SNAKEBITE POISONING

A patient presented in emergency with vomiting, salvation ,hypotension ,muscle

weakness causing ptosis diplopia and dysphagia with suspicion of snake bite .

On examination BP 80/40mmhg pulse 120/m ,tachypneic ,B/L crepts GCS 8/15 .

What is your diagnosis ?

Neurotoxin snake bite .

Can you name any snake .

Cobra. koral

All snakes are poisonous ?

No

What are common types of poisonous snakes ?

Poisonous species of snake fall into families:

Viperideae: such russel viper ,pit viper.

Elapidae: such as cobra krait, coral snake.

Hydeophidae: such as sea snake.

Describe PATHOGENESIS & CLINICAL FEATURES of each type

Poisonous snakes have a pair of enlarged teeth called fangs in their upper jaws
that venom into the tissue of their victim.

Snake venoms are complex mixtures of proteins and small polyperptideswith

activity.

Effects of venoms may be:

Hematocicity : they cause the vasculature leaky resulting in local or systemic
bleeding heading to hypotension and shock .

Cytotxicity: causing local tissue neceosis, maygolinuria and eanal failure.

Cogulopathy: casing bleeding or clotting disorders.

Cardiotoxicity: inhibiting peripheral nerve impulses leading to paralysis.

Viperidae:

Local swelling ,echymosis and blistering at the site of bite.

Systemic involvement within 30 min including vomiting hypotebsion and shock .

Bleeding and clotting disturbances (coagulopathy) bleeding gums or venpuncture

site, bleeding may be fatal.

Elapidae

Usally no swelling at the site of bite

Vomiting salivation.

Hypotenion and shock resulting from loss of intravascular fluid into soft tissues.

Neurological symptoms; muscle weakness causing ptosis diplopia and dysphagia

with paralysis of respiratory muscles in severe cases.

Myocardial depression causing reduced cardiac output and disturbances.

Hydrophidae (sea snake)

Muscle involvement causing rhabdomyolsis with myalgia and mylobinuria that

may lead to acute renal failure.

Cardiac and respiratory paralysis may occur.

INVESTIGATIONS
Blooding grouping and cross matching; as soon as possible before the effect of
circulating venom interfere the blood grouping.

Complete blood count: to evaluate degree of hemorrhage and hemolysis.

Urea, cereatinine and electrolytes

Liver function tests (LFTs)

PT, APTT,BT.CT.FDP; to assess coagulpathy.

Urine analysis: for hemoglobinuria

Abgs

ECG: arrhythmias

Chest X –ray

What's GENERAL measures in snake bite management

All patient with suspected snake bite should be observed for 12-24 hours as initial
manifestations may be delayed, especially with elapid bits.

Reassuring the patient not all snake are posisonous and even bite by the
poisonous snake may be dry bite i-e no venoum in the bite,

Try to identify the snake.

Immobilize the bitten area minimize the venom spread.

Application of firm bandage to occlude lymphatic drainage (not the arterial

supply); use of tourniquet is diacouraged because they do not prevent spread of
venom.

Incision at the site of bite and attempts to suck out the venom with mouth should
not be made.
Pain and vomiting symptomatic treatment.aspirin should not be used for sine this
may aggravate bleeding.

Saline and dopamine for hypotension.

Monitor blood pressure, coagulation renal. Neurological and cardio respiratory

status.

Large bore IV canulla should be inserted in unaffected limb.

HOW WILL YOU MANAGE THIS PATIENT .?

ABC APPROACH

Assesment and management go side by side

Airway and breathing management ..by air way or ETT as required

Q. What will be indications for intubation and ventilation .?

Salvation excessive

Airway blockage

ASPIRATION

Resp muscleweakness or paralysis

CIRCULATORY SUPPORT .

with fluids and vasopressors

Q. WHAT WILL BE DEFINITE TREATMENT /Antigenic?

Antivenin:

Antivenum is indicated in patient with severe or progressing local tissue local

reation at the site of bite ,clinical or laboratory evidence of systemic involvement.
In about 50% of snake bites no venom are injected ( dry bite) and however when
indicated antivenoms should be give early as the antivenoms only neutraliz
venom they can not reverse the frequent complication of antivenin.

Antivenom should be give slow IV ,the same dose being given to children and
adults.

Before starting antvenom a test dose is given 0.02 ml of saline- diluted antivenom
is injected subcutaneously and observed for at least 10min for redness.

Hives, pruritus or other allergic reactions .A syringe containing0.5 ml of 1:

1000 adrenaline must be available to combat anaphylaxis whenever
antivenin is asministered. Adrenaline is given subcutaneously.

Howere skin test dose not always predict which patient will have allergic
reaction to antivenom: a skin test may be false positive or false negatibe.

Intravenous antihistamine and ranitidine should be given before starting

antivenin infusion to limit the acute allergic reaction

In severe cases the antivenom infusion should be continued even with allergic
reaction with closely controlled conditions and premedication with adrenaline
antihistamine and steroids.

Antivenin ashould be diluted in 1000ml of saline ringer’s lactate or 5% dextrose

water and should be given slowly ,in children 20ml/kg.

Physician should be at the bedside to intervene in the event of an acute allegic

reaction. Total dose may be given in 1-4 hours. Further antivenin may be
ancessary if clinical abnormalities worsen.

GENERAL ICU CARE

VENTILATION RELATED QUESTIONS