BANGALORE BAPTIST HOSPITAL Snakebite Study Workshop Vellore, Mar 2013 Dr Tarun/ Dr Indira Menon

Questionnaire. Name of centre—BBH No. of snake bites per year-- 55—60 No. of snake bites in last year No. of venomous bites last year --50 approx. No. of non venomous bites in last year—15 Snake bites due to main syndromes % Haematotoxic—90% Neuro—10% Combination 1-2 % No.of cases where dead snakes are brought—5

Questionnaire (contd.) Indications for ASV—systemic or local envenomation No prophylactic adrenaline is given prior to ASV Initial dose of ASV—8—10 vials both haematotoxic and neurotoxic. Time duration of administration –1 hour Response to ASV is monitored by 20 WBCT every 6 hourly When to repeat dose of ASV? Haematotoxic every 6 hours—10 vials Neurotoxic every 1 hour –10 vials Is continuous low dose of ASV administered after normalization of coagulation –NO

Questionnaire (contd.) Ceiling dose—Haematotoxic—30 vials( exceeded very rarely) Neurotoxic— 20 vials Do you use Neostigmine in neurotoxic bites –Yes Indication for antibiotics—local swelling/ cellulitisChoice of antibiotic—Crystalline penicillin + ciprofloxacin + metronidazole. When to admit to ICU ?—all patients are observed in ICU initially. When do you refer –we do not refer. Which ASV do we use—Bharath serum Stock in pharmacy at any given time—20—30 vials

Questionnaire (contd.) Last year cases of allergy to ASV— - minor angioedema—swelling mouth/ bronchospasm—2 - anaphylaxis fall in BP death –nil

Questionnaire (contd.) Outcomes : - Mechanical ventilation –10—15 % - Haemodialysis—2-3 % - Deaths—2 % Facilities available: - Coagulation parameters –yes - Blood transfusion—yes - Haemodialysis –yes - Mechanical ventilation –yes - ICU yes Protocol for snake bite management –yes Blood tests routinely done —20WBCT, CBC,PT - PTT,creatinine,,ECG Electrolytes, Urine RE

Snake bite management protocol Check airway breathing circulation Inj TT 0.5ml IM to all patients OBSERVE ALL PATIENTS for minimum 24 hrs Determine time of bite What was the patient doing at that time ? Release any tourniquet very slowly Assess envenomation –local / systemic

Snake bite management protocol (contd.) Local - swelling > ½ bitten limb - swollen digits - rapid extension of swelling. Systemic - Haematotoxic-deranged 20 WBCT / bleeding gums - Neurotoxic - ptosis/ external ophthalmoplegia/ neck muscle weakness - CVS—hypotension/arrythmias - Persistent vomiting/ abdominal pain.

Investigations 20 WBCT CBC S Creatinine Electrolytes CPK/PT /APTT Urine RE ECG

Protocol (contd.) IF CLOT forms  repeat 20 WBCT every ½ hourly x 3 hours  If still normal repeat every 1 hourly for 3 hours  Then every 6 hourly for 24 hours. ( done at bedside in glass test tube ) If NO CLOT at 20 mins  repeat 20WBCT every 6 hours till normal.

Snakebite Protocol (contd.) Local /systemic envenomation present ? Premedication –hydrocortisone 100mg + Avil 1 ampoule ASV -- 8—10 vials in 500ml N.Saline over 1 hour No test dose. Haematotoxic---assess 20WBCT 6 hrly and give further doses of 5 vials if needed. Max- 30 vials ( usually)

Snakebite Protocol (contd.) Neurotoxic- Try neostigmine 1.5mg -2mg IM plus 0.6mg Atropine IV stat.—if response repeat neostigmine every 30 mins and give atropine 0.6mg infusion over 8 hours. If no response to Neostigmine – discontinue. Support with mechanical ventilation till weakness improves ASV—initial 8—10 vials. Reassess every 1 hour and repeat ½ dose of initial ASV till a maximum 20 vials. ASV is costly and not freely available therefore do not waste. ASV only acts on unbound venom.

Snakebite Protocol (contd.) If anaphylaxis to ASV occurs —stop the infusion, administer 0.5ml(1:1000) adrenaline IM stat +avil + hydrocortisone + ranitidine. 200ml NS bolus. Repeat adrenaline dose after 10 mins if required. Restart ASV as soon as patient stabilizes

Snakebite Protocol (contd.) Pain ---give paracetamol IV 1000mg +/- inj tramadol 25—50mg IV Antibiotics—Crystalline penicillin+Ciprofloxacin+Metronidazole Surgical consult only if severe swelling seen. Ensure adequate hydration to maintain an hourly urine output of 0.5ml/kg Monitor creatinine and K+ daily Haemodialysis if needed.

BANGALORE BAPTIST HOSPITAL Thank you!