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A&E(VMH) Dr Pavan.M MD(A &EM), VMKVMC. A&E(VMH) Epidemiology 3 million bites and 1,50,000 deaths/year from venomous snake worldwide. Bites highest in.

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Presentation on theme: "A&E(VMH) Dr Pavan.M MD(A &EM), VMKVMC. A&E(VMH) Epidemiology 3 million bites and 1,50,000 deaths/year from venomous snake worldwide. Bites highest in."— Presentation transcript:

1 A&E(VMH) Dr Pavan.M MD(A &EM), VMKVMC

2 A&E(VMH) Epidemiology 3 million bites and 1,50,000 deaths/year from venomous snake worldwide. Bites highest in temperate and tropical regions. 3000 species of snakes, out of them only 10-15% of snakes are venomous 97% of all snake bites are on the extremities

3 A&E(VMH) Common Snakes - INDIA Cobras(nagraj) –Naja naja,N.oxiana, N.kabuthia Neurotoxicity usually predominates.

4 A&E(VMH) Common krait(karayat)-Bungarus caeruleus

5 A&E(VMH) Russell’s viper(kander)-Daboia russelii Heat-sensing facial pits (hence the name "pit vipers").

6 A&E(VMH) Echis.carinatus(afai)-Saw scaled viper

7 A&E(VMH) Features of poisonous & non-poisonous snakes Approximately 2500 different species of snakes are known. Approximately Non Poisonous Snakes Head - Rounded Fangs - Not present Pupils - Rounded Anal Plate - Double row Bite Mark - Row of small teeth. Poisonous Snakes Head – Triangle Fangs – Present Pupils - Elliptical pupil Anal Plate - Single row Bite Mark - Fang Mark

8 A&E(VMH) Snake Venom Snake venom is highly modified saliva

9 A&E(VMH) Mechanism of toxicity Cytotoxic effects on tissues Hemotoxic Neurotoxic Systemic effects. Toxic dose. The potency of the venom and the amount of venom injected vary considerably. 20% of all strikes are "dry"

10 A&E(VMH) Snake Venom, Necrosis Proteolytic enzymes have a trypsin-like activity. Hyaluronidase splits acidic mucopolysaccharides and promotes the distribution of venom in the extracellular matrix of connective tissue. Phospholipases A 2 - break down membrane phospholipids -causes cellular membrane damage

11 A&E(VMH) Contd.. All these enzymes cause oedema, blister formation and local tissue necrosis

12 A&E(VMH) Snake Venom,Paralysis Blocks the stimulus transmission from nerve cell to muscle and cause paralysis Does not penetrate the blood-brain barrier

13 A&E(VMH)

14 A&E(VMH) Contd.. Postsynaptic effects are reversible with antivenom and neostigmine. Presynaptic nerve terminal, e.g. beta-bungarotoxin and here neostigmine will not be effective.

15 A&E(VMH) Snake venom, Hemorrhages Activate prothrombin (e.g. ecarin from Echis carinatus) Effect on fibrinogen and convert it into fibrin - thrombin-like activity, such as crotalase (rattlesnake venom) Activate factor 5, factor 10, Protein C Activate or inhibit platelet aggregation Haemmorhagins- cause endothelial damage

16 A&E(VMH)

17 A&E(VMH) Clinical syndromic approach Syndrome 1 Local envenoming (swelling etc) with bleeding/clotting disturbances VIPERIDAE

18 A&E(VMH) Syndrome 2 Ptosis, external opthalmoplegia, facial paralysis etc and dark brown urine =Russell's viper, Sri Lanka and South India

19 A&E(VMH) Syndrome 3 Local envenoming (swelling etc) with paralysis =Cobra or king cobra

20 A&E(VMH) Syndrome 4 Paralysis with minimal or no local envenoming Krait, Sea snake

21 A&E(VMH) Syndrome 5 Paralysis with dark brown urine and renal failure: Russle viper

22 A&E(VMH) Grade 0 No evidence of envenomation Suspected snake bite Fang mark may be present Pain and 1 inch edema & erythema No systemic signs- first 12 hours No lab changes

23 A&E(VMH) Grade 1 Minimal envenomation Fang wound & moderate pain present 1-5 inches of edema or erythema No systemic involvement in present after 12 hours No lab changes

24 A&E(VMH) Grade 2 Moderate envenomation Severe pain Edema spreading towards trunk Petechiae and ecchymosis limited area Nausea,vomiting,giddiness Mild temperature

25 A&E(VMH) Grade 3 Severe envenomation Within 12 hours edema spreads to the extremities and part of trunk. Petechiae and ecchymosis may be generalized Tachycardia Hypotension Subnormal temperature

