Snake-bites in remote areas by Dr David Williams

1. Snake bites in remote areas
Dr David Williams
Charles Campbell Toxinology Centre
School of Medicine & Health Sciences
University of Papua New Guinea
Department of Pharmacology & Therapeutics
University of Melbourne
25/10/14 1

2. PAPUA NEW GUINEA
Port Moresby
AUSTRALIA
25/10/14 2

3. We run nationwide clinical training
courses in snakebite management

4. Photo: Dr Wolfgang Wüster

5. Photo: Dr Wolfgang Wüster

6. We teach fundamental clinical skills and
basic life-support techniques with active
participant involvement

8. Photo: Dr Wolfgang Wüster

9. We are identifying critically placed key rural
health workers who are extensively trained in
advanced airway management

10. Photo: Dr Wolfgang Wüster

11. Photo: Dr Wolfgang Wüster

12. Snakebite in remote areas
• Many rural health facilities are not in a position to
manage snake bite patients because of a lack of drugs,
equipment, skills and specific knowledge
• They can potentially apply good first aid, provide
emergency treatment for shock, and if necessary
provide supportive care and non-invasive airway
management
• In these situations patients will need to be sent to
another hospital for definitive treatment
• All health centres should develop and maintain a clear,
pre-existing plan for how patients will be transported,
and to which hospital they will be sent
25/10/14 12

18. 25/10/14 18

23. Successful early snakebite management
• Excellent outcomes can be achieved in even the most
basic care environments.
• Snakebite can treated in remote locations by nurse
practitioners.
• Medical evacuation should not need to be an
automatic process.
• Intensive care admission is avoidable.
• Training, education and appropriate basic resources
are the basic requirements.

25. Be prepared for snakebite
• Having a protocol in place that is known to all
personnel.
• Stocking adequate appropriate antivenom if possible.
• Have an organised emergency room.
• If you are going to seek advice from an external
consultant, have their details in a place where anyone
can find them.
• Plan early: if evacuation is necessary you should
organise it sooner rather than later

26. Have a protocol in place
• Systematic and sequential investigations.
• Immediate assessment of ABC.
• Thorough history.
• Good clinical examination to demonstrate specific life-threatening
deficits:
– Threats to airway and breathing (neurotoxic signs)
– Bleeding (seen and unseen)
– Other defects (severe cytotoxicity, shock)
• 20WBCT
• Be realistic about who to treat and who to refer.

27. Treatment or Referral
• Need to decide as quickly as possible if it is possible to
treat the patient locally, or if they will require referral
to hospital elsewhere:
– Bites with no signs, or minimal local swelling and no other
signs may not need referral
– Bites with extensive local swelling (>50% limb) or very severe
localised swelling (e.g.: fingers/hands/toes/feet), or with
bleeding, paralysis should be referred to hospital without
delay
• Referrals need to be well planned and consequences
carefully considered.
25/10/14 27

28. Key considerations
• There should always be a clear reason for patient
referral, and this should be recorded in both the
patient’s notes, and in the referral letter.
• Patient transport should not put the patient at
additional risk or reduce the level of patient safety
• Referral should be to a facility that provides a higher
level of care
• Patients at risk of life-threatening problems such as
bleeding, neurotoxicity, shock or renal failure should
always be accompanied by medical staff trained in
basic emergency life support
25/10/14 28

29. Timing of medical referrals
• A patient who needs referral should be send onward as
soon as possible
• Don’t wait for complications to occur!
• Specific timing:
– after first aid (immobilisation or PIB) applied
– once you have resuscitated Airway, Breathing and
Circulation, in that order, to the best of your ability &
resources
• Do not wait until the patient has deteriorated before
initiating referral or they may die enroute
• Early referral saves limbs and saves lives! 25/10/14 29

30. Types of transport
• Carried by stretcher
• Private vehicles:
– Motorcycles
– Cattle-drawn carts
– Tractors
– Cars and trucks
• Ambulances
• Government vehicles
• Boats
• Aerial retrieval in rare situations
(i.e.: military)
25/10/14 30

31. 25/10/14 31

32. 25/10/14 32

33. Criteria for referral (1)
• Does the health facility have the resources to treat the
patient?:
– Essential drugs and medical supplies
– Equipment (diagnostic, treatment delivery and life support)
– Staff with the necessary knowledge and experience to
provide treatment and make informed decisions
• If the answer to any of these points is no, then early
referral to a better facility should be a priority once the
patient is stabilised
25/10/14 33

34. Criteria for referral (2)
• Will referral of the patient result in a significant
improvement in patient care, or provide access to an
essential, but locally unavailable medical service?
– If the answer is yes, then referral is appropriate
– If the answer is no, reconsider referral of this patient
25/10/14 34

35. Patient safety (1)
• Will the safety of the patient be compromised by
attempting to transport them to another facility?:
– Is the patient clinically unstable?
• Is there severe bleeding?
• Is the patient shocked?
• Does the patient has airway and breathing problems?
– Will it be possible to provide emergency treatment to the
patient in the type of transport that is available?
• If not, are there any alternatives available?
– Are the road conditions suitable to ensure that the patient
can reach the referral hospital?
• Is there a risk of the vehicle getting bogged or stopped by floods
25/10/14 35

