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DR TRC/ KRH
Management of Snake Bite Victims
with Respiratory Paralysis in ICU
Facts given
Snake bite which has lead to Respiratory
Paralysis
Patient in ICU
Answer
Management aspects
How to prevent snake bites?
A world free of snakes
1 2 3 4
Species: Medical Implications
Signs/Symptoms Russell’s
Cobra Krait Saw Scaled Other
and Potential Viper
Viper Vipers
Treatments
Venomous snakes
About 50% of bites are dry
Causes
ARF, DIC, Shock, Pulmonary edema,
Sepsis
Snake bite and Respiratory paralysis
More cases why ?
Neurotoxic
MV for respiratory ASV
paralysis MV as Supportive care
20-30%
Case scenario…….
34 yr old male shifted from rural health center with H/O
snake bite 6 hrs back has ptosis, respiratory distress, RR
35/mt, BP 120/60, oral secretions present, absent gag
and cough reflex shifted to ICU for teritary care.
On ASV 100ml stat, & 50ml in NS over 6 hrs
Oxygen 3l/mt
Patient is comfortable, vitals stable
No ptosis, distress
Patient received
in casualty
Patient is dead –what do you think
went wrong ?
Patient is dead –what do you think went wrong ?
Why does
Neurotoxicity occur ASV, Anticholineesterases,
MV…
Snake venom components
Krait- Pre-synaptic action
Beta-bungarotoxin- Phospholipases A2
“Curare-mimetic toxins’’
Ptosis
Ophthalmoplegia
RS
r
Bulba ss involvement
e
weakn
ASV is polyvalent
Syndromic approach helps in examination
and investigations and outcome predictions
Skin testing for ASV
Skin/conjunctival hypersensitivity testing does not
reliably predict early or late antivenom reactions
and is not recommended.
What is ASV?
Antivenom is immunoglobulin (usually the enzyme
refined F(ab)2 fragment of IgG) purified from the serum
or plasma of a horse or sheep that has been immunised
with the venoms of one or more species of snake.
Monovalent or monospecific antivenom neutralises the
venom
of only one species of snake
Polyvalent or polyspecific antivenom neutralises the
venoms of several different species of snakes
The ASV that is available in India is a polyvalent type
which is active against the commonly found snakes in
India including the FAB Four.
Indications for ASV
Neurotoxicity
ARF
Bleeding/coagulopathy
Myoglobinuria/haemoglobinuria
Cardiac toxicity
Local swelling involving more than half of the bitten limb
Rapid extension of swelling
Development of an enlarged tender lymph node draining
the bitten limb
Timing of ASV
There is no consensus as to the outer limit of time of
administration of antivenom. Best effects are observed
within four hours of bite .
It has been noted to be effective in symptomatic patients
even when administered up to 48 hours after bite.
Reports suggest that antivenom is efficacious even 6-7
days after the bite from vipers
When there are signs of local envenoming, without
systemic envenoming, antivenom will be effective only if
it can be given within the first few hours after the bite
Dose
5 vials(50ml)
5-10 vials
(50-100ml)
10-20 vials
(100-200ml)
Large vs small dose
High dose group 100ml stat and 100 ml every 6 hrs
Low dose group 100ml stat and 50 ml every 6 hrs
Until recovery of neurological signs
Results :
In the low-dose group
Mortality rate of 10%, 18% required dialysis and 6%
required ventilatory support. LOS 8.42 days
In the high-dose group
Mortality rate of 14%, 26% required dialysis 6% required
ventilatory support.LOS 9.02 days
Conclusion : While there was no additional advantage in
following a high-dose regime for snake bite cases, there
was considerable financial gain by following the low-dose
regime,
Most of the parameters showed a beneficial trend for
the low-dose group though the differences were not
statistically significant
JAPI • VOL. 52 • JANUARY 2004
High vs low ASV
Repeated high doses of ASV to restore the clotting time
to normal within the shortest time, do not seem to be
necessary to reduce the ultimate morbidity and mortality.
A smaller dose sufficient to make the clotting time graph
take a downward trend is sufficient.
The body’s detoxifying system will bring down the clotting
time eventually though it may take a slightly longer time.
This delay does not seem to affect the morbidity and
mortality as shown by the results of this trial.