snakebite... now what?
DESCRIPTION
Slides from an overview of Australian snake bite assessment and management. The talk was given by Chris Nickson at the Bedside Critical Care 2012 conference in the Whitsunday Islands.TRANSCRIPT
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Snakebite…Now what?
A Talk by Chris Nickson
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No $
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“Julius Caesar and the Crossing of the Rubicon,” Francesco Granacci, 1494
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Assessment
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If so, what antivenom & treatment is needed?
Is the patient envenomed?
Photo by Iguana Joe
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Snake bite
Lymphatics
Non-specific Systemic Features
Specific Envenoming Syndromes
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Specific Envenoming Syndromes
Venom-inducedConsumptive Coagulopathy
Anticoagulation
Neurotoxicity
Myotoxicity
Others
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Does he look sick?
Photo by JD Hancock
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Life Threats
HypotensionRespiratory failure
SeizureHaemorrhage
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AssessmentGeographic area
Anatomic site of biteNumber of strikes
Use of PIBPre-hospital course and treatment
Previous snakebitesSystemic features
Investigations
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Brown snake Pseudonaja spp
Tiger snake Notechis spp
TaipanOxyuranus spp
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Death AdderAcanthophis spp
Black snake Pseudechis spp
Sea SnakesHydrophiidae
Photo by Gnangarra
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InvestigationsWhole blood clotting test
Coagulation profile (INR, APTT) Fibrinogen, D-Dimer, FDPs
Full blood count Creatine kinase
Renal function and urinalysisLactate Dehydrogenase
Venom Detection Kit (VDK)
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VDK does NOT tell you if a patient is
envenomed
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If envenomed… VDK is an aid to
monovalent antivenom selection
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First Aid
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Pressure Immobilisation Bandage
PIB
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Warrell DA. Treatment of bites by adders and exotic venomous snakes. BMJ. 2005 Nov 26;331(7527):1244-7.
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Management
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Not envenomed
Remove PIBSerial examination
Serial laboratory testsObserve for 12 hours
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Envenomed
Address life threatsReplace PIB
Give AntivenomSerial assessment
Seek and treat complications
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AntivenomIndications
CollapseCoagulopathy
ParalysisRhabdomyolysis
Protracted GI distress
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1. Geography2. Clinical features
3. Laboratory findings
Which Antivenom to give?
http://www.kingsnake.com/aho/species/extras/budden.html
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What about the snake?
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How to give AntivenomResuscitation area
2 x IV lines
Give in 500 mL normal saline over 20 min
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Give Monovalentif Possible
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SevereAnaphylaxis
1% Monovalent
5% Polyvalent
Isbister et al. MJA 2008; 188: 437-476
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Polyvalent Antivenom
Appropriate monovalent AV not available
Need >2 monovalent AVand
No SVDK or no time to wait
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Premedication?Photo by Gaptone
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DoesAntivenom
Work?
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Isbister GK. Antivenom efficacy or effectiveness: the Australian experience. Toxicology. 2010 Feb 9;268(3):148-54.
Efficacy
Effectiveness
Inefficacious antivenom?Irreversible venom effect?Rapid onset venom effect?
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Yeung JM, Little M, Murray LM, Jelinek GA, Daly FF. Antivenom dosing in 35 patients with severe brown snake (Pseudonaja) envenoming in Western Australia over 10 years. Med J Aust. 2004 Dec 6-20;181(11-12):703-5.
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Isbister et al. Pathology (2006) 38(6) 568-572
Expect >8 hours until fibrinogen returns
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FFP: Fuel for the Fire?
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Don’t forget
ASP
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THE END
http://lifeinthefastlane.com
/education/toxicology/
Photo by Peter Firminger