Snakes M Anto ED prov fellow MVH 12

Intro • 3000 snake bites per yr • Large proportion are dry bites or

Hx and exam • Bite site • Neurological • Haematological

Hx and exam Bite site: Usually painless May have fang marks Usually lacs/scratches Bruising

• - Early symptoms (<1 hr): Headache Irritability Nausea D+V Confusion Syncope (?

• - Symptoms (1 -3 hrs): CN paralysis Abdo pain Haemoglobinuria HT Tachycardia

• - Late sx (>3 hrs): Limb/resp paralysis Shock Myoglobinuria Death

Toxin syndromes • • [Syncope] VICC Neurotoxicity Myotoxicity + ARF

Sydney/NSW snakes • Brown snake: - Syncope, VICC • Red-bellied black snake: - VICC,

1 st aid • • • Do not wash site, do not suck out

Management • • - Critically ill patients Other patients IV access Bloods (? POC

Antivenom • • • What to give? How to give How much to give

AV indications • • - Absolute: Abnormal INR History of sudden collapse, seizure or

Further management • Disposition? • Further tests? • Discharge advice?

Summary • 1 st aid • AV if symptomatic, no pre-med (caution with adren)

References/resources • Snakebite and Spiderbite Clinical Management Guidelines (3 rd ed, 2014) • http:

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Snakes M Anto ED prov fellow MVH 12 Jan 2017

Intro • 3000 snake bites per yr • Large proportion are dry bites or nonvenomous • 200 -500 receive antivenom • 1 -2 fatal • 50% brown snake • 50% tiger/taipan/death adder

Hx and exam • Bite site • Neurological • Haematological

Hx and exam Bite site: Usually painless May have fang marks Usually lacs/scratches Bruising bleeding swelling Local tissue destruction uncommon with Aus snakes - Assoc lymphadenopathy • -

• - Early symptoms (<1 hr): Headache Irritability Nausea D+V Confusion Syncope (? 2 dary to hypotension)

• - Symptoms (1 -3 hrs): CN paralysis Abdo pain Haemoglobinuria HT Tachycardia Haemorrhage

• - Late sx (>3 hrs): Limb/resp paralysis Shock Myoglobinuria Death

Toxin syndromes • • [Syncope] VICC Neurotoxicity Myotoxicity + ARF

Sydney/NSW snakes • Brown snake: - Syncope, VICC • Red-bellied black snake: - VICC, paralysis, hypotension • Eastern tiger snake: - Hypotension, paralysis, VICC, seizures • Death adder: - Paralysis

1 st aid

1 st aid • • • Do not wash site, do not suck out venom Do not cut or incise bite PIB - 15 cm, elasticised, <4 hrs from bite Splint Immobilise How about head/neck/back?

Management • • - Critically ill patients Other patients IV access Bloods (? POC test) Urine ? Other tests

Antivenom • • • What to give? How to give How much to give Once AV given, what do we do with our PIB? What are potential complications?

AV indications • • - Absolute: Abnormal INR History of sudden collapse, seizure or cardiac arrest Any evidence of paralysis (ptosis +/- ophthalmoplegia earliest signs) Relative: Systemic symptoms (vomiting, headache, abdominal pain) Abnormal a. PTT Leukocytosis CK > 1000 U/L

Further management • Disposition? • Further tests? • Discharge advice?

Summary • 1 st aid • AV if symptomatic, no pre-med (caution with adren) • VDK does not tell you if the patient is envenomated • Look for subtle CN/eye signs • Check ADT status • Bloods/examination up to 12 hrs • Serum sickness

References/resources • Snakebite and Spiderbite Clinical Management Guidelines (3 rd ed, 2014) • http: //www. anaesthesia. med. usyd. edu. au/res ources/venom/snakebite. html • Wikipedia: List of fatal snake bites in Australia