Presentation on managing the snake bite victim for the emergency nurse in Australia.

1. Snake Bite Management
for the ED Nurse
By Kane Guthrie FCENA

2. Snake Bites in Australia
• Definitive or suspected bites are common
• Severe envenoming rare
– Potentially fatal!
• Each snake has characteristic clinical
syndrome
• Limited clinicians with limited knowledge

3. Quiz
• How many poisonous snakes
do we have in Australia?

4. Risk Assessment
• Geographic area
• Anatomic site of bite
• Number of strikes
• Use of PIB
• Pre-hospital course & treatment
• Previous snakebites
• Systemic features
• Investigations

5. Physical Exam
• Vital Signs
• Mental Status
• Evidence of bite
• Lymphadenopathy
• Evidence of abnormal bleeding
• Signs of paralysis
• Respiratory Function

6. Investigations
• Whole blood clotting (resource limited)
• FBC
• Coagulation profile
• Fribrinogen, D-Dimer
• U & E, CK

7. Snake Venom Detection Kit
• Dose not determine if envenomed or not!
• Useful test to:
– Confirm which one 5 groups responsible for
envenoming.
– Helps determine which antivenom is required.
– Best done in laboratory.
– Use bite site swabs or urine.
• Use geographic area & clinical exam
alongside!

8. SVDK

9. Clinical Effects
Non Specific:
• Nausea & vomiting
• Headache
• Abdominal Pain
• Diarrhoea
• Dizziness
• Collapse

10. Specific Envenoming Syndromes
• Coagulopathy
• Neurotoxicity
• Myotoxicity
• Rhabdomyolysis

11. Pre-Hospital Care
First Aid:
– PIB
Transport:
– ASAP –> hospital capable of:
– Dr able to Mx snakebite
– Laboratory open 24/7
– Stocks adequate supplies antivenom

12. Pressure Immobilisation Bandage
Canale, E. Isbister, G. Currie, B. (2009). EMA. 21, 184-190.

13. Pressure Immobilisation Bandage

14. In-Hospital
• Resus Bay
• Get help – consider PIC 131126
• Determine if envenomed:
– History
– Physical exam
– Laboratory investigations/SVDK
• Determine if antivenom required
• Supportive care and treatment (ADT)

15. Antivenom
Two types:
1. Monovalent:
– More specific, cheaper, safer less serum sickness.
2. Polyvalent:
– Contains equivalent of 1 vial of each monovalent.
• Give 1 vial 500mls N/saline over 20mins!
• Risks: anaphylaxis, serum sickness!

16. Major Types: by Clinical Syndromes
5 major groups:
1. Brown Snakes
2. Tiger Snakes
3. Mulga/black snakes
4. Taipans
5. Death Adders

17. Brown Snakes
• Eastern/western brown snake, Dugite
• Found all throughout Aust! (except Tasmania)
• Most common cause of death from snake
bite!

18. Brown Snake
Envenoming:
• VICC- bleeding gums, cannula site, ICH.
• Renal failure & oliguria infrequent.
• Rare – diplopia, ptosis & MAHA.

19. Brown Snake
Management:
1. PIB- Resus bay
2. Check Coag’s FBC and U&E
Signs of Envenomation:
• 1 vial of CSL brown snake antivenom
• Serial coag test to check if safe for D/C
• New recommendation only 1 vial!
• White, I. Buckley, N. (2012) Antivenom Update. Australian Prescriber (35, 5).

20. Tiger Snakes
• 9 types of tiger snakes.
• Found along coastal regions southern/eastern
Australia.
• Fast moving, easily alarmed that strike readily.
• Have high rate of dry bites!

21. Tiger Snake
Similar to brown snake but cause paralysis!
Envenoming:
• VICC
• Neurotoxicity – progressive flaccid paralysis
– Diplopia, ptosis, Resp failure
• Rhabdomyolysis
– Significant pain, muscle breakdown

22. Tiger Snake
Management:
1. PIB-Resus bay
2. Bloods, Coag’s, FBC, U&E,
3. Serial peak flow, neuro exam!
Envenomed:
• 1 vial Tiger snake antivenom
• Consider intubation for resp failure

23. Mulga/Black Snakes
• Mulga, king brown, Red-bellied or black snake
• Found around Australia
• Large, aggressive with painful bite

24. Mulga/Black Snake
Envenomation:
• Severe rhabdomyolysis
• Anticoagulation abnormalities
– Increased INR and aPTT.
• Non specific symptoms:
– Headache, nausea & vomiting

25. Mulga/Black Snake
Management:
1. PIB-Resus bay
2. Bloods, Coag’s, FBC, U&E, Urine
Envenomed:
• IDC – fluids, monitor CK
• 1 vial black snake antivenom

26. Taipans
• Coastal & Inland Taipans
• Found northern Aust (NT & QLD)
• Envenoming rare, but lethal without AV!

27. Taipans
Envenoming:
• VICC
• Neurotoxicity
– Venom causes paralysis, seizures
• Rhabdomyolysis
• Systemic envenoming can causes rapid onset
collapse within minutes!

28. Taipans
Management:
1. PIB-Resus bay
2. Bloods, Coag’s, FBC, U&E, Urine
Envenomed:
• IDC – fluids, monitor CK
• Prepare for resp failure – intubation
• Give 1-2 vials taipan antivenom
• Supportive care & monitoring

29. Death Adder
• Common, desert, northern, pilbra- death
adder.
• Found mainland Australia.
• Characterised viper like appearance, short, fat
with diamond shaped head!

30. Death Adder
Envenomation:
• Neurotoxicity- descending flaccid paralysis
• Manifest with 6 hours
Early signs:
• Diplopia, ptosis, difficulty swallowing.

31. Death Adder
Management:
1. PIB-Resus bay
2. Bloods, Coag’s, FBC, U&E,
3. PEFR- neuro assessment
Envenomed:
• Intubation for respiratory failure.
• 1 vial death adder antivenom
• Sx resolve 1-2 days

32. Questions

33. Take Home Points
• PIB always!
• Envenomation is rare!
• 1 vial of antivenom is usually suffice!
• Make use of the experts!

34. Thank-you