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Dr Megongusie Meru Christian Fellowship H ospital Oddanchatram .

Clinical study on snake bite syndrome, species correlation and ASV dose requirement. . Dr Megongusie Meru Christian Fellowship H ospital Oddanchatram . Number of snake bites and syndromes. Number of snake bites/ year (or in the last year): 87

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Dr Megongusie Meru Christian Fellowship H ospital Oddanchatram .

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

  2. 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

  3. Snake Bite in 2012

  4. Snake Species

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

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

  7. 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

  8. 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

  9. 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.

  10. Neostigmine? • Any neurotoxic bite with evidence of envenomation.

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

  12. 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

  13. 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)

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

  15. 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.

  16. 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.

  17. 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.

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

  19. Is it Viper, Cobra or Krait ??? Viper 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.

  20. 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.

  21. 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.

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

  23. 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.

  24. COBRA BITE • If Ptosis is present to give ASV 4 vials IV in half an hour followed byInj 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.

  25. Thank you

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