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Snake bite sazwan

snake bite

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Snake bite sazwan

  1. 1. SNAKE BITE Dr. Sazwan Reezal Shamsuddin Emergency Department Hospital KL
  2. 2. Outline • case • identify venomous snakes • family of snakes • pathological effects of snake’s venom • management • anti venom
  3. 3. Case 1 56 y Indian female @ 3pm Bitten by a black snake at 12.30pm while feeding chicken at home. Was sent to private clinic where she developed cardiorespiratory arrest. Pt. was resuscitated and sent to KKM Hospital At the ED she was unresponsive, intubated and manually ventilated PR 140, BP 100/87, pupils 3 mm and sluggish bilaterally. Swelling and blue black discolouration over dorsum of left hand. 2 bite marks seen.
  4. 4. Specific anti-venom for the Naja naja (Cobra) was given. ATT, Chlorphenaramine and hydrocortisone was given before the anti-venom Pt. was transferred to HKL where she was ventilated in CCU. In CCU she developed hypoxic fits. Bullae formation over left hand which later turned gangrenous Pt. died form septicaemia.
  5. 5. Case 2 35y male Burmese. Bitten by a black snake on the right foot while feeding his rabbits at 12.30pm. On arrival at the ED , he complained of pain over his right foot.He was conscious, alert, PR 70/min, BP 133/60, RR 20/min. There was bilateral ptosis. The dorsum of right foot - swelling and erythema
  6. 6. ATT, chlorphenaramine, hydrocortisone and diclofenac was given Polyvalent anti-venom was started in the ward The ptosis immediately disappeared. He remained stable in the ward. The right foot became swollen with cellulitis, necrotic area and desloughing was done. Patient discharged well. Follow up ortho clinic
  7. 7. Case 3 56 y female Iban at 11.10am referred from Batu Arang clinic. Bitten by a black snake with yellow dots at the left hand at 8.30am in the flat. At ED , complained of difficulty in breathing and chest pain on and off. Pt. was conscious and alert, PR 103/min, BP 149/100 RR 22/min, a single bite mark seen at base of left thumb dorsally, minimal erythema and no swelling.
  8. 8. ATT given Anti-venom was not given and patient was closely observed in the ward. No further swelling of the left hand. Pt. discharged well.
  9. 9. 5 Genera of Venomous Snakes In Malaysia • Pit Vipers • Cobras • Kraits • Coral Snake • Sea Snake
  10. 10. Venoumous Snake • triangular head • Elliptical pupil • Heat-sensing pit • Retractable fangs • Venom duct • Venom gland
  11. 11. Non-venomous Snake • Rounded head • Round pupil • No heat-sensing pit • No fangs
  12. 12. Some Facts on Snake Bites • Even though not all snake bites are venomous,it is best to consider all snakes are dangerous. • A fang mark does not necessarily mean that venom is injected. • Most snake bite in defense which venom injected usually minimal. • If venom injected it is usually quite deep & it serves no purpose to incise wound to remove venom. • Very little venom reaches blood stream if firm pressure is applied & limb is immobilized. • Not to handle `dead snake’ as reflex envenomation by a decapitated snake can occur several hours after death
  13. 13. EPIDEMIOLOGY OF SNAKE BITE 75% of snake bites are reported form the northern states namely Perlis, Kedah and Penang 60% are due to the Malayan Pit Viper (Reid et al. 1963) Mortality rates 0.1% - 1.6% The Malayan Pit Viper, Cobra and Kraits constitute higher percentage around human habitat than other poisonous snakes.
