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case presentation of snake bite - BHS Education Resource

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					 Case presentation
       snake bites

Grampians EMET training Hub
Case 1 - VICTORIA
56 year old male
   Arrived at 1140                    What could be done
    - bitten by snake on right
    hand                                differently here?
    - whilst trying to scare it
    away from his children
    - in afternoon at nearby
    picnic ground
    - He had consumed alcohol
    - snake killed by friends and
    brought in
   States feels weird and
    nauseated

   No bandage applied initially
Past History
   Angina => angioplasty        Any specific features on
    5 yrs ago, nil since          history that you should
                                  ask about?
   Drugs
       Simvastatin, Aspirin

   Allergies
        Morphine
Examination

   Anxious, mildly confused,        Any specific features that
    breathalyser 0.32                 should be documented?



   Bite to 1st web space right
    hand
       puncture wounds dorsum

   Observations stable


   Otherwise NAD
Management- Initial
   Swab taken from bite         What further action is
    site, then compression        appropriate now?
    bandage applied

   IV line

   Blood for FBE, U+E,
    CK, Coagulation profile

   ADT given
30 minutes later…
   Venom detection kit positive      20 minutes later…
    for tiger and black snake         A staff member has called the
   Patient feels better, alert,       local wildlife park
    orientated,                       Snake seen by herpetologist,
                                       identified as copperhead
   neuro exam normal
   APTT 33, INR 0.9
   FBE, U+E, CK normal
   Bandage removed
What do we learn from this
case?
   Pre hospital issues           In Victoria, Australia
    include public                The only antivenom
    education, and first aid       required is tiger and
                                   brown snake
                                  Exceptions include
                                   snake handlers, the
                                   wildlife park/zoos, and
                                   people with other
                                   snakes as pets
25 minutes after the snake
identification…
   Patient disorientated, slurred speech c/o
    weak arms and legs, and blurred vision
   Slight ptosis
What action is needed?
   Do you put the bandage back on?
   Do give antivenom?
   If yes, which antivenom?
   Who can you ask for help?
Further management
   One vial tiger snake         Putting the bandage back on
                                  while getting the antivenom
    antivenom given in            ready is a good idea
    Hartmans solution over       But then the antivenom must
    30 minutes                    come in contact with the
                                  venom, so after infusion
                                  commenced and patient is
   IV hydrocortisone given       stable, take off bandage
                                 Tiger antivenom is given for
                                  black or tiger snake
   Adrenalin and
                                 HELP - seek senior help, and
    phenergan drawn up            POISONS centre 131126 is
                                  available PRN
40 minutes later (10 mins post
infusion complete)
   Patient feels a bit        Following morning
    better, with clinical      Feels well, no
    evidence of
    improvement                 neurological
                                signs/symptoms, no
   No respiratory
    compromise                  bleeding
   Admitted and               Repeated blood tests
    transferred to ICU          all normal
    overnight                  Discharged
    for observation
Case 2 - WESTERN AUST.
38 year old male
   Snake bite to middle finger           In transit, the patient
    of left hand                           complained of feeling unwell
       Whilst trying to catch snake       with chest tightness and
        in house                           rapidly became unresponsive.
   Placed a single layer                 Decision to seek medical
    compression bandage on                 attention at Urban Hospital
    his own arm from fingers to            en route (still 30 minutes
    elbow                                  approx from tertiary referral
   Drove to his GP in 10                  hospital)
    minutes
   No symptoms or signs of
    envenomation
   Decision to transfer to
    Tertiary referral Hospital by
    ambulance (60 minutes)
Initial Management 02.15
hours following the bite
   Unresponsive with no            Antivenom IV bolus;
    cardiac output                  1 ampoule polyvalent
   ECG: pulseless electrical        2 ampoules brown snake
    activity, narrow complexes       2 ampoules tiger snake

