- Mrs. N, a 45-year-old woman, was bitten by a snake in her bedroom around 4 am. She felt pain and swelling at the bite site on her abdomen and was referred to the emergency department.
- At the ED, she reported nausea, vomiting, and weakness in her left leg. Examination found swelling and necrosis at the bite site. Tests showed elevated white blood cell count and slightly low carbon dioxide levels.
- She was diagnosed with local and systemic envenomation from a cobra snake bite. She was given antibiotics, antivenom, morphine, and IV fluids. Her symptoms improved with antivenom treatment and she was monitored for complications in the ward.
- Mrs. N, a 45-year-old woman, was bitten by a snake in her bedroom around 4 am. She felt pain and swelling at the bite site on her abdomen and was referred to the emergency department.
- At the ED, she reported nausea, vomiting, and weakness in her left leg. Examination found swelling and necrosis at the bite site. Tests showed elevated white blood cell count and slightly low carbon dioxide levels.
- She was diagnosed with local and systemic envenomation from a cobra snake bite. She was given antibiotics, antivenom, morphine, and IV fluids. Her symptoms improved with antivenom treatment and she was monitored for complications in the ward.
- Mrs. N, a 45-year-old woman, was bitten by a snake in her bedroom around 4 am. She felt pain and swelling at the bite site on her abdomen and was referred to the emergency department.
- At the ED, she reported nausea, vomiting, and weakness in her left leg. Examination found swelling and necrosis at the bite site. Tests showed elevated white blood cell count and slightly low carbon dioxide levels.
- She was diagnosed with local and systemic envenomation from a cobra snake bite. She was given antibiotics, antivenom, morphine, and IV fluids. Her symptoms improved with antivenom treatment and she was monitored for complications in the ward.
- Mrs. N, a 45-year-old woman, was bitten by a snake in her bedroom around 4 am. She felt pain and swelling at the bite site on her abdomen and was referred to the emergency department.
- At the ED, she reported nausea, vomiting, and weakness in her left leg. Examination found swelling and necrosis at the bite site. Tests showed elevated white blood cell count and slightly low carbon dioxide levels.
- She was diagnosed with local and systemic envenomation from a cobra snake bite. She was given antibiotics, antivenom, morphine, and IV fluids. Her symptoms improved with antivenom treatment and she was monitored for complications in the ward.
(Snake Bite) Mohd Zikrullah / Izzat Syameer / Nabilah Akmar / Sahira Afiqah / Cylvia George History Mrs. N, a 45 years old lady with no underlying medical illnesses was referred from a clinic suspected of a snake bite 2 hours ago History of Presenting Illness Around 4 am, patient was asleep in her bedroom when suddenly she noticed something slithering up her body from her leg to the abdomen. Surprised at that time, she attempted to get rid of it when suddenly she felt herself being bitten at the right upper abdominal region. As the room was dark, she was not able to identify specifically what it was, however manage to notice something that was approximately 1 metre long as it flew off her. With a snake in mind, she quickly got up and ran out the room. The snake was described as black in color but unsure of its features. Unfortunately, her husband whom was sleeping beside her failed to witness the incident and the snake was said to have escaped. Post after she was bitten. She claimed to have a sustained pain over her right upper abdomen with pain score of 10/10. She also noticed mild bleeding originated from the bite mark. She was then went to the nearest clinic 10 minutes away home and was the further referred to the Emergency Department of a Hospital 1 hour later. Patient also noted to have progressive swelling with a blackish blister within 2 hours after the incident. Systemic review
● No nausea and vomiting ● No circumoral or gum paresthesia
