1. Management of Snake Bite Victims with Respiratory Paralysis in ICU Dr. T.R. Chandrashekar Director Critical Care K.R.Hospital Bangalore DR TRC/ KRH

6. Species: Medical Implications Yes NO Yes No No Renal Problems No NO No? No? Yes Neostigmine & Atropine Yes Yes Yes No No Coagulation No NO Yes! Yes Yes Ptosis/Neurotoxicity Yes Yes Yes No Yes Local pain/ Tissue Damage Other Vipers Saw Scaled Viper Russell’s Viper Krait Cobra Signs/Symptoms and Potential Treatments

10. Snake bite and Respiratory paralysis Neuromuscular paralysis- blockade of neuromuscular transmission. Cobra- post-synaptic Krait- pre-synaptic Bulbar paralysis-Aspiration Sepsis, DIC-shock ARF-Pulmonary edema Neurotoxic MV for respiratory paralysis ASV MV as Supportive care More cases why ?

15. Snake venom components

16. Krait- Pre-synaptic action Beta-bungarotoxin- Phospholipases A2 1) Inhibiting the release of acetylcholine from the presynaptic membrane 2) Presynaptic nerve terminals exhibited signs of irreversible physical damage and are devoid of synaptic vesicles 3) Antivenoms & anticholinesterases have no effect Paralysis lasts several weeks and frequently requires prolonged MV. Recovery is dependent upon regeneration of the terminal axon.

18. Snake envenomation in a north Indian hospital Ptosis RS involvement Bulbar weakness N Sharma, S Chauhan, S Faruqi, P Bhat, S Varma, Emerg Med J 2005;22:118–120 Ophthalmoplegia

28. Dose 5 vials(50ml) 5-10 vials (50-100ml) 10-20 vials (100-200ml)

29. Large vs small dose Low dose of snake antivenom is as effective as high dose in patients with severe neurotoxic snake envenoming Agarwal, Aggarwal, Gupta, et al Emerg Med J 2005;22:397–399 . High dose group 100ml stat and 100 ml every 6 hrs Low dose group 100ml stat and 50 ml every 6 hrs Until recovery of neurological signs

32. Observation of the response to Antivenom Cobra bites-Post synaptic May begin to improve as early as 30 minutes after anti-venom, but usually take several hours . Krait and sea snakes- Pre synaptic Depends on the timing of ASV administration If delayed may not produce any action or Minimal delayed action

36. 34 yr old male shifted from rural health center with H/O snake bite 6 hrs back has ptosis, respiratory distress, RR 35/mt, BP 120/60, oral secretions present, absent gag and cough reflex shifted to ICU for tertiary care. On ASV 100ml stat, & 50ml in NS over 6 hrs Oxygen 3l/mt Is given neostigmine 0.6mg and 0.6 mg atropine iv You can have alive but a sicker patient You can have dead patient Cobra Krait

37. Alive but a sicker patient Shifted to ICU placed on a Ventilator lot of secretions Do we continue anticholinesterases ? Issues to consider Increased secretions Increased incidence of VAP ? We rarely use these drugs once the patient is in the ICU under observation

44. Fasciotomy

47. Clinical features of a compartmental syndrome • Disproportionately severe pain • Weakness of intracompartmental muscles • Pain on passive stretching of intracompartmental muscles • Hypoaesthesia of areas of skin supplied by nerves running through the compartment • Obvious tenseness of the compartment on palpation Criteria for fasciotomy in snake-bitten limbs Haemostatic abnormalities have been corrected (antivenom, with or without clotting factors) • Clinical evidence of an intracompartmental syndrome • Intracompartmental pressure >40 mmHg (in adults) Early treatment with antivenom remains the best way of preventing irreversible muscle damage

49. Thank you Wishing you all a wonderful 2009