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management of Snake bite

snakes in bangladesh and management of snake bite

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management of Snake bite

  1. 1. Presented by: MD. MOHIUDDIN JUWEL Capt MO CMH Ghatail Snakes in Bangladesh & Management of Snake Bite
  2. 2. INTRODUCTIONSnake bite is an important public health hazard in Bangladesh Estimated an annual incidence of 623/100,000 6,041 deaths annually. Neurotoxic snakes like (Cobra, Kraits) are causing significant mortality and morbidity Among the vipers green pit viper is very common but there are few cases of Russell's viper. Rahman R,Faiz MA,Selim S,Rahman B, Bashar A,et el.Annual incidence of snake bite in rural Bangladesh. PLoS Negl Trop Dis.2010 Oct;4(10):e860.
  3. 3. hh Moonocled Cobra (Naja Kaouthia) Binocellate Cobra Naja naja
  4. 4. King cobra (Opiophagus hannah)
  5. 5. Branded Krait (Bungarus fsciatus) Common Krait (Bungarus Caeruleus) Bungarus walli Bungarus nijer
  6. 6. Common vipers in Bangladesh Spot tailed pit viper White lip pit viper Pope’s pit viper Russel’s viper
  7. 7. Russell’s viper
  8. 8. Sea snake
  9. 9. What is venomous snake bite?
  10. 10. ► A bite by venomous snake which produces specific symptoms or a syndrome is considered as venomous snake bite. ► A venomous snake may not and do not always features of envenoming ► 50% of bites by Russell’s viper , 30 % of bite by Cobras and 5-10% of bites by saw scaled viper do not result in any symptoms or signs of envenoming ► A victim may develop some features due to anxiety or apprehension in case of bite by a venomous as well as NV snake.
  11. 11. Traits Poisonous Non Poisonous 1. Colour Generally brightly coloured Usually not brightly coloured 2. Shape of head long, triangular and posterior portion is wide narrow and elongated 3. Neck always constricted. No constriction 4. Hood Present Absent 5. Tail abruptly tapered tapered and long except burrowing snakes 6. Head scales usually small Scales on the top of the head are large 7. Dorsal scales are smaller but the spinal (vertebral) scales are larger longer but spinal (vertebral) scales are not longer and hexagonal 8. Loreal shield Present Absent 9. Teeth Most of the teeth are solid and uniform except maxillary teeth which are large, and provided with groove or canal. These large teeth are called ‘Fangs’. Uniform and solid
  12. 12. Traits Poisonous Non Poisonous 10. Poison Gland Present Not Present 11. Mental shield Fourth one is large. Small 12. Muscular system Less- developed Well-developed 13. Lungs One of the lungs has either been reduced or absent. Both lungs are present. 14. Hypophysis developed throughout the vertebral column. absent or present on the posterior dorsal vertebrae. 15. Streptostylism Well marked Absent 16. Example: Saw Scaled Viper (Echis carinatus), Common Krait (Bungarus caeruleus), Banded Krait (B. fasciatus), Russell’s Viper (Vipera russelli), King Cobra (Ophiopagus hannah), Indian Monocled Cobra (Naja naja kaouthia). Rat Snake (Ptyas mucosus), Indian Python (Python molurus), Sand Boa (Eryx conicus), Checkered keel back [Natrix (Xenocrophis) piscator], Wolf Snake (Lycodon aulicus), Striped Keel back (Amphiesma stolata).
  13. 13. Total no. of snake species -98 Total no. of venomous snake species- 32 Total no. of non-venomous snake species- 66 Total no. of threatened snake species(IUCN 2000) -28 Snakes in Bangladesh: Venomous snakes in Bangladesh:  Common krait (Kal-keutey) Monocellate cobra (Gokhra) Spectacled cobra (Khoia gokhra) King cobra (Padmagokhra) Banded krait (Shankhini shap) Russell’s viper (Chandro-bora) Green pit viper (Sabuj bora) Spot-tailed pit viper (Tila-leji sabuj bora)
  14. 14. Most venomous snake in land: Inland Taipan. Top most venomous snakes: Belcher's Sea Snake
  15. 15. History Taking
  16. 16. •Where (in which part of your body) were you bitten? •When were you bitten and what were you doing when were you bitten?” •Where is the snake that bit you?” What did it look like? did anyone take a picture?” •How are you feeling now?” Non specific symptoms: Headache, Nausea, vomiting, abdominal pain, loss of consciousness, difficulty in vision, convulsion.
