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BANGALORE BAPTIST HOSPITAL

BANGALORE BAPTIST HOSPITAL

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BANGALORE BAPTIST HOSPITAL

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  1. BANGALORE BAPTIST HOSPITAL Snakebite Study WorkshopVellore, Mar 2013 Dr Tarun/ Dr Indira Menon

  2. Questionnaire. • Name of centre—BBH • No. of snake bites per year-- 55—60 • No. of snake bites in last year-- -65 • 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

  3. 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

  4. 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

  5. Questionnaire (contd.) • Last year cases of allergy to ASV—- minor -10- angioedema—swelling mouth/ bronchospasm—2- anaphylaxis fall in BP---2- death –nil

  6. 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

  7. 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

  8. 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.

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

  10. 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.

  11. 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)

  12. 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.

  13. 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

  14. 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.

  15. BANGALORE BAPTIST HOSPITAL Thank you!