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Case Presentation

Case Presentation. 日期： 96/06/26 報告者： Intern 盧彥廷. Patient data. Name: 柯 X 操 Sex: female Age: 69 years old Date of visiting our ER: 96/06/23 Chart No: 2371374 檢傷分級：第 1 級 Vital signs: HR:95, RR:14, BP:210/110, BT:36.5℃. Chief complaint. snake bit over left ankle by 龜殼花. 龜殼花.

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Case Presentation

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  1. Case Presentation 日期：96/06/26 報告者：Intern 盧彥廷

  2. Patient data • Name: 柯X操 • Sex: female • Age: 69 years old • Date of visiting our ER: 96/06/23 • Chart No: 2371374 • 檢傷分級：第1級 • Vital signs: HR:95, RR:14, BP:210/110, BT:36.5℃

  3. Chief complaint • snake bit over left ankle by 龜殼花

  4. 龜殼花

  5. Present illness • This is a 69 y/o female suffered from snake bit over left ankle by 龜殼花 at about 22:30 on 96/6/22 and sent to 義大hospital for help • There was no hemorrhagic bullae or ecchymosis but only one tooth puncture. • Because of out of Antivenin, she was transferred from 義大 hospital to KMU ER for help.

  6. Past history • Hypertension (+) • Diabetes Mellitus: denied • Allergy history: denied • OP history: left total knee reconstruction

  7. Initial assessment • Consciousness:clear, E4V5M6 • General appearance: easy-looking • Vital signs: HR:95/min, RR:14/min, BP:210/110mmHg, BT:36.5℃, • Airway: patent without obstruction • Breath: smooth and regular, no dyspnea • Circulation: no pallor or cyanosis, tachycardia • Disability: alert • Exposure: no trauma

  8. Lab data

  9. Lab data

  10. Lab data

  11. Case progression 00:05 Admitted to ER • BT:36.5, BP:210/110, HR:95 , • check PT,PTT,CBC, WBC classification, SGOT,SGPT,Sugar,Na,K,Cr, Urea N, 00:24 08:17 • Tetanus Toxoid • Vit.K1 10mg 1 Amp+ Aq dest 20ml IVP • Antivenin of Tr.M and Tr.G+ N/S 250ml IVD • Cefazolin 1 gm 1 vial+ Aq dest 20ml IVP • Dacoton 9 tab PC • Nakacef 250mg 9 cap PC • Topaal 9 tab PC, • BT:36.0 ℃, BP:154/80mmHg, HR:83 • MBD at 15:00 14:56 Arrange to plasty OPD to follow up on 96/6/25

  12. Impression • Snake bit over left angle • Hypertension

  13. Case outcome • Admitted to Plasty OPD on 96/06/25

  14. Treatment • Antivenin of Tr. M and Tr. G 1 vial IVD ( with N/S 250ml) • Vit. K1 10mg 1 Amp IVP(with Aq-dest 20ml ) • Antibiotics use: Cefazolin 1 gm 1 vial IVP((with Aq-dest 20ml )

  15. Snake Bite

  16. Introduction • Snake venom varies in potency and action, but several syndromes can be distinguished following envenomation: (A)Neurotoxicity (B)Systemic toxicity including hypotension and shock (C)Coagulopathy (D)Rhabdomyolysis (E)Renal failure (F)Local tissue necrosis

  17. Principle of management • The principles of management of snake bites are summarized includes: (A)Field management, (B)Hospital assessment, (C)Hospital management.

  18. Field management • General Principle: • (a)The patient should be removed from the snake's territory, kept warm and at rest, and be reassured. • (b)The injured part of the body should be immobilized in a functional position below the level of the heart. • (c)The wound should be cleansed, except in areas in which a venom detection kit is used (such as Australia). • (d)Withhold alcohol and drugs that may confound clinical assessment. • (e)Attempt to identify the snake, without endangering the patient or rescuer. A digital photo taken at a safe distance may be useful. Snake parts should not be handled directly. • (f)Transport the patient to the nearest medical facility as quickly as possible.

  19. Field management • Pressure imobilization: • The pressure immobilization technique is generally recommended following envenomation by snakes with neurotoxic venom, including Australian elapids. • It is usually not advised following bites from snakes with locally necrotic venom, such as cobras and vipers.

  20. Field management • Methods not recommended: • (A)Incision and oral suction, • (B)mechanical suction devices, • (C)cryotherapy, • (D)surgery, and electric shock therapy • (E)Tourniquet compression have been widely used but are no longer recommended.

  21. Hospital assessment • 1.Evaluation of the bite • 2.The first clinical indications of systemic envenomation are often nonspecific symptoms such as nausea, vomiting, abdominal pain, and headache. • 3. Neurotoxicity: ptosis, diplopia, and bulbar palsy with onset between 1 to 10 hours following envenomation.

  22. Hospital assessment • Coagulopathy: (1)WBCT>20min (2)INR>3.0,aPTT>50sec., plt<50,000/ul, fibrinogen<75mg/dl • Hypotension and shock • Rhabdomyolysis: (1)muscle pain, weakness, and dark urine is suggestive (2)Urine dipstick tests for the presence of blood detect both myoglobin and hemoglobin (as well as hematuria) and positive results

  23. Hospital assessment • Renal failure: (1) Cause: hypotension, rhabdomyolysis and/or disseminated intravascular coagulation (DIC) (2)Risk factor: age less than 12 years , a delay in antivenom therapy of >2 hours a creatinine kinase at admission >2000 U/L (3) diuresis at admission >90 mL/hr

  24. Hospital management: • Antivenom: • Antivenoms are generally indicated: (1)There is evidence of systemic envenomation (neurotoxicity, coagulopathy, rhabdomyolysis, persistent hypotension, and/or renal failure). (2)There is severe local envenomation, manifested by local tissue destruction. • Although delays in administration result in lowered effectiveness, anecdotal evidence suggests that some improvement is possible even days after envenomation with some snakes

  25. Hospital management: • Antivenom: • Adverse reactions : (1)Early allergic reactions (2)Pyrogenic reactions (3)Late allergic reactions (serum sickness)

  26. Hospital management: • Premedication with epinephrine is appropriate in the following settings : (1)Use of antivenom is associated with high rates of allergic reactions. (2)There is an appreciable risk of allergic reaction associated with antivenom use and the management of acute allergic reactions is problematic because of limited staffing or facilities. (3)If premedication is not given, epinephrine (0.5 to 1 mL of an 0.1 percent [1:1000] solution) should be prepared prior to the administration of any antivenom in the event that it is needed.

  27. Hospital management • Prophylactic antihistamines alone were not beneficial in the Brazilian study • Corticosteroidsare often used with early and late allergic reactions • The routine use of antibiotics is controversial and depends in part upon the local rates of infection. • Intubation and ventilation is required for airway protection or respiratory support if bulbar palsy, increasing dyspnea, or respiratory failure are present.

  28. Hospital management • Coagulation: (1)Persisting bleeding should prompt the administration of additional antivenom. (2)Clotting factor replacement with whole blood or fresh frozen plasma is only indicated in cases of life-threatening hemorrhage after the use of antivenom. • Rhambdomyolysis: (1)Initial fluid resusciation: Plasma volume expansion with intravenous isotonic saline (2)Following fluid resusciation: alkaline-mannitol diuresis to a goal urine pH of 6.5.

  29. Reference • 1.Principles of snake bite management worldwide Allen C Cheng, MB, BS, FRACPhttp://www.uptodate.com/ • 2.Tintinalli’s Emergency medicine 6th ed. • 3.Current Emergency medicine Chapter 44.

  30. Thanks for your attention!

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