  17. 17. Neurological symptoms: 1. Muscle paralysis 2. difficulty in moving jaw,toungue,eye 3. heaviness of eye lids (ptosis) 4. weakness of neck muscles (broken neck sign) 5. difficulty in swallowing, dribbling of saliva 6. nasal regurgitation, nasal voice 7. difficulty in respiration, 8. extreme generalized weakness Haematological symptoms: 1. Spontaneous bleeding from gum, 2. vomiting of blood, Coughing out of blood,
  18. 18. 3. passage of blood per urethra, 4. persistent bleeding from bite site, venepuncture site and inflicted wound if any. Others: Severe muscle pain, dark urine, scanty urination, collapse. Concomitant medical illness: H/O allergy, Bronchial asthma, kidney, heart disease, bleeding disorders, neurological disease, limb swelling etc. In female: Whether the victim is pregnant or not, whether the victim menstruating or not.
  19. 19. H/O pre hospital treatment: 1. Home treatment. 2.Treatment from traditional healers (Ozha or Baiddya). 3.Application of tourniquet. 4.H/0 immunization against tetanus. 5.Treatment by initial attending physician.
  20. 20. Physical Examination
  21. 21. Early clues that a patient has severe envenoming: • Snake identified as a very dangerous one or a large specimen • Widely spaced fang puncture marks or evidence of multiple strikes • Rapid early extension of local swelling from the site of the bite • Tender enlargement of local lymph nodes, indicating spread of venom in the lymphatic system • Systemic symptoms: collapse (hypotension, shock), nausea, vomiting, diarrhoea, severe headache, “heaviness” of the eyelids, inappropriate (pathological) drowsiness or early ptosis/ophthalmoplegia • Spontaneous systemic Bleeding • No urine passed since the bite • Passage of dark brown/black urine
  22. 22. 1.Rapid clinical assessment especially vitals: Pulse, BP, Respiration, Temp 2.Systemic signs of envenoming: Chronology of onset and progression of signs. a. Neurotoxic sign: • Ptosis(Partial or complete) usually symmetrical and progressive • Diplopia, external ophthalmoplegia • Bulbar palsy • Nasal voice • Facial paralysis • Inability to open the mouth and to protrude the toungue • Paralysis of chest muscle and diaphragm (Shallow breathing) • Broken neck sign: Weak grip, diminished reflexes
  23. 23. Neurotoxic sign
  24. 24. b.Signs of haematological abnormality: • Persistent bleeding from bite site, venepuncture site and or inflicted wound if any • Multiple bruise or large blood collection • Haemorrhagic blisters • Bleeding from gingival sulci • Haemoptysis • Haematuria • Epistaxis
  25. 25. Haematological Sign
  26. 26. c.Signs of Renal failure: Scanty or no micturation,dark urine Clinical uraemic syndrome: Nausea, vomiting, hiccups, fetor, drowsiness,coma, flapping tremor, muscle twitching, convulsion, pericardial friction rub, signs of fluid over load d.Signs of myotoxicity: Muscle tenderness, weakness, respiratory failure, black urine, renal failure c.Signs of local envenoming: Swelling, tenderness, bleeding, ulceration,necrosis, local lymphnode enlargement
  28. 28. Examination of the bitten part: • Extent of swelling • Lymph nodes • A bitten limb may be tensely oedematous, cold, immobile, painful on passive movement and with impalpable arterial pulses. •Early signs of necrosis may include blistering, demarcated darkening(easily confused with bruising) or paleness of the skin, loss of sensation and a smell of putrefaction(rotting flesh).
  29. 29. Identification of snake • Identification of snake by description or by model, photograph, brought snake, preserved specimen. By local examination- • Classic fang and teeth mark rarely occur and if present indicate venomous snake bite • Scratch usually indicates nonvenomous snake bite but may rarely found in krait bite • Snake may bite through clothing
  30. 30. Laboratory investigations
  31. 31. • Coagulation test- 20 min whole blood clotting test (Bed Side) • ECG • CBC • Blood urea, S.Creatinine • Urine R/E and naked eye examination of urine • APTT ,PT • S.CPK • ELISA • Blood grouping and Rh typing • Arterial blood gas analysis & pH
  32. 32. The management of snake bites
  33. 33. • First-aid treatment • Transport to hospital • Rapid clinical assessment and resuscitation • Detailed clinical assessment and species diagnosis •Investigations/laboratory tests • Antivenom treatment • Observing the response to antivenom
  34. 34. • Deciding whether further dose(s) of antivenom are needed • Supportive/ancillary treatment • Treatment of the bitten part • Rehabilitation • Treatment of chronic complications • Advising how to avoid future bites
  35. 35. Recommended First Aid 1. Reassurance 2. Immobilization of whole body 3. Apply Pressure Pad Immobilization. 4. Avoid any interference with the bite wound CAUTION: Delay the release of tight bands, bandage & ligatures
  36. 36. Pressure Immobilization Method
  37. 37. PLEASE KEEP IT IN MIND • DO NOT WASTE TIME TO ANY OZHA OR TRADITIONAL HEALERS 1.NOT scientific 2.Waste of time 3.May cause infection, bleeding, gangrene 4.Damage to artery , vein 5.Loss of life 6.Always harmful
  38. 38. HARMFUL- NOT RECOMMENDED 1.Tight tourniquets 2.Incision at the bite site 3.Local suction 4.Cauterization by chemicals 5.Application of materials 6.Ingestion of herbal products to induce vomiting 7.Unnecessary delaying
  39. 39. Treatment in Hospital 1. Rapid clinical assessment and resuscitation (ABC) Assisted Ventilation, Blood Transfusion 2. Detailed clinical assessment (Local, Neurological, Haematological) 3. Identification of species (Brought snake live, dead or description,photograph 20 min WBCT, Syndromic approach)
  40. 40. Treatment: a.Antibiotic b.Tetanus prophylaxis c.Antivenom Polyvalent Antivenom: In our country now only Polyvalent antivenom from Vins (lindia) is available in lyophilized powder form. Each vial contain 10 mg of antivenom, which is effective against systemic envenoming by Cobra, Krait, Russell's Viper and Saw scaled viper only (there is no evidence of Saw scaled viper in Bangladesh). So this type of antivenom should not be used in bites by Green snake, Sea snakes and identified non-venomous snake.
