snake- sudeep

M.S.V.Sudeep

Pharm.D. [4th yr].

Management of snake bite

Snake:

INTRODUCTION

Snake is limbless,scaly,elongated reptiles of sub order serpentes comprising of venomous and non venomous species inhabiting tropical and temperate region Snake To Crawl (or)To Creep.

Snake Venom:-Highly Modified Saliva.-Contain Zootoxins.-Immobilize & Digest Prey.-(or) serve as Defense Mechanism against Predators (or)other threats.Venom contains protiens,enzymes and other substances with toxic and lethal properties.

Clinical Manifestations:Signs:

Fang Marks,

Bleeding,

Discoloration,

Burning sensation,

Bleeding spots,

Sweat,

Numbness,

Tingling,

Swelling.

Severe Pain, Fever,

Dizziness, Fainting,Severe Shock,

Rapid Pulse, Low B.P.

Blurred Vision,

Convulsion, NumbnessExcessive Sweat,

Skin Discoloration,Nausea, Vomiting.

Symptoms:

COMPLICATIONS:Renal damage,

Respiratory damage,

Cerebral haemorrhages,

Paralysis,infection,

Chroniculceration,

Hyperkalaemia,

Hypocalcemia,

Rhabdomyolysis,

Myonecrosis.

Cardio vascular syndrome.

Lab tests:20 WBCT,CBC,THROMBOCYTOPENIA,

PROLONED CLOTTING TIME,ELEVATED FDP,

DEPRESSED FIBRINOGEN LEVELS,

HYPERKALEMIA,HYPOCALCEMIA,METABOLIC ACIDOSIS,

URINE TESTS,PROTENURIA,HAEMATURIA,MYOGLOBINUREA,

RENAL TESTSELISA TESTS.

Electro Cardio Gram,

Chest X-Ray,

E.E.G.

Diagnostic Tests:

Snake Bite Injury:When a snake bite,it may excrete venom but this depend on type of snake & venom causing injury to victim.

Venom is excreted through modified parotid salivary gland.

Snake bite

Elapid bite

Viperid bite

Hydrophid bite.

Venom

Venom

Hematoxin

Neurotoxin Myotoxin

Toxin

Type of Snake::

Type of Venom:

Toxins/Venoms:

1)Myotoxins-Destructing skeletal muscle cells and renal failure.

2)Neurotoxins-Paralysis,Numbness.

3)Haemotoxins-EXCESSIVE BLEEDING, -CEREBRAL HAEMARHAHGES.

General ManagementFirst aid is Recommended based on Do it Right Decision.1) Reassurance of Patient :Explain: 70% bites are non venomous & only 30% are venomous.And 50% bites of venomous species are only envenomated to patient.2) Immobilization: Use bandages,torniquets,splints,cloth to hold the affected site proximally and bind it.Do not apply any compression,nor block blood supply as it is dangerous.3) GH-go to hospital immediately.Traditional remedies are non benefit.4) Tell-the doctor if any systemic symptoms experienced by patient.

First Aid:DO’S

I. Assurance of pt.

II. Immobilization

III. Application of Torniquet.

DON’T’sI. Incision,Suction.

II. Apply of Ice,Massage.III.Electric shock.

IV. Chemical Treatment,V. Bevarages-coffee,Alcohol.

TREATMENT:1) Surgery: Tracheotomy for paralysis patient.2) Mechanical ventillation,Endotracheal Intubation for Res[piratory failure patient.3) Pressure Dresssings applied for venepuncture site to prevent Oozing.

Pharmacological Treatment:

1) Paracetamol-For Fever, Mild and Moderate Pain.2) Narcotic Analgesic-For CNS Depression& Severe Pain.3) Anti Snake Venom Therapy.4) Allergy-Antihistamins / Corticosteroids.5) Vomiting-Head down to avoid aspiration,Chlorpromazine(iv)6) Infection-Prophylactic Antibiotics.Avoid-Aspirin and other NSAIDS- cause Gastric Bleeding & Incoagable Blood Pt’s in snake bite victims.

