User:Rajnish jaiswal/sandbox

General
Snake bite is a medical emergency and survival depends much on the appropriate first aid immediate transportation to the nearest health care facility.

First aid

 * 1) Reassurance of the victim is essential as most of them would certainly be terrified,all snake bite need not any treatment because most of them are not poisonous, complete bed rest is advised.
 * 2) The affected part is to be immobilized with a splint of sling in a functional position below the level of heart, if available firm binding of the splint with the crepe bandage can be very effective.
 * 3) Immediate transportation of the patient to the nearest health centre/clinic or hospital.
 * 4) The edge of the local swelling is marked with a pen for future assessment of progression or regression, to be watched every 15 -20 min, also circumferential measure are to be taken as several points above and below the bite - q 15-20 min.
 * 5) All harmful and time wasting treatment should be avoided and discouraged.

The following procedures are potentially harmful and should not be used

 * Suction by mouth/vacuum/venomex apparatus, cooling with ice and electric shock as it causes- tissue necrosis.
 * Incision, excision, cauterization, amputation of the bitten digit.
 * Instillation of KMnO4.
 * Tourniquets, ring constrictive bands, pads, bandages should not be applied.
 * However if a patient is bitten by a dangerous neurotoxic elapid (e.g. king cobra), where medical attention is likely to be delayed for 1-2 hrs, there is a risk that respiratory paralysis might develop en route to hospital.In this cases alone a tourniquet or a firm crepe bandage and splint should be applied to delay life threatening neurotoxicity.

history is obtained

 * Time elapsed from the time of bite.

*Whether symptoms of envenomation are present

 * local pain
 * nausea/vomiting
 * lethargy/weakness
 * circum-oral parasthesia, tingling of fingers/toes
 * metalic taste
 * breathlessness/blackout/bleeding

patiened is examined clinically for

 * vital sign
 * CVS,pulmonary and neurological status
 * Bleeding diasthesis
 * in cobra bite - earliest symptomof systemic envenomation is repeated vomitting.

early preparalytic symptom

 * contraction of frontalis
 * blurred vision
 * circum-oral parasthesia
 * headche
 * dizziness,vertigo
 * hyperventillation
 * congested conjunctiva

earliest paralytic symptom

 * ptosis
 * external ophthalmoplegia

in viper bite

 * local sign and symptoms are more prominent
 * first clinical evidence is bleeding diasthesis
 * persistent bleeding from wound
 * venupuncture sites
 * gingival sulci

blood for
these tests are repeated every 4 hourly in first twelve hours and then daily till the acute phase is over.
 * TLC/DLC/Hb/Platelet count
 * Urea/Creatinine/
 * electrolyte
 * Blood grouping and Cross matching,
 * Coagulation profile(PT/APTT/FIBRINOGEN) in sever cases,

MANAGEMENT
mild manifestation= 5 vials AVS. Moderate manifestation= 10 vials Severe manifestation= a5-20 vials, ininitial phase. b. systemic symptom disappear c. lab findings suggest containment of poisoning. In neurtoxic poisoning or cobra bite-neostigmine and mechanical ventilation is recquired.
 * 1) If the snake is confidently diagnosed as nonvenomous,the patient can be discharged after receiving a booster dose of tetanus toxoid.
 * 2) In case of suspected venomous snake= *i.v. line is secured with 5% dextrose.
 * 10 vials of antisnake venom should be procured and kept at hand.
 * After clinical assesment,if no feature of envenomation are found= the patient should be observed for 24 hrs before discharged.
 * if sign of envenomation is present - polyvalent anti snake venome solution is definite therapy.
 * The freeze dried powder is reconstituted with 10 ml saline.AVS is administered i.v. at 20 ml/kg/hr. initialy and then slowed later.
 * sensityvity test is done = there may be chances of anaphlactic reaction, so there is requirement of antihistaminic,corticosteroids, other resuscitation measure should be kept at hand.
 * If there is evidence progressive toxicity,more antivenom solution is to be infused till --a. local swelling regresses.
 * Moist oxygen inhalation
 * Tetanus toxoid and human tetanus immunoglobulin(HTIG)-500IU.
 * FFP or fresh blood transfusion in viper bite are recommeded adjunct.