  41. 41. Antivenom Treatment Indication /criteria for using antivenom: (Not indicated in Green snake and sea snake) 1.Neurotoxic signs. 2.Rapid extension of swelling (more than half of the bitten limb). N.B- not due to green snake bite or tight tourniquet. 3.AKI (not due to sea snake). 4.Cardiovascular abnormalities 5.Bleeding abnormalities. 6.Haemoglobinuria/myoglobinuria not due to sea snake.
  42. 42. Anti snake venom therapy • Dose: Each dose consists of 10 vial of polyvalent antivenom irrespective of age and sex of the victim. • Time and administration: Each vial is diluted with 10-ml. of distilled water. 10 such vials (100 ml) is further diluted or mixed with 100 ml of fluid (Dextrose water or saline). Then it is administered with intravenous infusion within 40-60 min (60-70 drops/min). • Observation and monitoring: Continuous observation and frequent monitoring of vital signs should be ensured during antivenom therapy and few hours after its completion. Careful clinical assessment for appearance of signs and symptoms of antivenom (A/V) reaction should be performed.
  43. 43. Active against: 1. Cobra 2. Common Krait 3. Russsel’s viper 4. Saw scaled viper
  44. 44. DAY 1 DAY 1 DAY 2 DAY 3 DAY 4
  45. 45. Criteria for repeating the initial dose of antivenom: Persisting or deteriorating signs of systemic antivenom.eg. 1. If no improvement or deterioration of neurotoxic features (cobra or krait) 1-2 hours completion of antivenom. 2. Persistence or recurrence of blood coagulopathy after 6 hours of antivenom treatment.
  46. 46. Drugs not recommended: 1. Antihistamine except for antivenom reaction 2. Corticosteroid except antivenom reaction 3. Sedative 4. Antifibrinolytic agent 5. Heparin 6. Traditional medicines (from ozahs)
  47. 47. Treatment of bitten part: • Elevation of limb with rest • Simple washing with antiseptic solution • Broad spectrum antibiotic (especially when there is features of contamination, multiple incisions) • In case of local necrosis and gangrene: Broad spectrum antibiotic Surgical debridement and split thickness skin grafting is indicated. • In case of Compartment syndrome: Fasciotomy
  48. 48. Follow up: Local envenomation: 1. Need to follow up for at least 5- 7 days to see the sequential changes of color changes, blisters, ulceration, necrosis and desquamation. Children : To observe any neurological residual deficit present or not with also attention to neurocognitive function. Pregnancy: Long term follow up of children is also needed to see the neurological cognitive function.
  49. 49. Rehabilitation:  Physiotherapy  Reconstructive surgery Discharge assessment • Implications of having had a snakebite: • Rehabilitation exercises: • Follow-up appointment: encourage the patient to return after an interval of 1-2 weeks to check on their progress and to allow further reassurance. • Late serum sickness-type reactions: warn them of the symptoms and reassure them that this complication of antivenom can be treated. • Reducing the risk of further bites: provide advice, ideally in the form of a leaflet, explaining the principles of snakebite prevention , to be shared with their familiesand neighbours.
  50. 50. What should we do when no antivenom is available? Incase of neurotoxity: • Assisted ventilation via ambu bag or mechanical ventilation • Inj.Atropine and Neostigmine In case of Haematological abnormality: • Strict bed rest to avoid even minor trauma • I/M injection must be avoided • Fresh whole blood or FFP transfusion should be given
  51. 51. THANK YOU
  52. 52. ANY QUESTION ?