  14. 14. • In M’sia : >/= 18 species of venomous land snakes & >/= 22 species of venomous sea snakes • 5 subfamilies : 1. Crotalinae 2. Elapinae 3. Laticaudinae 4. Hydrophiini 5. Ephalophiini (1) & (2) – land snakes ; (3) , (4) & (5) – sea snakes
  15. 15. LIST OF VENOMOUS SNAKES: Family CROTALIDAE (Pit vipers) Malayan pit viper (Agkistrodon rhodostoma) (Ular Kapak Bodoh) Sumatran pit viper (Trimeresurus sumatranus) (Ular Kapak Sumatera) Mangrove pit viper ( Trmeresurus purpureomaculatus) ( Ular Kapak Bakau)
  16. 16. Malayan pit viper (Ular kapak bodoh) • North • Kedah, Penang, Kelantan
  17. 17. Malayan pit viper (Ular kapak bodoh)
  18. 18. Sumatran pit viper (Ular Kapak Sumatera)
  19. 19. Sumatran pit viper (Ular kapak sumatera)
  20. 20. VIPER BITES 1. Local symptoms are prominent - severe persistent pain - Intense swelling of the limb - blisters - slough and necrosis 2. General symptoms - haemopthysis - haemorrahge under the skin and mucous membrane (discoid ecchymosis) - epistaxis - bleeding gums - haematuria - maleana - oozing from bite - +ve torniquet test
  21. 21. 3. Internal haemorrhage - abdominal pain - vomiting - shock 4. Cardiotoxicity 5. Renal dysfunction #coaguability last for 6-10 hours @blood product will not correct it except anti-venom
  22. 22. Sign high volume venom
  23. 23. Discoid ecchymosis & gum bleeding
  24. 24. Family ELAPIDAE Common Black Cobra (Naja naja) (Ular Sendok) King Cobra (Opiophagus hannah) (Ular Tedung Selar) Banded Krait (Bungarus fasciatus) (Ular Katam Belang) Malayan Krait (Bungarus candidus) (Ular Katam Tebu) Blue Malayan Coral Snake (Maticora bivirgata) (Ular Pantai Biru-biru) Banded Coral Snake (Maticora intestinalis) (Ular Pantai Belang)
  25. 25. Common cobra (Ular senduk)
  26. 26. Common cobra (Ular senduk)
  27. 27. King Cobra (Ular tedung selar)
  28. 28. King Cobra
  29. 29. Malayan krait (Ular katam tebu)
  30. 30. Banded krait (Ular katam belang)
  31. 31. Banded coral snake (Ular pantai belang)
  32. 32. Blue Malayan coral snake (Ular pantai biru-biru)
  33. 33. COBRA BITES / KRAIT BITES 1. Local pain - appearance of bullae - cellulitis, necrosis - regional lymphadenopathy 2. Weak and sleepy 3. Paralysis gradually develop - perioral numbness (early sign) - ptosis, ohpthalmoplegia - difficulty in speech, swallowing, walking - respiratory paralysis
  34. 34. Family HYDROPHIDAE (Sea Snakes) Banded Sea Snake (Hydophis cyanocintus) Hardwick’s Sea Snake (Lapemis hardwickii) Amphibious Sea Snake (Laticauda colubrina) (Ular Laut Amfibia)
  35. 35. Amphibious sea snake (Ular laut amfibia)
  36. 36. Hardwick’s sea snake
  37. 37. Banded sea snake
  38. 38. SEA SNAKE BITES 1. History of painless bite occurring whilst swimming or sorting of fish net 2. Half to one hour after bite: - generalised muscle aches and pains - stiffness 3. Myoglobinuria 3 - 6 hours after the bite 4. Hyperkalaemia and renal dysfunction
  39. 39. PATHOLOGICAL EFFECTS OF SNAKE VENOM ELAPID VENOM: Local necrosis Respiratory paralysis Cardiac arrythmias HYDROPHIID VENOM: Respiratory paralysis Myonecrosis Kyperkalaemia Acute renal failure
  40. 40. CROTALID VENOM: Local oedema and necrosis Haemorrahages Disseminated intravascular coagulation
  41. 41. Venom MOA • Viper: contain complex enzyme mixture  cleavage of fibrinogen causing hyperfibrinolysis  consumptive coagulopathy alters blood vessel permeability  loss plasma & blood to surrounding tissue  shock
  42. 42. • Cobra act at NMJ bind to post-synaptic Ach receptor  depolarizing neuromuscular blockade  paralysis direct effect to heart  arrythmias & impaired contractility enzymes  proteinlysis & breakdown connective tissue  necrosis
  43. 43. TREATMENT OF SNAKE BITE DO NOT apply an arterial tourniquet DO NOT apply ice DO NOT incise or suck the bitten area DO NOT wash the bitten area