● No drowsiness ● No inability to open mouth ● No headache ● No muscle pain ● No shortness of breath ● No limb weakness ● No blurry of vision ● No prolonged bleeding at the site ● No hypersalivation ● No drooping of the eyelids Upon arrival of the patient to the Emergency Department at 6.30 am, patient had one episode of vomiting. The vomiting was non-projectile, copious with food containing vomitus. Amount of the vomit was approximately half cup. No blood or pus was noted and it was associated with feeling nauseous. Patient also complained of having left limb weakness. However, it was not associated with neither pain nor numbness Upon further history taking, this was the first time patient got bitten by a snake. The patient’s father (who also lives in the house) shared that she found the snake at the back of the house. It was described as a black and hooded snake, measuring approximately 1 meter long with a white ring feature at the back of its head. The snake was found and captured by JPAM when the patient was in ED. Picture was taken and it is a Cobra species (NAJA KAOUTHIA) The family just moved into a new bungalow that was surrounded by bushes. Other history, ● Past medical history → Patient had no known medical illness ● Past surgical history → Not done any surgeries before ● Allergy history → No known food or drug allergies ● Drug history → Not on any medication, traditional medication or any supplements ● Social history → Patient is an administrative officer, married and blessed with 4 children. Patient is not an IV drug user, not smoking and does not drink alcohol Missed History ● Where was the snake situated? ● Number of bites / strikes ● Duration of the bite ● What was done by the patient right after being bitten? ● What treatment was given by the primary healthcare? Physical Examination At ED, Patient oriented to time, place and person. GCS full= 15/15. She was able to speak in full sentences. Conscious. Not in respiratory distress. CRT< 2 secs. Warm peripheries
Vital signs
BP 155/100 mmHg
PR 115 bpm (good pulse volume, regular rhythm)
RR 22 breaths/ min
SpO2 100% ↓ RA
Temp 37 ℃
P/S 8/10 Lymph node No tenderness/ swelling
Respiratory Clear, equal air entry. No additional sounds heard
CVS Normal S1S2 sounds heard. No additional sounds
CNS No scars, muscle atrophy, fasciculations
Cranial nerve examination
CN I Intact CN VII Muscle of facial expressions intact
CN II intact CN VIII Intact
CN III CN IX Gag reflex present
CN IV CN X No deviated uvula No ptosis, no ophthalmoplegia
CN VI CN XI Intact
CN V Intact CN XII Intact
Bite site examination ● Seen at right hypochondriac region ● Size: 2x 2 cm ● Raised necrotic patch in centre with necrotic bullae (dermonecrosis) ● Erythema surrounding area ● No bruising ● Tender upon palpation ● Unable to visualise fang marks Investigations Investigations in ED 1. Full blood count 2. Electrolytes
Parameter Value Normal range Parameter Value Normal range
Platelets 290 150 - 400 x 10^9/L Magnesium 0.94 0.65 - 1.05 mmol/L 3. Renal profile 4. Liver function test Parameter Value Normal range - Normal Urea 4.2 2.8 - 7.2 mmol/L
envenomation Management Management in ED - IV Tramal 50mg STAT - IV Maxolon 10 mg STAT - Start 1 pint NS over 2 hours - IM ATT 0.5 mls STAT
- Missing: snakebite chart
Progression in ED Date/Time Clinical progress Management
4/1/2020 - No new complaint - To update RECS (Remote
7.47 am - Still nauseous but no vomiting. Envenomation Consultancy (Yellow zone) - Currently still having left leg weakness unable to Services) team to start Cobra Day 1 lift up her leg, not worsening, no pain or numbness. antivenin 5 vials. - No other weakness, no neurotoxicity - Start IV Rocephine 2g stat. - IV Morphine 2mg STAT. Examination - Monitor vital signs hourly. - BP: 160/90mmHg (Moderate hypertension) - Watch out symptoms of - PR: 96bpm neurotoxicity and hematotoxic. - SPO2: 99% under RA - Refer to medical. - Pain score : 6/10
Abdominal examination : No progression of the
dermonecrosis.
No new investigations done.
