rare complication of snake bite

RARE CASE OF SNAKE BITE

DR MANOHARI RM4 UNIT

HISTORY• A previously healthy 43 year old male

• Presented 6hrs after a snake bite in his right foot just below the medial malleolus

• Complains of pain around the site of bite• Chest pain with sweating of 1 hour duration• Abdominal Pain• Nausea

• No history of DM• No history of HTN• No history of cardiac disease• No history of Liver/Renal disease

EXAMINATION• Irritable• Confused• Anxious• Fang mark + just below Right medial malleolus• Cellulitis Right leg upto 5cm below the right knee joint – progressive• Profuse sweating

• No ptosis• No neck weakness• SBC ?• No hematuria /No excess Bleeding from wound

• Pulse rate 120/mt low volume thready• BP 70/40 mm Hg

• CVS S1, S2 Normal, Tachycardia +• RS BAE+ , Clear, Tachypneic, SpO2 95% with Room Air• P/A Epigastric tenderness +• NS Irritable, anxious , No FND

ECG

•CK – MB 85 IU/LNORMAL UPTO 25 IU/L

What to do..

• Rapid resuscitation with fluids ( crystalloids)• Anti tetanus toxoid• Antibiotics• Inotropes

ASV

THROMBOLYSIS

• Rowlands JB, Mastaglia FL, Kakalus BA, Hainsworth D. Clinical and pathological aspects of

a fatal case of mulga (Pseudechis australis) snakebite. Med J Aust 1969;1:226-30.

Copley AL, Banerjee S, Devi A. Studies of snake venoms on blood coagulation.

Thromb Res 1973;2:487-508.

Dissanayake P, Sellahewa KH. Acute myocardial infarction in a patient with Russell’s viper bite.

Ceylon Med J 1996;41:67-8.

Hoffman A, Levi O, Orgad U, Nyska A. Myocarditis following envenoming with viperae palaestinae in two horses.Toxicon 1993;31:1623-8.

Proposed mechanisms • DIC causing thrombus formation in coronaries• Direct vasculitis• Sarafotoxins causing coronary vasoconstriction• Coronary spasm due to endothelins in venom• Hypovolemic shock due to bleeding• Hypercoagulability in consumption coagulopathy• Hyperviscosity secondary to hypovolemia induced hemoconcentration• Direct cardiotoxic effect on myocardium

BACK TO THE CASE..

• Started on 10 vials of ASV• Blood pressure dropping• Maintained on boluses of Adrenaline• Patient had an episode of blood tinged vomiting (25-50ml)• 4 units FFP transfused

• 8 more vials of ASV issued under inotrope support• Patients chest pain reduced• Symptomatically better• BP improved to >110/70mm without inotropes in 12hrs• Chest clear

Admission

1 hr

5 hr

Day 2

Day 2

ECHOCARDIOGRAM• Mild Hypokinesia of inferior wall• Normal LV function

DAY S.CREATININE S.UREA

1 0.9 31

2 2.5 64

3 3.5 98

4 2.6 105

5 2.8 91

6 2.0 64

7 1.6 57

8 1.8 46

10 1.2 26

0 2 4 6 8 10 120

0.5

1

1.5

2

2.5

3

3.5

4

DAYS.

CRE

ATIN

INE

AT DISCHARGE• GC stable• No Complaints• Renal functions returned to normal• Cellulitis settled