26 A&E(VMH) Grade 4 Envenomation very severe Sudden pain rapidly Progressive swelling which leads to ecchymosis all over trunk Bleb formation and necrosis

27 A&E(VMH) Grade 4 contd … Systemic manifestations within 15 min after the bite Weak pulse,N&V,vertigo Convulsions, coma

28 A&E(VMH) What investigation to do? CBC RFT Coagulation studies Blood grouping & cross matching Sr.electrolytes Urinalysis

29 A&E(VMH) 20 min whole blood clotting time A few milliliters of fresh blood are placed in a new, plain glass receptacle (e.g., test tube) and left undisturbed for 20 min.

30 A&E(VMH) Contd … The tube is then tipped once to 45° to determine whether a clot has formed. If not, coagulopathy is diagnosed

31 A&E(VMH) Hess's test Blow up a blood pressure cuff to 80 mm Hg and leave it on for 5 minutes. If a crop of purpuric spots appears below the cuff, the test is positive.

32 A&E(VMH) First Aid

33 A&E(VMH) Donts No Tornique No Suction apparatus to be used(Sawyers) Do not run No role of Ice application

34 A&E(VMH) ASV When to use ASV? How much to use? What if a reaction occurs? When to stop ASV?

35 A&E(VMH) When to use ASV Hemostatic abnormalities(lab and clinical) Progressive local findings Neurotoxicity Systemic signs and symptoms Generalised rhabdomyolysis

36 A&E(VMH) Polyvalent antivenin Manufactured by hyper immunizing horses against venoms of four standard snakes Cobra (naja naja) Krait (B.caerulus) Russel’s viper(V.russelli) Saw scaled viper(Echis carinatus)

37 A&E(VMH) Contd.. Lyophilised form: stored in a cool dark place & may last for 5 years Liquid form: has to be stored at 4°c with much shorter life span Each 1ml of reconstituted serum neutralise 0.6 mg of naja naja 0.45 mg of Bungarus caerulus 0.6 mg of V.russelli 0.45 mg of Echis carinatus

38 A&E(VMH) Guide for initial dose of antivenin Grade Amount of Antivenin Route 0 None 1 2 5 vialsIV 1:10 dilutions 3 5-10 vialsIV 1:10 dilutions 4 10-20 vialsIV 1:10 dilutions

39 A&E(VMH) Dose in Paediatric Same as adult as the amount of venom does not change-hence the dose of antivenom should be the same Only the dilution changes

40 A&E(VMH) Skin testing- Done if patient is stable and time available 0.02ml of 1:100 solution of serum is injected sc A positive reaction occurs within 5 to 30 mins. Appearance of wheal & surrounding erythema

41 A&E(VMH) What to do in case of anaphylactic reaction to ASV Adrenaline 0.5 to 1ml IM If hypotension,severe bronchospasm or laryngeal edema give 0.5 ml of adrenaline diluted in 20 ml of isotonic saline over 20 mins iv.

42 A&E(VMH) contd.. A histamine anti H1 blocker-chlorpheniramine maleate-10 mg IV Pyrogenic reactions-antipyretics Late reactions-respond to CPM-2 mg, 6 hrly or oral prednisolone-5 mg 6 hrly

43 A&E(VMH) What if the patient needs ASV following reaction Dose should be further diluted in isotonic saline and restarted as soon as possible. Concomitant IV infusion of epinephrine may be required to hold allergic sequelae at bay while further antivenom is administered

44 A&E(VMH) When to stop using ASV Bleeding subsides Lab values returns to baseline Signs of neurotoxicity reverses Local effects halts progression

45 A&E(VMH) Supportive treatment Anticholineesterase have variable but useful role Trial Atropine sulphate 0.6 mg Edrophonium chloride 10 mg IV (or) Neostigmine: 1.5–2.0 mg IM (children, 0.025–0.08 mg/kg)

46 A&E(VMH) Contd.. If objective improvement is evident at 5 min continue neostigmine at a dose of 0.5 mg (children, 0.01 mg/kg) every 30 min as needed with atropine by continuous infusion of 0.6 mg over 8 h - children, 0.02 mg/kg over 8 h

47 A&E(VMH) Contd Hypotension Administration of crystalloid (20–40 mL/kg) Trial of 5% albumin (10– 20mL/kg) CVP guided fluids Inotropic support and invasive monitoring

48 A&E(VMH) Contd.. Oliguria & renal failure- fluids,diuretics, dopamine no response-fluid restriction- Dialysis Local infection- TT,antibiotics Haemostatic disturbances-FFP,fresh whole blood,cryoprecipitates

