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Snake Bite Management in Bangladesh 2
Snake Bite Management in Bangladesh 2
Snake Bite Management in Bangladesh 2
6,041
What is the annual
incidence of Snake
bite in Bangladesh?
623/100,000
INTRODUCTION
Estimated an annual incidence of
623/100,000
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.
Let us introduce
with the
snakes?
Moonocled Cobra
(Naja Kaouthia
Binocellate
Cobra
Naja naja
King cobra
(Opiophagus
hannah)
Copy right-
Dr.T N S
Murthy
Bungarus walli Bungarus nijer
Spot tailed pit White lip pit Pope’s pit viper Russel’s viper
viper viper
Russell’s viper
Sea snake (Hydrophidae spp
Copy right- Prof. D A Warrell
What is venomous snake bite?
► 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
Site
Face and limbs- Green pit
Limbs- Cobra
Any site- Krait
Forearm- See snake
Time:
Night time bite especially in Krait bite
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.
Physical examination
1.Rapid clinical assessment especially vitals: Pulse, BP,
Respiration, Temp
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
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
Presentation of pit
viper bites
1.Local swelling
2.Spontaneous bleeding
from bite site
3.Haemorrhagic blister
4.Myotoxicity
5.Renal failure
6.Intracranial haemorrhage
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
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
Syndromic approach
Syndrome-1
LOCAL ENVENOMING (SWELLING OF
LIMBS)
+
BLEEDING OR CLOTTING
DISTURBANCE
Rassell’s viper
LOCAL Syndrome -3
ENVENOMING
(SWELLING)
+
NEUROTOXIC
FEATURE
+
NO CLOTTING
DISTURBANCE
(WBCT <20 MINS)
COBR
Syndrome -4
NO LOCAL ENVENOMING
+
NEUROTOXIC FEATURES
+
WBCT <20 MINS
PARALYSIS
+
DARK BROWN URINE
+
NO LOCAL SWELLING Bite in the sea=
+ SEA SNAKE
WBCT <20 MINS
+
SEVERE MUSCLE PAIN
2. Immobilization
1.COMMUNITY CLINIC
2.UHC
3.DISTRICT HOSPITAL
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
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
Treatment in hospital
1.Rapid clinical assessment and resuscitation (ABC)
3.Identification of species
(Brought snake live, dead or description, photograph
20 min WBCT
Syndromic approach)
Treatment:
a.Antibiotic
b.Tetanus prophylaxis
c.Antivenom
d.NBM
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.
Adult and children should receive same dose of AV. Before initiating AV,
prophylactic subcutaneous adrenaline (dose - adult 0.25 ml of 0.1% solution
and in children 0.005 mg/kg) should be given to the victim (T).
Dose:
Each dose consists of 10 vial of polyvalent antivenom
irrespective of age and sex of the victim.
Active against
1.Indian cobra
2.Common Krait
3.Russsel’s viper
4.Saw scaled viper
Antivenom reaction:
Three types of reaction occurs
1.Early anaphylaxis
2.Pyrogenic reaction
Treatment of anaphylaxis
• Inj.Ranitidine 50 mg IV slowly
1mg/kg for children.
DAY 3 DAY 4
AFTER ADMISSION BITE SITE
AFTER ASV
TREATMEN RECOVERY
TT
Criteria for repeating the initial dose of antivenom:
Persisting or deteriorating signs of systemic antivenom.eg.
Physiotherapy
Reconstructive surgery
What should we do when no antivenom is
available?
Incase of neurotoxity:
• Assisted ventilation via ambu bag or mechanical
ventilation
• Inj.Atropine and Neostigmine: