MANAGEMENT OF
PATIENT WITH
SNAKE BITE
Learning Outcome
At the end of the session, student shall be able
to:
1. Explain the first aid management of patient
with snake bite.
2. Explain the assessment of patient with snake
bite.
3. Explain the importance of nursing observation
during administration of anti venom.
Equatorial
spitting cobra
Monocled cobra King cobra
Red Headed Malayan Krait
Kraits Banded Kraits
Banded Coral Spotted Coral Snake
Snake
Malayan Blue
Coral Snake
Ular Laut
Malayan Pit Mountain Pit Viper Snake
Viper Snake
Snake venom
• Complex toxic secretions produced by highly
specialised venom glands, and are comprised of
proteins and peptides.
• Can cause deleterious effects when injected through
modified teeth.
• Teeth located on the anterior maxilla into the tissue
of a recipient organism.
Manifestasi klinikal
coagulopathy Neuro
receptor
blockade
Clinical Features
Within 24hours
1. General:
• Nausea and vomiting,
• malaise, abdominal pain,
• weakness, drowsiness, prostration
2. Cardiovascular:
• Visual disturbances,
• dizziness, fainting or light-headedness,
• collapse, shock, hypotension,
• cardiac arrhythmias and pulmonary oedema.
Clinical Manifestation
Within 24hours_cont.
3. Bleeding and clotting disorder:
• Prolonged bleeding from the bitten site,
• site of venepuncture, conjunctiva, oral cavity,
• petechial rashes or bleeding from occult sites.
• Bleeding from occult sites include gastrointestinal, urinary and
intracranial bleeding.
4. Neurological:
• Paralysis, Ptosis
• Facial paralysis
• Dysphagia
Clinical Manifestation
Within 24hours_cont.
5. Musculoskeletal and renal
• Myalgia, stiffness, tenderness.
• Darked colour urine
• Oliguria / anuria.
First Aid Treatment
1. Moves the person beyond striking distance of the
snake.
2. Have the person lie down with wound below the
heart.
3. Keep the person rest and calm, remaining as still as
possible to keep venom from spreading.
4. Cover the wounds with loose sterile bandage.
Clinical Assessment
1. Resuscitation:
a. Airway and Breathing:
Assess for airway and breathing problem due to paralyzing
neurotoxic effect.
Assess breathing pattern and rate, SPO2
b. Circulation:
Assess local wound and control bleeding as necessary.
Assess vital sign: B/P, heart rate, Pain score, temperature.
2. Physical examination
Examine puncture site
Puncture site
edema
ecchymosis
Haemorrhagic bullae Tisu nekrosis
Montoring
1. Lymph nodes draining the bitten site:
Enlargement and tenderness.
Measure swelling progression (time of swelling present).
2. Progression of local injury tissue:
Necrosis, blister, bullae, redness or bruising.
Take serial pictures of bitten area.
3. Coagulopathy:
Reduced platelet count,
Prolong PT, aPTT & INR.
Swelling progress proximally after the left
thumb was bitten by a king cobra
History
Taking
Lab Investigation
1. Serially monitored:
a. Full blood count
b. Creatinine Kinase
c. Coagulation Profile
d. D-Dimer and serum fibrinogen level if coagulopathy present
2. Baseline
a. Renal function test (6hourly in sea snakebite)
b. Liver function test
c. Urine FEME and Urine for myoglobin
Treatment
1. Triage
systemic and local envenomation to critical/red zone
Asymptomatic patients can be managed in the semi critical/yellow
zone.
2. Primary Assessment:
a. Airway patency:
Perform head tilt chin lift with adequate suctioning.
Position patient depending on conscious state (lateral, supine or
propped up position)
Oropharyngeal airway. Do not attempt if gag reflex still present.
Treatment_cont.
b. Breathing effort:
Positive pressure ventilation via bag valve mask may be required.
followed by definitive airway insertion when indicated.
c. Circulation
Look for evidence of shock and bleeding.
Attach to cardiac monitor and look for arrhythmias.
CPR if cardiac arrest.
Insert 2 large bore of IV cannulas with fluids resuscitation.
Look for external bleeding and apply method of bleeding control.
Monitoring of vital sign:
BP, HR, RR, SPO2, Pain Score 5-15min
Temperature 4 hourly
Urine output hourly
Treatment_cont.
d. Disability of nervous system
Conscious level.
Muscle weakness
e. Exposure and environmental control
Management
1. Immobilize the bitten limb
Position in a neutral position.
examine the bite site for swelling, bleeding and neurovascular
compromise.
Monitor neurovascular compromise with bedside Doppler.
2. Anti tetanus toxoid
3. Analgesia
Mild pain: Paracetamol 4-6hourly
Moderate to severe pain: IV opioids in titrated doses
4. Anti venom
5. Irrigate the affected eye with copious irrigation (5 – 10litre)
Use normal saline or water or ringer's lactate or any bland fluid
(such as milk) if water or saline is unavailable.
Anti Venom Therapy
1. Given intavenously
• Dilute antivenom with the solution supplied or 10ml water for
injection
• Further dilute with:
Children: 5-10mls per kg body weight NS/D5%.
Adult: 250-500mls NS/D5%
• Infused 1-2ml/min for 10-15mins then increase……to complete
within 1 hour or earlier.
2. Observed for adverse reaction
a. Early anaphylactic reaction: 2min – 2 hours after treatment
b. Pyrogenic reaction: 1-2hours after treatment
c. Late reaction: 1 -12day after treatment
SEKIAN