36. Patient safety (2)
• A clinically unstable patient should not be moved until
the immediate risk has reduced:
– Shocked patients or those with severe bleeding require
adequate fluid resuscitation to maintain cerebral perfusion
(i.e: a minimum BP of 80/60)
– Airway and/or breathing support for paralysed patients
• Obtain qualified medical advice from an expert
– Consider the need to have the patient retrieved by
ambulance and a medical team
• Is it safer to delay referral until the patient is more
stable, or is it a case of ‘now or never’?
25/10/14 36

37. Stabilising shocked or bleeding patients
• Patients bitten by some species of pit viper may
present with hypovolaemia and vasodilatation leading
to hypotension and shock
• This may be due to migration of circulating fluid into
the swollen limb, or may be the result of external or
internal haemorrhage
• Emergency resuscitation with crystalloid or colloid
should be carried out.
• Endeavour to maintain a minimum blood pressure of
80/60 mmHg
25/10/14 37

38. Stabilising shocked or bleeding patients
• If antivenom is available it should be given without
delay to neutralise circulating toxins that contribute to
coagulopathy
• Be careful not to overload the patient with fluids as this
may lead to additional complications
• Patients in whom increased capillary permeability is
suspected may benefit from administration of i.v.i.
dopamine (2.5-5.0 μg/kg/min)
• When stable transport the patient while continuing to
monitor bleeding and blood pressure, and with
adequate intravenous fluid to continue treatment 25/10/14 38

39. Treatment of Shock (1)
• Specific treatments
– Assess for & treat Airway or Breathing problem
– Obtain good, large-bore IV access, if not available
– 20ml/kg crystalloid, saline or Ringer’s, as fast as possible
– eg. a 50kg person should be given 20x50=1000ml
– eg. a 15kg child should be given 20x15=300ml
– Repeat the vital signs frequently, e.g. every 10 minutes
– Give high flow oxygen (6-15l/min)
– Repeat the infusion if the patient is still unstable
– Give antivenom, if available
• Consider whole blood replacement after 40ml/kg of crystalloid, if there is
heavy bleeding & no antivenom is available
25/10/14 39

40. Treatment of Shock (2)
• Specific Treatments
– Treat obvious cause
• If cause is antivenom reaction (adrenaline, promethazine,
hydrocortisone)
• If septic shock, give broad spectrum IV antibiotics
– Atropine 5-20mcg/kg for bradycardia
– Consider dopamine (5-20mcg/kg/min)
25/10/14 40

41. Treatment of Shock (3)
• Intravenous access
– Try to be successful as soon as possible
– As large an IV cannula as possible
– Ideally 2 lines
– Use femoral, long saphenous or external jugular if necessary
– Avoid causing another site of bleeding
– Intraosseus, especially in child, if no IV access in first few
minutes
25/10/14 41

42. Patients with airway/breathing problems
• Protect the airway!
– Posture, chin lift or head tilt to
improve air entry
– Guedel’s airway devices
– Oropharyngeal airways
– Laryngeal masks
– Endotracheal intubation
• Support breathing
– Supplementary oxygen
– Ambu Bag ventilation
– Mechanical ventilation
• Transport only if the airway is
secure and breathing can be
supported by trained staff
25/10/14 42

44. Mask fits on patient’s face
over bridge of nose and
under the mouth
Don’t compress the patient’s
eyes
Bag and mask

45. Broad end fits under
patient’s mouth
Pointed end over the
patient’s nose
15 mm connector
Inflatable cushion

46. Positioning of the Mask
Watch the position of the mask regarding the eyes

47. 1. Place mask onto face & spread your fingers as shown

48. 2. Place your fingers under the jaw grasping mandibular
margins- don’t push into the soft tissues

49. 3. Double handed approach

50. 25/10/14 50

51. Complications of BMV
• Ineffective oxygenation: hypoxia
• Gastric inflation
• Aspiration
• Worsening of facial #s
• Compression of eyeballs
– retinal detachment
• Compression of facial and infraorbital nerves
• Complications related to oro-pharyngeal or
nasopharyngeal airways used

52. Laryngeal Masks
LLMMAA SSuupprreemmee EElllliippttiiccaall aaiirrwwaayy ttuubbee
pprreevveennttss kkiinnkkiinngg
TToouugghheerr ttiipp pprreevveennttss ffoollddiinngg
dduurriinngg iinnsseerrttiioonn..