Date/Time Clinical progress Management
4/1/2020 - Currently still having left leg weakness - Given IV Morphine 1mg stat 9 am -O/w no other active complaint - To run 1 vial of 100cc NS of (Yellow zone) - No neurotoxicity, no hematotoxicity symptoms antivenom over 20 minutes Day 1 - Watch out for antivenom Examination allergic reaction - BP: 167/90mmHg (Moderate hypertension) - If no reaction, to continue - PR: 96bpm run 4 vials in 100cc NS - SPO2: 99% under RA over 30 minutes - Pain score : 6/10 - IVD maintenance 4 pint/24 hour Abdominal examination : No progression of the - Monitor vital signs dermonecrosis. - Observe response to antivenom No new investigations done. - Watch out symptoms of neurotoxicity and hematoxicity Management in ward Date/Time Clinical progress Management
4/1/2020 -admitted to medical ward To access bite mark, full CNS
6pm -no new active complaint of envenoming effect exam, ECG 6 hourly Day 1 vital signs monitoring 4 hourly Vital signs: GM QID - BP: 145/82mmHg (Moderate hypertension) IVD NS 3 pints over 24 hour - PR: 96bpm - SPO2: 99% under RA Start: - Pain score : 3/10 - IV Tramal 50mg TDS - IV maxolon 10mg TDS GM: 6.3 - IV ranitidine 50mg TDS - Iv rocephine 2g OD Abdominal examination : Tenderness at affected area Refer to surgical TRO abscess collection Missing: urine output monitoring Date/Time Clinical progress Management
7/1/2020 - No new active symptoms Discharged
7.14 pm - comfortable Day 4 -able to ambulate Cloxacillin 500mg QID to -No fever, no abdominal pain, no vomiting complete for 1/52
Vital signs: Daily dressing at KK
- BP: 136/79mmHg - PR: 73bpm (regular rhythm, good volume) TCA 1/52 for FBC , RP, -RR: 20bpm coagulation profile - SPO2: 99% under RA -Temperature: 37oC - Pain score : 0/10
Abdominal examination : blister ruptures,
erythematous surrounding bite site Discussion Venom: complex substance produced in a specialized gland of a living organism. Fx: to digest prey or defence. Contains protein (enzyme). Have molecular weight that are large to cross capillaries, therefore lymphatic drainage is believed to be the main route. Components: ● Phospholipase A2 (cytotoxic, myotoxic and/or neurotoxic. ● Cardiotoxin: hemolysis and increased vascular permeability. ● Proteases: hydrolyzes supportive tissue structure ● Polypeptide toxin: disrupt neuromuscular transmission Classification of snake Elapidae: Cobra, King Cobra, Kraits, Coral Snakes, Sea Snakes and their allies.
Viperidae: True Viper & Pit
Vipers. (have long fangs) Natricidae: do not cause significant harm to human except for red-necked keelback. Cobra (Ular Kraits (ular senduk/ Ular Coral Snake katang/katam) senduk sembur) Calliophis sp. King Cobra (Ular Bungarus sp. Naja kaouthia tedung selar) Paralysis Ophiophagus hannah Paralysis Pain swelling, tissue dmg, Tissue dmg paralysis, Sea Snake (ular laut) Local necrosis Cardiac Paralysis dysarrhythmia Rhabdomyolysis (causing renal failure) & hyperK Paralysis Malayan Pit Viper (Ular Kapak Mountain Pit Viper Trimeresurus complex bodoh) (ular kapak gunung) sp. (ular kapak bakau, Pain, swelling, Same as MPV Tioman, Cameron) bruising, necrosis, Same as MPV bleeding.
Pain , swelling Lyocodon - common house snake Pytas - Rat snake (Ular Reticulated phyton (Ular tikus) sawa) Malayophyton Non-Venomous
Boiga - cat snake (Ular
cincin emas)
Chrysopelea - tea snake
(Ular pokok ) Can fly Approach to a patient with alleged/confirmed snake bite
RECS: Remote envenomation
consultation services.
24-h on call consultation
service. / FB/ Texts Clinical Assessment History:
1. Date and time (to monitor progress of signs and symptoms)
2. Where (knowledge of geolocation of Malaysian indigenous snake may give clue) 3. How (what is the patient doing before, situation of the snake, behaviour of the snake, number of bites/strike, duration, what happen to it, description, picture) 4. Where (manipulation or treatment given - tourniquet, cutting the wound, application of traditional medicine) 5. What (Medication given or procedures done) Clinical features 1. General : nausea, vomiting, malaise, abdominal pain, weakness, drowsiness, prostration. 2. Cardiovascular: faint, lightheadedness, collapse, shock, hypotension, cardiac arrhythmias, pulmonary oedema. 3. Bleeding and clotting d/o: prolonged bleeding, petechial rashes 4. Neurological: early sign is ptosis. Ophthalmoplegia, paralysis of facial muscle, other CN, nasal voice, aphonia, dysphagia. Examination Resuscitation Airways, breathing Assess local wound, and control bleeding
General Assess Vitals: BP, PR, RR, SP02. PS,
Temperature
Bite site examination Look for puncture wound (fang/teeth marks)
Swelling, inflammation, bruising, blistering Initiate RPP measurement Do not mark the wound with permanent marker (use tape) Take serial good quality pictures
Lymph node Palpate for tenderness or enlargement
Systemic signs General (N/V), neurotoxic effect,
coagulopathy, rhabdomyolysis Investigations 1. Coagulation profile : APTT/PT and INR, Fibrinogen level and D-Dimer. Repeat 6 hourly for suspected pit viper cases. 2. FBC: Platelet decreased, or drop in haemoglobin 3. Renal profile: Serum creatinine TRO renal failure. Electrolyte imbalance. 4. Creatine kinase: early detection of rhabdomyolysis 5. Urinalysis: myoglobinuria, hematuria, proteinuria. 6. LFT: Mild hepatic dysfunction is reflected in slight increase in serum enzymes after severe local muscle damage. 7. ECG: to detect arrhythmia involving Naja sp bite 8. ABG: monitor respiratory function, detect metabolic acidosis in RF. Arterial puncture is C/I in patients with suspected coagulopathy (viperidae). 9. Non-venomous snakebite - clinical sign and symptoms. May not require blood ix. 20 minute whole blood clotting test (20WBCT) 1. Place 2 ml of freshly sampled venous blood in small, heat cleaned, dry glass test tube. 2. Leave undisturbed for 20 minutes at ambient temp, then tip the tube once. If the blood has not clotted the patient may have coagulopathy. 3. May be repeated as necessary. 4. It is a quick bedside test for an unidentified bite or when a pit viper bite is suspected. 5. The test has been useful in a variety of clinical settings lacking laboratory instrumentation. Monitor 1. Swelling often progresses proximally from the bite site. 2. Ultrasound to determine the extent of tissue edema. 3. Serial Pain Score Progression (PSP) and Rate of Proximal swelling Progression (RPP) unit cm/hr Plan of Management 1. Triage - (critical/red zone?) (semi critical/yellow zone?) 2. A,B,C,D,E 3. Resuscitation 4. Administer oxygen 5. Consider oropharyngeal airway to aid airway, but don’t if gag reflex is still present. 6. Positive pressure ventilation via bag valve mask 7. Cardiopulmonary resuscitation (if cardiac arrest) 8. Cardiac monitor - arrhythmia Con’t ● Immobilize the bitten limb (examine closely) ● Position the affected limb in a neutral position or same level as heart. ● Anti tetanus toxins should be administered. ● If venom is exposed to the eye, perform eye irrigation with copious amount of NS. ● Analgesic (PCM every 4-6 hourly)/ Opioids (moderate to severe pain) ● Antivenom ● Anticholinesterase (Atropine) ● Antibiotics (with local tissue necrosis or extensive tissue injury) Antivenom therapy ● Definitive treatment/ ● Comprising immunoglobulin molecules or their fragments derived from the plasma of animals which has been immunised with venom. ● IgG, F(ab)2 fragments and Fab fragments. ● Administration: all administered IV. (Adrenaline should be prepared in readiness to treat anaphylaxis in response to antivenom). Appendix Snakebite chart Thank You!
