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Snake Bite ,Bee sting and Scorpian Bite

Snake Bite ,Bee sting and Scorpian Bite. Dr Pavan .M MD(A &EM), VMKVMC. 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

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Snake Bite ,Bee sting and Scorpian Bite

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  1. Snake Bite ,Bee sting and Scorpian Bite Dr Pavan .M MD(A &EM), VMKVMC

  2. 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. Common Snakes - INDIA • Cobras(nagraj) –Naja naja,N.oxiana, N.kabuthia • Neurotoxicity usually predominates.

  4. Common krait(karayat)-Bungarus caeruleus

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

  6. Echis.carinatus(afai)-Saw scaled viper

  7. Features of poisonous & non-poisonous snakes Approximately 2500 different species of snakes are known. Approximately Non Poisonous Snakes Head - RoundedFangs - Not presentPupils - RoundedAnal 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. Snake Venom • Snake venom is highly modified saliva

  9. 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" in which no venom is injected.

  10. 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 A2- break down membrane phospholipids -causes cellular membrane damage

  11. Contd.. • all these enzymes cause oedema, blister formation and local tissue necrosis

  12. Snake Venom ,Paralysis • block the stimulus transmission from nerve cell to muscle and cause paralysis • does not penetrate the blood-brain barrier

  13. Contd.. • postsynaptic effects are reversible with antivenom and neostigmine. • presynaptic nerve terminal, e.g. beta-bungarotoxin and here neostigmine will not be effective.

  14. 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

  15. Clinical syndromic approachSyndrome 1 • Local envenoming (swelling etc) with bleeding/clotting disturbances VIPERIDAE

  16. Syndrome 2 Ptosis, external opthalmoplegia, facial paralysis etc and dark brown urine=Russell's viper, Sri Lanka and South India

  17. Syndrome 3 Local envenoming (swelling etc) with paralysis=Cobra or king cobra

  18. Syndrome 4 • Paralysis with minimal or no local envenoming Krait, Sea snake

  19. Syndrome 5 • Paralysis with dark brown urine and renal failure: Russle viper

  20. 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

  21. Grade 1 • Minimal envenomation • Snake bite suspected • Fang wound & moderate pain present • 1-5 inches of edema or erythema • No systemic involvement in present after 12 hours • No lab changes

  22. 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

  23. Grade 4 • Envenomation very severe • Sudden pain rapidly • Progressive swelling which leads to ecchymosis all over trunk • Bleb formation and necrosis

  24. Grade 4 contd… • Systemic manifestations within 15 min after the bite. • Nausea,vomitings,vertigo, • Numbness,tingling lips and face, muscle fasciculations,urinary incontinence, • Weak pulse • Convulsions, coma

  25. What investigation to do? • CBC • RFT • Coagulation studies • Blood grouping & cross matching • Sr.electrolytes • Urinalysis

  26. 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.

  27. Contd… • The tube is then tipped once to 45° to determine whether a clot has formed. If not, coagulopathy is diagnosed

  28. 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.

  29. First Aid First Aid

  30. ASV • When to use ASV? • How much to use? • What if a reaction occurs? • When to stop ASV?

  31. When to use ASV • Hemostatic abnormalities(lab and clinical) • progressive local findings • Neurotoxicity • Systemic signs and symptoms • Generalised rhabdomyolysis

  32. 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)

  33. Contd.. • Lyophilisedform: 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 neutralise0.6 mg of najanaja0.45 mg of Bungaruscaerulus0.6 mg of V.russelli0.45 mg of Echiscarinatus

  34. Guide for initial dose of antivenin

  35. 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

  36. 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.

  37. 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

  38. 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

  39. Serum Sickness • Characterised by fever, chills, urticaria, myalgias, arthralgias, and possibly renal or neurologic dysfunction developing 1–2 weeks after antivenom administration • systemic glucocorticoids (e.g., oral prednisone, 1–2 mg/kg daily) until all findings resolve • dose is tapered over 1–2 weeks. Oral antihistamines (e.g., diphenhydramine in standard doses) provide additional relief of symptoms

  40. When to stop using ASV • Bleeding subsides • Lab values returns to baseline • Signs of neurotoxicity reverses • Local effects halts progression

  41. 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)

  42. 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

  43. Contd Hypotension • administration of crystalloid (20–40 mL/kg) • a trial of 5% albumin (10– 20mL/kg) • CVP guided fluids • Inotropic support and invasive monitoring

  44. Contd.. • Oliguria & renal failure- fluids,diuretics, dopamine no response-fluid restriction, Dialysis • Local infection- TT,antibiotics • Haemostatic disturbances-FFP,fresh whole blood,cryoprecipitates

  45. Cobra spit opthalmia • topical antimicrobial • 0.1% adrenaline relieves pain • No need for ASV

  46. 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

  47. 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

  48. Venom • Histamine. • Melittina –membraneactive 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

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