Snakebite Poster

Presentation
Approach to identification of common
snakebite patients of Bangladesh by
clinical syndrome and treatment
principle
Patient presents with a history of snakebite but no brought
specimen of snake and no description of snake
• Admission, Reassurance and Assessment
 Marked local NO
swelling
Yes
No other features
Neurotoxicity Coagulopath Neurotoxici of envenomation
y ty

Cobra Bitten in Bitten sea Non

bite land Venomous

Green Russell's Krait bite Sea 24 h

pit viper snakebite observation
Reassurance
Care for local Rhabdomyoly
Supportive
sis and AKI
swelling, care
Supportive care for Discharge
coagulopathy
Antivenom (Polyvalent), Conservative
Anticholinesterase (Neostigmine) and treatment,
atropine for neurotoxicity: Cobra Support for
Supportive care for coagulopathy, neurotoxicity,
rhabdomyolysis and AKI for Russell's and Supportive for AKI.
Krait.
• The above clinical syndrome is applied for all areas of Bangladesh.
• Russell's viper is more common in northern area (Rajshahi,
Chapainobabgonj, Faridpur etc).

Identify the snake by brought specimen, description or by photograph.

Identified as venomous, non-venomous, snake not identified, suspected
snakebite, treat accordingly.
Refer if necessary after stabilization.
Antivenom Therapy: if systemic envenoming or local
envenoming
• Indications for antivenom (AV): AV treatment is recommended if and
when a patient with proven or suspected snakebite develops one or
more of the following signs:
– Systemic signs – Clinical
– Laboratory.
 Indications for antivenom
Systemic signs Clinical
Haemostatic Spontaneous systemic bleeding
Neurotoxic signs Ptosis, external ophthalmoplegia,
paralysis etc.
Cardiovascular abnormalities Hypotension, shock, cardiac
arrhythmia.
Acute kidney injury (renal Oliguria/anuria.
failure)
Haemoglobin-/myoglobin-uria Dark brown urine, muscle aches
and pains (feature of generalized
rhabdomyolysis).
Local envenoming
 Indications for antivenom
Laboratory:
• 20WBCT
• Prothrombin time, Thrombocytopenia (<100 x
109/litre or 100 000/cu mm).
• Abnormal ECG
• Rising S. creatinine / urea
• Urine dipsticks,
• Hyperkalemia
• Low Hemoglobin/ Haematocrit.
 Local sign

• Local swelling involving more than half of the bitten limb

(in the absence of a tourniquet) within 48 hours of the bite.
• Swelling after bites on the digits (toes and especially
fingers).
• Rapid extension of swelling (for example, beyond the wrist
or ankle within a few hours of bite on the hands or feet).
• Development of an enlarged tender lymph node draining
the bitten limb.
• It is never too late to give AV provided the indications are
present: only if features of systemic envenoming are
present for bites of snakes mentioned.
• Do not give AV for local envenoming alone, except for
Cobra and Russell’s viper bites when indicated.
• Commence AV immediately if indicated for the bites of:
Cobra, Krait, Russell’s viper.

Currently available AV is not recommended for the bites of:

Green pit viper, Sea snake.
 Dose
• Dose: 100 ml (10 amp/vials) of polyvalent AV mixed with
100 ml of normal saline should be infused intravenously
over one hour.
• Start infusion at a lower rate, monitor for 10-15 minutes.

Adult and children should receive same dose of AV.

 Prophylaxis
• Before initiating AV, prophylactic subcutaneous adrenaline (dose - adult 0.25 ml of 0.1%
solution and in children 0.005 mg/kg) should be given to the victim.
• Adrenaline is available as 0.1% (1 in 1000) solution, 1 ampoule containing 1 ml.
• Draw adrenaline in an Insulin syringe (100 unit) upto mark 25 (for adult), administer
• Subcutaneously (in case of premedication).
• For treatment of anaphylaxis, draw 0.5 ml of adrenaline (for adult) & give IM.
• CAUTION: Have Adrenaline (+Inj. Hydrocortisone, Inj. Anti histamine) available at
bedside.
• Observe the patient carefully during the time of administration of antivenom and upto 3
hours for signs of anaphylaxis.
 Antivenom reaction

Early reaction Late reaction

Anaphylactic reaction Pyrogenic reaction Serum sickness

(Develop within (Occurs within
(Develop within 1 to 2 hour) 1-12 days)
10-180 min)
 Anaphylactic reaction
(Develop within 10-180 min)

Clinical features Management

 Urticaria, itching, fever • Stop antivenom
 Palpitation, vomiting, • Inj. Adrenaline (0.5 mg for adults and 0.01 mg/kg
 Dry cough body weight for children.)
 Abdominal pain, diarrhoea • Inj. Chlorfeniramine maleate adults 10 mg,
 Severe anaphylaxis: children 0.2 mg/kg by intravenous injection over
Hypotension a few minutes)
bronchospasm • Inj. Hydrocortisone (100mg; children 2mg/kg
angioedema. • If bronchospasm: nebulize with salbutamol.

The dose can be repeated every 5-10 minutes if the reaction persists or
the symptom worsens.
 Management Anaphylaxis contd..

Anaphylaxis unresponsive to When Inj. Adrenaline should

I/M Inj. Adrenaline not be given:
• I/V 0.9% Normal saline • Hypertension
• I/V Inj. Adrenaline Infusion • Cardiac diseases
• I/V Inj. Dopamine Infusion. • H/O Cerebrovascular disease
• Coagulopathy.
 Pyrogenic reaction
(Develop within 1 to 2 hour)

Clinical features Management

• Fever, chills (rigors) • Stop antivenom

• Vasodilation • Paracetamol suppository.
• Fall in blood pressure.
 Serum sickness
(Occurs within 1-12 days)
Clinical features Management

• Fever, nausea, vomiting, diarrhoea • Oral Prednisolone adults 5 mg six

• Itching, recurrent urticaria hourly, children 0.7 mg/kg/day and
• Arthralgia, myalgia, periarticular • Chlorpherniramine
swelling • adults 2 mg six hourly, children 0.25
• Lymphadenopathy, mg/kg /day in divided doses.
• Mononeuritis multiplex, • Rx for 5-7 days
• Proteinuria
• Encephalopathy
Thank You