49 A&E(VMH) Cobra spit opthalmia Topical antimicrobial 0.1% adrenaline relieves pain No need for ASV

50 A&E(VMH) Compartment syndrome If signs of compartment syndrome are present and compartment pressure > 30 mm Hg: Elevate limb Administer Mannitol 1-2 g/kg IV over 30 min Simultaneously administer additional antivenom, 4-6 vials IV over 60 min If elevated compartment pressure persists another 60 min, consider fasciotomy

51 A&E(VMH) Bee Sting Honey bee belong Family- Hymenoptera Sub Family-Apidae Only the females have adapted a stinger from the ovipositor on the posterior aspect of the abdomen

52 A&E(VMH) Venom Histamine. Melittina –membrane active polypeptide that can cause degranulation of basophils and mast cells, constitutes more than 50 percent of the dry weight of bee venom Venom commonly causes pain, slight erythema, edema, and pruritus at the sting site

53 A&E(VMH) Presentations Local reaction Toxic manifestation and anaphylaxis Delayed reaction –Serum sickness

54 A&E(VMH) Treatment Immediate removal is the important principle and the method of removal is irrelevant. Sting site should be washed thoroughly with soap and water to minimize the possibility of infection.

55 A&E(VMH) Contd.. Intermittent ice packs at the site- diminish swelling and delay the absorption of venom while limiting edema. Oral antihistamines and analgesics may limit discomfort and pruritus. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in relieving pain

56 A&E(VMH) Severe systemic reaction Epinephrine 0.3 to 0.5 mg (0.3 to 0.5 mL of 1:1000 concentration) in adults and 0.01 mg/kg in children (never more than 0.3 mg). Injected IM and the injection site massaged to hasten absorption If hypotension,severe bronchospasm or laryngeal edema give 0.5 ml of adrenaline diluted in 20 ml of isotonic saline over 20 mins Observation for 24 hours in ICU

57 A&E(VMH) Contd … Parenteral antihistamines (diphenhydramine 25 to 50 mg IV, IM, or PO) and H2-receptor antagonists (ranitidine 50 mg IV) Steroids (methylprednisolone 125 mg) -to limit ongoing urticaria and edema and may potentiate the effects of other measures. Bronchospasm is treated with -agonist nebulization.

58 A&E(VMH) Contd.. Hypotension -massive crystalloid infusion, and central venous pressure monitoring may be helpful in these patients. -Persistent hypotension require dopamine. -If dopamine is ineffective, an intravenous infusion of epinephrine can be used

59 A&E(VMH) Preventive Care Every patient who has had a systemic reaction - insect sting kit containing premeasured epinephrine and be carefully instructed in its use. Patient must inject the epinephrine at the first sign of a systemic reaction. Medic alert tag

60 A&E(VMH) Scorpion sting- C. exilicauda Scorpions have a world-wide distribution. Highly toxic species are found in the Middle East, India, North Africa, South America, Mexico, and the Caribbean island of Trinidad.

61 A&E(VMH) Mechanism of action Venom can open neuronal sodium channels and cause prolonged and excessive depolarization

62 A&E(VMH) Symptoms and sign Somatic and autonomic nerves may be affected Initial pain and paresthesia at the stung extremity that becomes generalised Cranial nerve- abnormal roving eye movements, blurred vision, pharyngeal muscle incoordination and drooling and respiratory compromise

63 A&E(VMH) Contd… Excessive motor activity Nausea, vomiting, tachycardia, and severe agitation can also be present. Cardiac dysfunction, pulmonary edema, pancreatitis, bleeding disorders, skin necrosis, and occasionally death can occur

64 A&E(VMH) Treatment Pain Management Ice pack Immobilization of limb Local anaesthetics are better than opiates Tetanus prophylaxis, wound care and antibiotics Benzodizepines for motor activity.

65 A&E(VMH) Contd.. Stabilize Airway Breathing and Circulation Hyperdynamic circulation Always combination of alpha blocker with beta blocker to prevent unopposed alpha action causing tachycardia Nitrates for Hypertension/MI

66 A&E(VMH) Contd.. Hypodynamic Circulation: CVP guided fluids Decrease preload with furosemide (not hypovolumic) Reduction of afterload improves outcome-Prazosin, nitroprusside, hydralizine, ACE inhibitor Dobutamine is the best inotrope, avoid Dopamine Noradrenaline can be used

67 A&E(VMH) Newer modality Insulin has shown to improve cardiopulmonary status in case of scorpion envenomation

68 A&E(VMH)

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