Management of Snake Bite Victims with Respiratory Paralysis in ICU

Posted by e-Medical PPT Monday, July 30, 2012
India estimates in the region of 200,000 bites and 15-20,000 snake bite deaths per year
Originally made in the last century, are still quoted. No reliable national statistics are available.
Males are bitten almost twice as often as females
Majority of the bites being on the lower extremities.
50% of bites by venomous snakes are dry bites. that result in negligible envenomation

Syndromic approach
No local signs with Neuro-toxicity- Krait
With or with out local signs and Neuo-toxicity-Cobra
With or with out Neurotoxicity and local signs and hemotoxicity-Rusell’s Viper
Local signs with hemotoxicity-Saw Scaled Viper

Snake bite and Respiratory paralysis
Neuromuscular paralysis-blockade of neuromuscular transmission.
Cobra-  post-synaptic
Krait- pre-synaptic

Krait- Pre-synaptic action
1) Inhibiting the release of acetylcholine from the presynaptic membrane
2) Presynaptic nerve terminals exhibited signs of irreversible physical damage and are devoid of synaptic vesicles
3) Antivenoms & anticholinesterases have no effect
Paralysis lasts several weeks and frequently requires prolonged Mechanical Ventilation. Recovery is dependent upon regeneration of the terminal axon.

Cobra –post-synaptic
alpha-neurotoxins
“Curare-mimetic toxins’’
Bind specifically to acetylcholine receptors, preventing the interaction between acetylcholine and receptors on postsynaptic membrane.
Prevents the opening of the sodium channel associated with the acetylcholine receptor and results in neuromuscular blockade.
ASV -rapid reversal of paralysis.
Dissociation of the toxin-receptor complex, which leads to a reversal of Paralysis
Anticholinesterases reverse the neuromuscular blockade

Neurotoxic envenoming-Examination
Ask the patient to look up and observe whether the upper lids retract fully.
Test eye movements for evidence of early external ophthalmoplegia .
Check the size and reaction of the pupils.
Krait can cause fixed, dilated non reactive pupils simulating brain stem death – however, it can recover fully
Ask the patient to open their mouth wide and protrude their tongue; early restriction often paralysis of pterygoid muscles.
The muscles flexing the neck may be paralysed, giving the “broken neck sign

What is ASV?
Antivenom is immunoglobulin (usually the enzyme refined F(ab)2 fragment of IgG) purified from the serum or plasma of a horse or sheep that has been immunised with the venoms of one or more species of snake.
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