   CPR commenced
   Intubation
   1mg adrenalin
   1000ml normal saline

Subsequent course

   Spontaneous circulation              Further antivenom:
    resumed within 1 minute of this      1 ampoule polyvalent
    antivenom, total 11 minutes          3 ampoules brown snake
    CPR
                                         Creatinine 108, ALT 113, CK
   Platelets 33, INR >10, APTT           143, Troponin I < 0.4,
    >180, Fibrinogen < 0.3, FDP >
    20
                                         Stabilised and transferred to
                                          tertiary centre, developed
   Discussed with on-call                bleeding lips and gums en
    toxicologist                          route
    3 hours following the bite
    Pulse 105, BP 135/60,
     pupils 4mm equal and
     reactive
    Bleeding gingivae and
     venepuncture sites,
     petechiae around eyes,
     haematuria
    ECG: sinus tachycardia,
     RBBB, mild ST-segment
     depression
    Venom detection kit from
     bite site positive for brown
     snake
    Compression bandage
     reinforced and extended
     to include the whole limb
Subsequent course
10 ampoules brown snake              No further oozing noted and
   antivenom given in 100 ml          compression bandage
   0.9% saline over 15 minutes        removed

  Platelets 111, INR > 10, APTT       Patient’s condition remained
  > 180, Fibrinogen < 0.3, FDP        stable
  >20

  Creatinine108, ALT 201, CK
  164, Troponin I < 0.4

  CT head normal
   5 hours following the bite            9.30 hours following bite
   Transferred to ICU, where remained
    stable                                   Platelets 161, INR > 10, APTT > 180,
   Platelets 214, INR >10, APTT > 180,       Fibrinogen <0.3, FDP > 20,
    Fibrinogen < O.3, FDP > 20                Creatinine 127, ALT 243, CK 366,
   Creatinine 133, ALT 277, CK 259,          Troponin I 10.8
    Troponin I 2.8
   Further 5 ampoules brown snake
    antivenom infused
15 hours following bite
   Platelets 148, INR 1.8, APTT 44.7, Fibrinogen 0.5, FDP > 20,
    Creatinine 134, ALT 223, CK 462, Troponin I 6.8

   Extubated, neurologically normal.

   Commenced on 5 days oral prednisolone 50 mg
1 month later
   Follow up, well

   Flu like illness with rash and sore joints
    between days 17 and 21 after envenomation
Learn from this case?
   A correctly applied          Expert advice is
    pressure immobilisation       needed
    bandage should allow         In WA, there is a
    stable transfer of            different profile of
    patients long distances       snake bites
   E.g Flying doctor            The recommendations
                                  for antivenom have
    service                       changed since this
                                  case, and will continue
                                  to change, hence seek
                                  advice
Scenario 3
   A 23 yr old man present to your emergency
    department complaining of dizziness, blurred
    vision, nausea and vomiting. He was well
    until about 1 hour ago. Today he has been
    chopping wood and re organising the wood
    heap, he sustained a scratch to his R thumb,
    but did not see what did it.
   What is your assessment & management?
Assessment/examination
   cubicle
   ABC
   consider risk of snake bite
       swab wound for VDK
       pressure/immobilization
   full hx & ex
   bloods fbe, uec, clotting, glucose
Investigation
   VDK + for brown snake
   FBE 12.3, 12(10), 120
   UEC NAD
   Clot INR 4 APTT 65 Fibrinogen 0.5
   what now?
Management
   Resus
   prepare antivenom & give
       1unit now recommended starting dose
       dilute as described
       consider premedication
       when do you remove the Pressure immobilisation
   neuro obs
   what next
continued
   recheck coags                  There are recent updates in
   do you correct the coags?       recommendations re
   Where to?                       treatment of coagulopathy
                                   http://www.australianprescri
                                    ber.com/magazine/35/5/152
                                    /5
                                   Replaces 2006 article
                                       http://www.australianprescri
                                        ber.com/magazine/29/5/125
                                        /9/

				
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posted:4/3/2013
language:English
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