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Snakebite
Snakebite
Dr Mohammad Zikri Ahmad Emergency Medicine Specialist Hospital Universiti Sains Malaysia
Orang mulia atau berpangkat tinggi tidak akan jatuh darjatnya sekalipun dia bergaul dengan orang kebanyakan
Anda diingatkan bahawa tindakan tatatertib akan dikenakan kepada sesiapa yang mengular di dalam kelas ini
He suspects something has bitten him and quickly it slithers away into the wood..
First aid
Suck Cupping Incise Ice Tourniquet DONT!
Key points
Retard absorption BLS Complications
Triage ABC + Resuscitation Release tournique? Surge of venom Anti venom Anaphylaxis
Ular dipalu biarlah mati, pemalu janganlah patah, tanah janganlah lembang
Apabila membuat sesuatu pekerjaan biarlah dengan cermat, bijak, dan berhati-hati
With ptosis
Brain at stake? Elapidae? Viperidae? Other findings? Whats the worst that can happen?
Kraits
Extensive local effects Immediate pain Swelling Blisters Necrosis Systemic bleeding tendencies
Ask for
Part of body Timing Type of snake Atopy
Look for
Vital signs Fang marks Local skin signs Distal pulses Bleeding/ecchymosis Neurotoxicity Muscle tenderness Urine
Ix
Urine 20 min whole blood clotting test PT/aPTT/INR Others
Antivenom : Indications
Progressive signs and symptoms i.e. Worsening local injuries Abnormal results Systemic manifestations
Antivenom : Systemic
Hemostatic abnormalities Neurotoxity CVS dysfunction Rhabdomyolysis ARF
Which antivenom?
Monovalent Polyvalent
Dosages
Species Antivenom Manufacturer
(Monovalent)
50 mls (local) 100 mls (systemic) Serum Institute of India; 50 mls (local) Biological E. Limited, India 100 150 mls (Polyvalent) (systemic)
Thai Red Cross (Monovalent)
50 100 mls
Antivenom Preparations
May repeat until sign resolved Dilute 5-10ml/kg Big child dilute in 500ml 1 hour
Controversies
Sensitivity test X Local injection X Pretreatment adrenaline SC controversial Adrenaline/HCT/H-antagonist/resus
HCT/antihistamine premed?
Reaction to antivenom
Early Anaphylaxis Pyrogenic reactions Late reactions serum sickness
Anticholinesterase
Malaysian krait/coral snakes Edrophonium Neostigmine Atropine
What else?
Analgesia Antibiotics Antitetanus Respiratory support AKI
Wound management Compartment syndrome > fasciotomy Ortho/surgeon referral DIVC Wound I&D
What do I do?
First Aid Resuscitation Antivenom Symptomatic Supportive Neuro complication Hemorrhagic complications Rhabdomyolysis/AKI
Reflex bite
Is it venomous?
Viperidae Elapidae (Cobra/Coral/Krait/Sea snake)
Pitfalls
prophylactic antivenom
Pitfalls
Delayed antivenom at district hospitals
Pitfalls
Polyvalent antivenom for ALL
Pitfalls
Smaller antivenom doses for children
Pitfalls
Hydrocortisone/antihistamine pretreatment
Ular tikus
Reference
Tintinnali Emedicine A PPT by Consultant Paediatrician