A 30 years old man presented to ED after getting snake bite in his hand while trying to catch. He presented 30 minutes after the bite with mild pain at bite site , otherwise no other symptoms. Examination, and vitals signs were unremarkable apart from fangs mark at thumb, no swelling
This is the snake he is trying to catch
Q1. Is this a venoms snake? If yes what it is and what is the expected manifestations?
Q2 .What is your management plan for this patient?
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Tangled cont'
Thanks Mohd
This is actually one of the Saw-scaled viper (Echis Genus) also commonly known as carpet viper which one of the most common venomous snakes in Oman
Mechanism of toxicity depends on the type of snake and could be divided into hematotoxic ,myotoxic and neurotoxic
This patient need to be admitted for observation and monitoring of envenomation , Resources are having different period of observation from bite with no obvious envenomation due to delay manifestation of envenomation and can range from 8-24 hours . In Our National guidelines of poisonings observation period should be for 24 hours from bite.
The Management of this patient should include the following:
Obtain initial history to include circumstances of bite and symptoms
Allergy history, prior history of snakebite and the treatment
Reassure, asses ABCD ,obtain basic vitals and provide supportive treatment if needed
Clean the wound area cautiously with saline and administer tetanus prophylaxis, if indicated. Antibiotics only if signs of infection observed.
Analgesics to control the pain. Severe pain can be treated with narcotics.
Immobilize the bitten area and keep it at or just below heart level.
Measure the girth of the bitten area q2-4 hours in the first 12-24 hours of management to assess for local progression.
Send blood for an urgent coagulation profile, INR, CBC, UE, BS, LFT, DIC screen, blood group and save serum, urine for microscopy.
Do the 20-minute Whole blood clotting test
Mild-moderate envenomation: mild-moderate local signs of bite but no circulatory collapse or significant systemic bleeding, abnormal 20-minute whole blood clotting test (WBCT) and/or mild mod coagulopathy/or DIC (PT 15-50 S, INR < 3, PLT > 50,000, Fibrinogen > 0.75 g/dL)
Severe envenomation: severe local signs, systemic signs, circulatory collapse or systemic bleeding, severe coagulopathy/or DIC (PT > 50 S, INR > 3, PLT< 50,000, fibrinogen < 0.75 g/dL)
The following are the national guidelines for management of hematotoxic snake and the indication and doses of antivenom
References :
1- National Management Guidelines of poisoning Third edition 2018
Unfortunately, it is very venomous snake
1- This snake is Rattlesnake which consider as pit viper (from Crotalidae family). Even if the type of snake was undefined the triangle shape of snake head one feature of venomous. The clinical expected manifestation can be divided to local and systemic manifestations
· Local manifestation: pain, local edema (may cause compartment syndrome and spreads proximally) progressing to petechiae, bruising, bullae and skin necrosis
· Systemic manifestation :
o Early: weakness, nausea, fever, vomiting sweating, muscle fasciculations, hypotension
o Late: ↑ capillary permeability + coagulopathy → pulmonary edema, shock & death
o Pts may have IgE mediated reaction on repeat exposure → anaphylaxis
2- Management:
· Print and follow National guideline of snake bite.
· ABCD
· Close cardio monitoring
· Physical Exam:
o Bite area for fang marks, look for local manifactations (edema, petechiae, ecchymosis, bullae)
o Check distal pulse to the bite site
o neuro exam
o measure the circumference of the extremity at the site of
· Identify snake if possible
· Investigations: ECG, CBCd, CK, coag profile including D-dimer, fibrinogen, renal function, type & cross match x 4 units
· If signs of compartment syndrome, measure compartment pressure; if > 30 mmHg requires fasciotomy (antivenin may lower compartment pressures as well)
· Wound care and tetanus prophylaxis +/- Antibiotics
BUT we have to take in consideration
1-the type of snake which is very venomous
2-the presentation time
3- site of bit high risk of compartment syndrome
Currently pt fall in mild grade of envenomation (grade 1) which is dose not required antivenin
But he required 6-12 hours observation with lab repeated at 6 hours and 12 hours if there is no clinical manifestations
And consultation of toxicology medicine is required for possible early administration of antivenin
after consultation of toxicology may i give antivenin to prevent compartment syndrome ???