Snake Bite Management for the ED Nurse By Kane Guthrie FCENA
May 07, 2015
Snake Bite Management for the ED Nurse
By Kane Guthrie FCENA
Snake Bites in Australia
• Definitive or suspected bites are common• Severe envenoming rare – Potentially fatal!
• Each snake has characteristic clinical syndrome
• Limited clinicians with limited knowledge
Quiz
• How many poisonous snakes do we have in Australia?
Risk Assessment
• Geographic area• Anatomic site of bite• Number of strikes
• Use of PIB• Pre-hospital course & treatment
• Previous snakebites• Systemic features• Investigations
Physical Exam
• Vital Signs• Mental Status• Evidence of bite• Lymphadenopathy
• Evidence of abnormal bleeding• Signs of paralysis
• Respiratory Function
Investigations
• Whole blood clotting (resource limited)• FBC
• Coagulation profile• Fribrinogen, D-Dimer
• U & E, CK
Snake Venom Detection Kit
• Dose not determine if envenomed or not!• Useful test to:– Confirm which one 5 groups responsible for
envenoming.– Helps determine which antivenom is required.– Best done in laboratory.– Use bite site swabs or urine.
• Use geographic area & clinical exam alongside!
SVDK
Clinical Effects
Non Specific:• Nausea & vomiting
• Headache• Abdominal Pain• Diarrhoea• Dizziness• Collapse
Specific Envenoming Syndromes
• Coagulopathy• Neurotoxicity • Myotoxicity
• Rhabdomyolysis
Pre-Hospital Care
First Aid:– PIB
Transport:– ASAP –> hospital capable of:– Dr able to Mx snakebite– Laboratory open 24/7– Stocks adequate supplies antivenom
Pressure Immobilisation Bandage
Canale, E. Isbister, G. Currie, B. (2009). EMA. 21, 184-190.
Pressure Immobilisation Bandage
In-Hospital
• Resus Bay• Get help – consider PIC 131126• Determine if envenomed:– History– Physical exam– Laboratory investigations/SVDK
• Determine if antivenom required• Supportive care and treatment (ADT)
Antivenom
Two types:1. Monovalent:– More specific, cheaper, safer less serum sickness.
2. Polyvalent:– Contains equivalent of 1 vial of each monovalent.
• Give 1 vial 500mls N/saline over 20mins!• Risks: anaphylaxis, serum sickness!
Major Types: by Clinical Syndromes
5 major groups:1. Brown Snakes2. Tiger Snakes
3. Mulga/black snakes4. Taipans
5. Death Adders
Brown Snakes
• Eastern/western brown snake, Dugite
• Found all throughout Aust! (except Tasmania)
• Most common cause of death from snake bite!
Brown Snake
Envenoming:• VICC- bleeding gums, cannula site, ICH.• Renal failure & oliguria infrequent. • Rare – diplopia, ptosis & MAHA.
Brown Snake
Management:1. PIB- Resus bay2. Check Coag’s FBC and U&ESigns of Envenomation:• 1 vial of CSL brown snake antivenom• Serial coag test to check if safe for D/C• New recommendation only 1 vial!
• White, I. Buckley, N. (2012) Antivenom Update. Australian Prescriber (35, 5).
Tiger Snakes
• 9 types of tiger snakes.
• Found along coastal regions southern/eastern Australia.
• Fast moving, easily alarmed that strike readily.
• Have high rate of dry bites!
Tiger Snake
Similar to brown snake but cause paralysis!Envenoming:• VICC• Neurotoxicity – progressive flaccid paralysis– Diplopia, ptosis, Resp failure
• Rhabdomyolysis– Significant pain, muscle breakdown
Tiger Snake
Management:1. PIB-Resus bay2. Bloods, Coag’s, FBC, U&E, 3. Serial peak flow, neuro exam!Envenomed:• 1 vial Tiger snake antivenom• Consider intubation for resp failure
Mulga/Black Snakes
• Mulga, king brown, Red-bellied or black snake
• Found around Australia
• Large, aggressive with painful bite
Mulga/Black Snake
Envenomation:• Severe rhabdomyolysis• Anticoagulation abnormalities – Increased INR and aPTT.
• Non specific symptoms:– Headache, nausea & vomiting
Mulga/Black Snake
Management:1. PIB-Resus bay2. Bloods, Coag’s, FBC, U&E, Urine
Envenomed:• IDC – fluids, monitor CK• 1 vial black snake antivenom
Taipans
• Coastal & Inland Taipans
• Found northern Aust (NT & QLD)
• Envenoming rare, but lethal without AV!
Taipans
Envenoming:• VICC• Neurotoxicity– Venom causes paralysis, seizures
• Rhabdomyolysis
• Systemic envenoming can causes rapid onset collapse within minutes!
Taipans
Management:1. PIB-Resus bay2. Bloods, Coag’s, FBC, U&E, Urine
Envenomed:• IDC – fluids, monitor CK• Prepare for resp failure – intubation• Give 1-2 vials taipan antivenom • Supportive care & monitoring
Death Adder
• Common, desert, northern, pilbra- death adder.
• Found mainland Australia.
• Characterised viper like appearance, short, fat with diamond shaped head!
Death Adder
Envenomation:• Neurotoxicity- descending flaccid paralysis• Manifest with 6 hours
Early signs:• Diplopia, ptosis, difficulty swallowing.
Death Adder
Management:1. PIB-Resus bay2. Bloods, Coag’s, FBC, U&E, 3. PEFR- neuro assessment
Envenomed:• Intubation for respiratory failure.• 1 vial death adder antivenom• Sx resolve 1-2 days
Questions
Take Home Points
• PIB always!• Envenomation is rare!• 1 vial of antivenom is usually suffice!• Make use of the experts!
Thank-you