CASE

DISCUSSION
MANAGEMENT OF SNAKE
BITE IN ED
CASE 1
 11 Malay girl presented on 4/7/14 at
8.21pm
 History of snake bite over left ankle
while playing firecracker in front of her
house around 8pm
 She denies shortness of breath ,
numbness or weakness , swelling of the
leg ,bleeding tendency and able to
ambulate
 On examination patient alert and
conscious
 Not tachypnoec , no ptosis
 Blood pressure: 124/77
 Pulse rate:134
 Spo2:100%
 Lung , CVS, abdomen was normal
 Left ankle :

-4 bites mark seen at medial malleolus

-no swelling , no redness
-no bleeding from bite site
 Relative bring the
snake together with
patient
 The snake image
shown to the ED
specialist
 Snake species
recognized as
Homolopsis Buccata-
non venomous
 Diagnosis:

-alleged snake bite with local reaction

 Management:

-IM ATT 0.5mls stat

-Iv ketorolac 30mg
-patient send to observation ward while
awaiting for blood investigation
 Investigation:

FBC : Twc=9.5, Hb=13.3, plt=310

BUSE: 3.3/137/3.2/104, CREAT:47
PT:13.6, APTT:36.1, INR:1.01
 Disposition:

-she was discharge home after blood

investigation review was normal
CASE 2
 23 years old Malay female JPAM staff
presented to ED on 4/6/14 at 4.18pm
 She was spitted by venom (spitting
cobra snake) over face while trying to
put a caught snake into a bag around
11.30am
 Shecomplaints of pain and gritty
sensation of left eye with watery
discharge
 She went immediately to Klinik
Kesihatan and her eye was irrigated
with 1 pint NS
 She then was referred directly to
ophthalmology clinic (eye casualty
clinic) and her left eye was irrigated with
3 pint NS
 Otherwise no shortness of breath, no
bleeding tendency
Cont.
 On examination patient alert not tacypnoec
 Pupil 3mm reactive
 Blood pressure:136/72
 Pulse rate:90
 Spo2:100%
 Lung , CVS , abdomen was normal
 Left eye examination: redness , watery
discharge , no ptosis , vision intact
 Management:

- left eye irrigation with 3 pint NS

- topical analgesic alcaine 0.5% applied
 Investigation:

FBC: twc=9.8,hb=13.8,plt=308
BUSE:3.2/143/4.1/106
CREAT:43
PT=14.2,INR=1.07,APTT=23.8
 Disposition: she was referred to
ophtalmology team and was send to 5B
for review
Ophtalmology review
 She was seen by ophtalmology mo and
noted reduced visual acuity on left eye
6/9,upper lid mild swollen, conjunctiva
injected and stained about 4mm x 3mm
just next to the limbus at 7-8 o’clock
 She was treated as new ocular trauma
with LE grade 1 chemical injury
 She was admitted for observation for 1
day
 She was discharge with

- g maxidex qid
- g ciloxan 4hrly
- g artificial tears free preservative 2hrly
- g homotropine tds
 given tca clinic x 1/52 ( 9/6/14)
Ophtalmology clinic review
 Patient was review during TCA after 1/52
post injury
 There was no more eye pain , discharge,
swelling or reduce vision
 On examination her visual acuity on left
eye was 6/6,lids clean , conjunctiva
white and cornea clear
 She was discharge with g.maxidex tds,g
ciloxan tds and given tca prn
Case 3
 23 years old Orang Asli Male presented
to ED HSNZ on 2nd June 2014 at 4.32pm
 He work as photographer for Malaysia
NGO researcher group
 He was bitten by snake over his left
medial leg at Sanctuari Kelah (Tasik
Kenyir) around 8am
 He complaints of pain over left medial
region
 The pain score was 3/10 which was
localised and non radiating
 However it was not swollen until 3pm
 Otherwise no bleeding tendency , no
neurological manifestation , no muscle
pain , no shortness of breath
 Hedescribed the snake as green in
colour, red tail , triangular head and 5
feet long which match with the green pit
viper
 Ittakes about 3hr from Sanctuari Kelah
to main Jetty
 and 3 hr more to the HSNZ
Upon arrival at ED HSNZ at 4.32pm
(8 hr 32min post bite)
 On examination patient alert and conscious
 Vital sign:

BP=164/98,
PR=89,
SPO2=100%,
RR=22
 CVS:DRNM
 P/A: soft , no tender

 lung : clear
 Left lower limb :
 swollen from DIPJ up to just above the knee joint

 presence of 2 bite mark

 surround bite area bluish
 no active bleeding from bite area
 tender upon palpation

 sensation reduce due to swelling

 DPA/PTA not palpable
 SPO2 of all toes 100%

 Calf circumference : larger compare to normal side

 Inguinal lymph nodes palpable over the left side, tender
 Diagnosis :
Alleged snake bite with local
envenoming
 Local painful swelling involving more
than half of the left lower limb within 48
hours of the bite
 Development of tender left inguinal lymph
nodes
Treatment
 He was started on nasal prong oxygen
3L/min
 2 large bore iv cannula inserted
 iv morphine 2mg + 2mg given
 At 5.30pm 3 vials of hemato polyvalent
diluted in 500cc NS was started and run
in 1 hr
 Patient develops rashes over cheek , left arm
and left lower limb after 15min of antivenom
infusion
 No sob
 antivenom infusion was withold for 10min and
iv hydrocortisone 200mg, iv piriton 10mg and
iv ranitidine 50mg given
 The antivenom was started back with
400cc/hr and remaining polyvalent completed
at 7.15pm
 Patientwas referred to medical,
ortopedic and anesthesiology
 He was admitted to ICU for closed
observation
In ICU

 Left lower limb examination : swollen up

to thigh, palpable pulses, non tender,
able to wiggle toes and lift up the leg,
SPO2 of all toes 100%
 was given another 3 vials of Hemato
Polyvalent, no allergic reaction reported

 Was transferred out to general ward after

1 day in ICU
IN THE WARD
 Worsening coagulation profile, renal
profile and reduction of haemoglobin
level
 COAGULATION PROFILE
2/6 3/6 3/6 4/6 5/6 6/6 7/6 8/6 9/6

PT null null 23.3 49.8 null null 40.5 23.8 0.95

INR null 4 2.07 2.79 null null 4.31 2.13 2.15

APTT null null 36.3 29.2 null null null 53.4 65.7
 RENAL PROFILE
2/6 3/6 4/6 5/6 7/6 8/6 11/6 15/6 18/6
UREA 6.8 7.6 13.5 12.8 11 10.4 7.3 6.3 7.1
CREAT 237 228 309 296 241 263 229 201 204
POTASSIUM 4.2 4.4 4.6 3.8 3.6 4.5 3.5 3.4 3.8
SODIUM 137 136 130 137 137 138 141 141 139
 FULL BLOOD COUNT
2/6 3/6 4/6 5/6 7/6 8/6 12/6 13/6 16/6
Hb 12 10 9.5 7.7 6.7 7.3 5.9 9.5 9.7
Platele 201 158 169 128 134 130 120 170 168
t
TWC 18.9 17.2 19.3 14 7.8 8.7 6.3 8.0 8.2
 Worsening renal function
 Referred to nephro team
 AKI sec to nephrotoxin (non oliguric phase) sec to
pit viper sting
 KUB USG : bilateral renal parenchyma disease

 Worsening coagulopathy
 Coagulopathy sec to hematotoxin
 Resolved after 13 days of admission
 Was given Haemato Polyvalent total of 11 vials
 Dropping of Haemoglobin level
 Was tranfused with 2 pints PC (Hb : 5.6 9.5)

 Tender, erythematous and swollen of left lower

limb
 U/S lower limb : cellulitis with myositis changes or
possible early intramuscular abscess or
hematoma formation of left calf
 Was given IV fortum 1g BD and IV Cloxacillin 500
mg QID
 Skin nick by ortho team : no pus
 After 13 days of admission, condition
improved
 Left lower limb swollen subsided
 Coagulopathy resolving
 Urea reducing but creatinine remain high
 Static Hb 9.5 g/dl

 Was discharged after 17 days of

admission with nephro TCA
Thank you