  44. 44. DO: 1. Do not panic and keep calm 2. Reassure the individual as complete recovery is the rule 3. Lie the patient down to ensure minimal activity 4. Apply a broad pressure bandage over the bite extend it as high as possible
  45. 45. 5. Apply a splint to immobilise the limb 6. Ask for help and transport the patient to hospital as soon as possible 7. If the snake has been killed, bring it to the hospital for identification
  46. 46. TREATMENT OF SNAKE BITES IN HOSPITAL 1. A B C D E 2. Take a detailed history from patient - Identify location of snake bite - Ask for detail description of the snake if the snake is not caught - Establish time interval between incident and medical treatment - Examine the site of snake bite and note characteristics of the fang marks - signs and symptoms of snake bit poisoning
  47. 47. 3. IM ATT 4. Evaluation of the severity of envenomation
  48. 48. Grades of envenomation MINIMAL:  no pain to moderate pain,  erythema,  oedema 2.5-15cm,  no systemic symptoms MODERATE  severe pain  tenderness  oedema 25-40cm  spreading erythema  petechiae  vomiting  fever  weakness
  49. 49. SEVERE  widespread pain  oedema 40-50cm  ecchymosis  systemic sign VERY SEVERE  rapid swelling  ecchymosis  CNS symp  visual disturbance  shock  convulsion
  50. 50. Guide for dosage of antivenin grade of envenomation dosage minimal not indicated moderate 20-40ml (2-4 vials) severe 50-90ml (5-9 vials) very severe 100-150 ml (10-15vials)
  51. 51. Anti-Venom in HKL • Specific: 1. Pit Viper 2. Cobra (Equinae, Naja-naja, Karaothia) 3. Sea-snake 4. King Cobra • Polyvalent : • Standard Cobra (Naja- naja) • Standard Krait (Bunganus Caeruleus) • Russel’s Viper • Saw-Scale Viper (Echis Carinatus)
  52. 52. How snake anti-venom made? • the venom is "milked" from the snake • it's diluted and injected into a horse or goat. • the animal builds up immunity to the venom, the dosage is increased, and the animal creates blood rich in antibodies. • antibodies collect in the serum
  53. 53. Administration of antivenom • specific antivenom for the particular species of snake is prefered. • Dilute 1-2 vials of antivenom in 200mls NS, run a drip slowly at 5 drops per minute for first 20 minutes. If no allergic reaction run the rest fast within 1 H.
  54. 54. Reaction!!!?? What to do?? • skin test has no predictive value. • if reaction occur, stop infusion immediately. • administer H1,H2 blockers, aderenaline & fluids. • dilute antivenom further & administer at lower rate • re-assess at 6,12 & 18 H KIV repeat antivenom
  55. 55. 5. Investigations - FBC - Haematocrit - PT, APTT - Urea and electrolytes - UFEME - blood gases - urine for myoglobin - coagulation profile - ECG
  56. 56. 6. Supportive treatment - analgesia for pain - Observe patient closely - maintain adequate hydration - surgical debridement of necrotic bite site - antibiotics - Renal dialysis - ? Blood and blood products
  57. 57. WHAT TO DO IF YOU SEE A SNAKE: 1. Do not be afraid. 2. Allow the snake to go away or move away from the snake. 3. Do not kill the snake unnecessarily. 4. Snakes do not attack man, They only bite only when attacked or agitated.
  58. 58. HOW TO AVOID SNAKE BITE: 1. When walking in the jungle - wear tall boots - be alert - do not put your hands in holes or put your foot in pits - do not overturn stones or logs. 2. Most snakes are active nocturnally, take extra care when walking at night.
  59. 59. Enzymes • proteolytic enzme • Thrombin like enzyme • Hyaloronidase • Phospholipase A2 • Acethylcholinesterase • Lactate dehydrogenase
  60. 60. First Aid • Do not torniqueyt • Compression bandage with splint • ATT • Clean wound • Analgesia • Mark the fang & measure • Whole blood clotting test Whole Blood Clotting Test 20 mins leaved undisturbed- hypofibrogenemia
  61. 61. National ZOO, Hulu Klang • Hospital Zoo  Veterinary Officer (Dr Naim) • Contact : 03 41083422 ext Zoo Hospital.
  62. 62. THANK YOU!!!!!!!

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