 Oedema
 Signs of pulmonary oedema
 Feeble heart sounds
 Changes in ecg

Start Dobutamine Drip
(5-10microg/min)
Uncorrected-Neurogenic
shock
 Dopamine

drip(10-12microg /min)
BP is coming up
Nor adrenaline (0.1- 0.5 microgram/kg)
 Early
dialysis
uremia
anuria
Peritoneal
dialysis
hyperkalemia
Flluid
overload
 Treat
cardigenic shock
 Treat ccf
 Avoid fluid overload
 Oxygen inhalation
 Tacypnea
 Hypoxemia
 Unexplained
 Mild

drowsiness
acidosis
treatment-o2inhalation
cpap
ventillation
 Correct
coagulation failure
 FFP-10ml/kg
 Correct platelet deficiency
 Whole blood– frank bleeding