53. GGaassttrriicc ddrraaiinnaaggee ttuubbee
SSeeccuurriinngg bbaarr,, sshhoouulldd bbee aatt lliippss
BBiittee bblloocckk
VVeennttiillaattiinngg ttuubbee
25/10/14 53

54. Epiglottic fins pprreevveenntt eeppiigglloottttiiss
ffrroomm eenntteerriinngg aaiirrwwaayy
RReeiinnffoorrcceedd ttiipp
pprreevveennttss ffoolldd oovveerr
GGaassttrriicc ddrraaiinnaaggee ttuubbee
CCuuffff mmuusstt bbee ffuullllyy ddeeffllaatteedd ttoo pprreevveenntt
bbuullggiinngg hheerree dduurriinngg iinnsseerrttiioonn
25/10/14 54

55. Laryngeal Masks
• Advantages:
– Easy to insert, and it technique can easily be taught to non-doctors.
– Better oxygenation than with use of bag/mask alone.
– Rescue airway
• Disadvantages:
– Gastric inflation if not correctly positioned
– Aspiration risk not 100% removed
– Cuff pressure need to be monitored
– Risk of pharyngeal trauma is forcefully inserted including risk
of hypoglossal nerve injury

56. Why and when to insert LMA
• Patients who can tolerate a Guedel airway will tolerate
an LMA equally well
• LMA may not protect against aspiration but very few
cases of aspiration have been recorded
– but better protection than BMV alone
– increasing use in first aid trauma
• Easier to insert than endotracheal tube
– Don’t need laryngoscope
• Can insert while ECM being conducted
– Difficult to intubate in these conditions

58. Excessive oral secretions
• Often a serious, life-threatening complication of
neurotoxic snake bites (e.g.: mamba bites)
• Careful, regular suctioning of the airways is essential:
– Hand-held or foot-operated suction pumps available
– Ignored, death from airway obstruction may be very rapid
• Ancillary drug treatment with atropine (0.6 mg) every
3-4 hours can help to reduce secretion levels
• Position the patient appropriately:
– Recovery position on their side
– NEVER transport a neurotoxic patient in supine position
25/10/14 58

59. Preparation for patient referral (1)
• Organise transport:
– What type of transport is necessary? Is it available?
– If not, what are the alternatives?
– Basics: vehicle with fuel, driver, spare tyre, mobile phone
– Check that road conditions & weather appropriate
– Who will accompany the patient?
• Prepare the patient:
– First aid measures in place and patient stable as possible
– If antivenom is available, administer before departure
– airway & breathing managed appropriately
– circulation: nil by mouth, IV line secured well, IV fluids
25/10/14 59

60. Preparation for patient referral (2)
• Ensure staff are ready:
– Adequately trained & experienced to manage circulation
problems, airway and breathing enroute
– Do they have personal items & money ready
– Are their shifts covered
– Have arrangements been made for their return
– if you absolutely cannot send a staff member with the
patient, reconsider the need to refer the patient, or consider
waiting until you can send a staff member
• Drugs & equipment ready in box/bag
– Adequate i.v. fluids, sphygmanomometer, stethoscope
– Airway equipment, oxygen, suction pump & attachments
– Flashlight or lantern 25/10/14 (for night transfers) 60

61. Preparation for patient referral (3)
• Communication complete:
– Consult the referral hospital for advice before you send the
patient onwards
– Ensure that they have the capacity and resources to be able
to accept the patient
– Once referral is confirmed, prepare documentation
• Documentation:
– referral letter
– copy of notes, snakebite admission sheet or snakebite
observation sheet
– Chest X-Ray if available, especially for intubated patients
25/10/14 61

62. Referral letters
• In addition to clinical notes that are sent with patient,
send a referral letter that includes:
– Date & time
– Name of referring person, referring facility
– Name of the doctor the patient is being referred to
– Telephone call details, telephone number for feedback
– Name and details of patient
– Summary of history (bite history, symptoms and signs),
examination, results and times of investigations
– Any information about type of snake suspected
– Summary of treatments given, timing & response
– Details of improvement or deterioration
– Reasons for referral
25/10/14 62

63. Patient care during transport
• Position the patient in a sitting position if they have no
airway or breathing problems
• If the airway is compromised, lay them on their side,
with the head supported and tilted slightly downwards
to prevent aspiration of mucus/saliva
• Hang the I.V. fluid bag and monitor it
• Staff member should remain with the patient so that
emergency treatment can be given if needed
• If no staff member accompanies the patient, and the
referral is urgent, then a family member must be
taught to provide basic life support.
25/10/14 63

64. Summary (1)
• Have a clear reason for referral of the patient (i.e.: to
obtain antivenom treatment, or gain access to a
ventilator)
• Be sure that referral will result in an improvement in
care for the patient, and that the transport of the
patient does not place them at greater risk
• If referral is necessary, do it as soon as possible
• Choose appropriate transport
• Ensure that the patient meets the criteria for referral to
another hospital
25/10/14 64

65. Summary (2)
• Do not refer the patient until they are clinically stable in
terms of airway, breathing and circulation
• Be well prepared:
– Organise transport
– Prepare the patient
– Ensure staff are ready to travel with patient
– Assemble necessary drugs and equipment
– Communicate with the referral hospital and prepare the
documentation
• Care for the patient during transport
25/10/14 65