Anti Snake Venom Therapy1)1St Antivenom: 1895-French physician(Albert calmette)-for

treatment of Indian Cobra bites.

2) Adm : IV or Infusion only.

3) Indications: Spontaneous systemic bleeding. WBCT>20 min, Thrmbocytopenia,shock, Paralysis, Hypercalcemia, Swelling more than a half of bitten limb.

4) Side effects: Anaphylactic Reaction,Allergic Reaction like Urticaria,cough,Nausea,Vomiting,Headache,fever,etc..

Dose: In Infusion-2ml/min rate. Mild case:5vial Moderate:5-10vial. Severe-10-20vial. Additional infusion-5-10 vial until swelling is decreased/stopped.

Timing: Ideally adminster within 4hr but effective if given within 24 hrs.

Treatment for Adverse effects established by ASV therapy: 1)Adrenaline: 0.5mg-adults 0.01mg/kg-child(sc) 2)Antihistamine- For Allergy-5days. chlorphenaramine maleate(10mg)adult. 0.3mg/kg-child. 3)Corticosteroids: Prednisolone-5mg/6hrs. 4)Pyrogenic rxn- Fever-PCM(5mg/kg) Hypothermia blankets,Fanning,tapid sponging,etc.

Supportive therapy for ASV:a)For Coagulopathy:

Fresh Frozen Plasma, Cryoprecipitate-fibrinogn,factorVIII. Fresh Whole blood. Platelet concentrate.

b)Bulbar Paralysis& Resp.Failure:

ASV alone not sufficient. Tracheotomy, Inj.Neostigimine Glycopyrrolate-0.25mg.

c)Antibiotic prophylaxis for Infections.

Additional Measures:1. Clean the bite site with Povidine-Iodine solution.2. Do not apply dressing.3. Leave blister alone.

4. If there is local necrosis-apply saline dressings.5. Vaccination for Tetanus Toxoid.6. Rehydration & Nutrition.

7. PCM for fever.8. Infection-Pencillin/Erythromycin treatment.9. Shock-ASV therapy given.10.Renal failure-Diuretics given-Furosemide(upto 100mg,IV) Dialysis performed for Critical cases.

11. Neurotoxicity-Atropine(0.6mg adult) (0.05mg/kg-child) Neostigimine inj.(1.5mg)12. Resp.Failjure: Keep airways clear,Head low,Jaw

elevated. Mechanical Ventillation.

Preventive Measures:A. Do wear shoes & prefer Leather boots & long

trousers in going on thick grass.

B. Carry Electric torch/Flash lighjt at Night.

C. Take care when colecting fire wood at debris,rocks,etc.-as snake hide there.

D. Take care when climbing Trees & rocks with dense folage.

E. Take care when swimming in lakes with lots of weeds.

F. Do use repellantsin basements,store rooms etc..to get away rodents & snakes.

Eg: DDT,Formaldehyde,etc..

G.. Do not make sudden movements near snake.

H. Do not go near snake even if it ios deadf.They act sometimes dead to avoid attack.

I. Do not keep Venomous snakes as Pets/performing animals.

J. Do not sleep on ground at night as snake may attract toward your warm body.

K. Do not walk in sea especially in coral reefs near sand.

1. Modern Medical Toxicology,VV.Pillay,4th Edition,page-157.

2. Gold, Barry S.; Richard C. Dart; Robert A. Barish (1 April 2002). "Bites of venomous snakes". The New England Journal of Medicine 347 page.

3. Kurecki B, Brownlee H (1987). "Venomous snakebites in the United States". Journal of Family Practice 25 (4): 386–92.

4. Patrick Walker, J; Morrison, R; Stewart, R; Gore, D (January 2013). "Venomous bites and stings". Current problems in surgery 50 (1): 9–44.