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