Steps in management of neurotoxic snake bite

1. MANAGEMENT OF NEUROTOXIC
SNAKE BITE
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700615/#!po=36.5385
DEVASHREE NADGAUDA
IX SEMESTER

2. 70% of all snakebites are by nonvenomous snakes and 50% of bites by
venomous species are dry bites
MANAGEMENT OF NEUROTOXIC SNAKE BITE
First Aid
I. Reassure the Victim
ASPERWHOGUIDELINES
by bandage or clothes to hold splint, but tight arterial compression is not
recommended.
II. Immobilize the affected limb
III. Promptly Transfer Victim to Hospital

3. When the patient
reaches the
emergency
department,
evaluation should
begin with the
assessment of the
airway,
breathing,
circulatory status,
and consciousness.
Emergency Care Department
MANAGEMENT OF NEUROTOXIC SNAKE BYTE
ASPERWHOGUIDELINES
Hospital Treatment
Urgent resuscitation will
be needed in those with
respiratory failure
(neurotoxin).
Oxygen should
be
administered
to every
envenomed
patient and a
large-bore
intravenous
catheter
should be
inserted.
A bolus of normal saline
or Ringer's lactate should
be given to all patients
with suspected
envenomation.

4. History
1 Whether a venomous snake has actually bitten the patient?
2 Cross-check by looking for fang marks and signs of local
envenomation.
3 If the victim has brought the snake, identification of the species.
(crotalids can envenomate even when dead so be careful in ED)
4
Time elapsed since the snakebite?
Brief medical history - date of last tetanus immunization,
use of any medication,
presence of any systemic disease,
history of allergy.

5. Bite Mark
1
To a large extent the manifestation of snakebite depends upon the
species of snake, and therefore identification of the type of snake is
important.
2 At times the bite mark might not be visible as in the case of Krait.

6. Bite Mark

7. Physical Examination
1
Initial evaluation begin with the bite site :
signs of local envenomation - edema, petechiae, bullae, oozing from
the wound etc and for the extent of swelling.
2
The bite site and at least two other, more proximal, locations should
be marked and the circumference of the bitten limb should be
measured every 15 min thereafter, until the swelling is no longer
progressing.
3
The extremity should be placed in a well-padded splint for at least 24
h. Serial measurement of circumference helps in estimating spread of
venom and effect of anti-venom.
4 Lymph nodes draining the limb should be palpated and the presence
of lymphangitic lines noted.
5 Distal pulses should be checked and monitored if there is presence
of gross swelling.

8. Assessment of Severity of envenomation

9. Supportive Therapy
PATIENT
MILD
ENVENOMATION
SEVERE ENVENOMATION
INTENSIVE CARE UNIT
ICU
CLOSE MONITORING IN
WARD

10. Specific Treatment
Anti-snake venom treatment alone cannot be relied upon to save
the life of a patient with bulbar and respiratory paralysis.
Loss of the gag reflex, failure to cough, or respiratory distress
Endotracheal intubation and initiation of mechanical ventilation is
indicated.
Tracheostomy and placement of a cuffed tracheostomy tube can be
done whenever expertise for endotracheal intubation is not
available.

11. Specific Treatment - continued
Pathophysiological changes resembling those of myasthenia gravis,
anticholinesterase drugs can have a useful effect in patients with
neurotoxic envenomation, especially in those bitten by cobras.
A trial of anticholinesterase should be performed in every patient
with neurotoxic envenomation.
Injection neostigmine can be given as 50–100 μg/kg 4 hourly or as a
continuous infusion.

12. Anti Snake-Venom
In India,
Polyvalent anti snake venom PAV (Kasauli HP) and
Haffkine Corporation, Mumbai)
is effective against the most common Indian species.

13. Administration and Dose of PAV
ASV is supplied in dry powder form and has to be reconstituted by
diluting in 10 ml of normal saline/D5 W. Mixing is done by swirling
and not by vigorous shaking.

14. Administration and Dose of PAV - continued
Each vial of PAV will neutralize about 6 – 8 mg of venom.
Its half life is about 90 hours.

15. Care of Bitten Part
As most snakes harbor aerobic as well as anaerobic bacteria in their
mouths, a prophylactic course of penicillin or erythromycin for
penicillin-hypersensitive patients.
And
A single dose of broad spectrum antibiotic course which will cover
anaerobes.
Booster dose of tetanus toxoid is recommended.

16.  There is painless and mark less bite mark.
 Pain in Abdomen is a very common
presenting symptom.
 There is painless and mark less bite mark.
 Convulsion is a very common feature.
 Pain in Abdomen is a very common
presenting symptom.
 PTOSIS may come even after 24 hrs of
Krait bite .
 AVS if administered at the onset of Ptosis,
it is life saving in a case of Krait bite.
 There is painless and mark less bite mark.
 Convulsion is a very common feature.
 Pain in Abdomen is a very common
presenting symptom.
 PTOSIS may come even after 24 hrs of
Krait bite .
 AVS if administered at the onset of Ptosis,
it is life saving in a case of Krait bite.

17.  One Patient named Zakir Sardar , 21 yrs , male from, West Bengal was brought to
the Canning Hospital at 8 AM on 29th May 2010.
 The patient was confused and had signs like hemiperesis of Rt. side of body
and ptosis.
 On interrogation, the Emergency Medical officer said that they got some
positive history to suggest a Kalach ( Common Krait ) bite.
 The patient was treated with IV infusion of 15 vials of Indian Poly Valent
AVS and survived.

18. What was the history from
the patient’s relatives?
 There was no history of any bite. Most relevant history was open floor bed in
the previous night.
 Sudden pain in abdomen which broke the sleep of the patient followed by
vomiting.
 There was whole body ache and blurring of vision which came latter on in
that order.

19. THANK YOU !
References :
1. NCBI NIH Pubmed – WHO guidelines (Internet)
2. Text book of Forensic Medicine and Toxicology.
3. www.kalachkrait.webs.com

20. http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC2700615/#!po=36.5385