Dr Megongusie Meru Christian Fellowship Hospital Oddanchatram. Clinical study on snake bite syndrome, species correlation and ASV dose requirement. Dr Megongusie Meru Christian Fellowship Hospital Oddanchatram.

Number of snake bites and syndromes Number of snake bites/ year (or in the last year):87  Number of venomous bites/ year (or in the last year):61  Number of non-venomous bites/ year (or in the last year):26 

Snake Bite in 2012

Snake Species

Number of snake bites due to main syndromes Neurotoxic-7   Haemotoxic-40 Combination of neurotoxic and Haemotoxic-3

Outcome of snake bites in our hospital Number requiring mechanical ventilation-4   Number requiring haemodialysis-3 Deaths Number-1

Facilities available in our hospital ICU Mechanical ventilators Coagulation parameters: Prothrombin time and partial thromboplastin time Blood transfusion facilities: Whole blood  Haemo-Dialysis facilities- X 

Indications for ASV Signs of local, regional or systemic envenomation Coagulopathy-bleeding,elevated clotting time (> 22 minutes) Features of neurotoxicity-ptosis,weakness of limbs, respiratory paralysis

Monitoring response to therapy for Haemotoxic bite Whole blood clotting time   Time of measurement of coagulation parameters - Q4-6 hrs or according to doctor’s order. Repeat dose of ASV- after completion of the initial ASV dose.

Neostigmine? Any neurotoxic bite with evidence of envenomation.

antibiotics Indications – -evidence of cellulitis/infection. -underlying coexisting infection. Common antibiotic choice - Cap cloxacillin + Tab Metronidazole -Cap cloxacillin -IV Metronidazole +Ceftriaxone 

Admission and referral ICU or Ward? ICU-All snake bite or suspected snake bite or unknown bite Referral? Acute renal failure for hemodialysis When patient/relatives request for referral to a tertiary centre When ventilators /required facilities are unavailable

Antisnake venom Polyvalent Anti Snake Venom(SII) Stock of ASV approx 200 vials. 46 snake bite patients received ASV. Reactions to ASV-9 (itching, chills)

Department of medicine Christian fellowship hospital. PROTOCOL OF SNAKE BITE Department of medicine Christian fellowship hospital.

Receive the client & inform to the duty Dr. Provide comfortable bed. Identify the snake. Blood to be sent for C.T. Inj.T.T. to be given-before that, when lost dose was taken. Identify the bite mark & clean the site with betadine if needed. Elevate the part with pillow sling.( if swelling). Check any respiratory distress.(R.Rate, Single breath count every half an hour,Neck lifting time.Ptosis,Swelling.). Check hourly urine out-put. Advise plenty of oral fluids.

Strict in-take & out-put chart. If C.T. > 18….C.F.H. ASV protocol. Explain to the client & relative the cost of 1 vial of Inj.ASV and its side effects. Before starting ASV injection as an infusion, administer Inj.Avil 1 amp and Inj.Hydrocort 100 mg I.V.stat .Followed by give test dose of Inj.ASV as 10 drops through infusion set or by blood set. Watch for any allergic reaction Inj.ASV should be administered in one pint of NS or DNS as per Dr’s order. ASV infusion should be administered in blood set. According to Dr’s order Repeat Clotting-Time has to be done.

If urine out-put is low inform Dr. Check urine albumin once in a day. Check vital signs Q 1 H. Watch for swelling and ptosis.

On DISCHARGE…………………………. Review P.R.N. If any complaints. Take more oral fluids.

Is it Viper, Cobra or Krait ??? Look for the following :- 1.Local swelling-Mark it. Every 2 nd hourly assess the swelling increase part. 2.Bleeding from anywhere- Gums. Haematuria etc. 3.Renal Involvement- Haematuria, Proteinuria, Renal failure, Hypertension.

Look for neurological manifestation:- COBRA Look for neurological manifestation:- 1.Ptosis-and other evidence of Opthalmoplegia. 2.Respiratory weakness-ability to cough, single breath count. 3.Weakness of limbs-Assessment at admission with regular intervals for any worsening- Document.

2.Bleeding from anywhere- Gums. Haematuria etc. KRAIT 1.Local swelling-Mark it. Every 2 nd hourly assess the swelling increase part. 2.Bleeding from anywhere- Gums. Haematuria etc. 3.Renal Involvement- Haematuria, Proteinuria, Renal failure, Hypertension 4.Ptosis-any evidence of Opthalmoplegia. 5.Respiratory weakness-ability to cough, single breath count. 6.Weakness of limbs-Assessment at admission with regular intervals for any worsening- Document.

Investigation to be done….. Viper ----BT; CT; Platelets; Creatinine and other investigation according to clinical condition. Cobra ----ONLY clinical assessment.

Viper bite Injection ASV 2 vials IV fast in 500 ml Normal Saline to be given for 4 hours as an infusion after skin sensitivity test if not cover with Injection Hydrocort. If there are signs of envenomation namely increase in BT,CT & swelling increased ---administered IV ASV 2 vials for next 6 hours to be continued q 6 h till signs are absent. When BT,CT becomes normal and no increase swelling --- Administer ASV one vial in 12 Hours, followed by ASV one vial in 24 Hours. Ordinarily ASV may stopped after 48-72 Hours.

COBRA BITE If Ptosis is present to give ASV 4 vials IV in half an hour followed by Inj ASV two vials as IV drip for next 4 hours. If there is weakness of LIMBS / RESPIRATION to give ASV 6 vials in half an hour followed by ASV 4 vials in 4 hours. RESPIRATORY SUPPORT- when needed….. 1.To assess Oxygenation by Pulse oxy meter/ Blood gas. 2.To keep ET tube , Ambu bag, Laryngescope ready. 3.To keep VENTILATOR ready.

Thank you