- •ICU Protocols
- •Preface
- •Acknowledgments
- •Contents
- •Contributors
- •1: Airway Management
- •Suggested Reading
- •2: Acute Respiratory Failure
- •Suggested Reading
- •Suggested Reading
- •Website
- •4: Basic Mechanical Ventilation
- •Suggested Reading
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Websites
- •7: Weaning
- •Suggested Reading
- •8: Massive Hemoptysis
- •Suggested Reading
- •9: Pulmonary Thromboembolism
- •Suggested Reading
- •Suggested Reading
- •Websites
- •11: Ventilator-Associated Pneumonia
- •Suggested Readings
- •12: Pleural Diseases
- •Suggested Reading
- •Websites
- •13: Sleep-Disordered Breathing
- •Suggested Reading
- •Websites
- •14: Oxygen Therapy
- •Suggested Reading
- •15: Pulse Oximetry and Capnography
- •Conclusion
- •Suggested Reading
- •Websites
- •16: Hemodynamic Monitoring
- •Suggested Reading
- •Websites
- •17: Echocardiography
- •Suggested Readings
- •Websites
- •Suggested Reading
- •Websites
- •19: Cardiorespiratory Arrest
- •Suggested Reading
- •Websites
- •20: Cardiogenic Shock
- •Suggested Reading
- •21: Acute Heart Failure
- •Suggested Reading
- •22: Cardiac Arrhythmias
- •Suggested Reading
- •Website
- •23: Acute Coronary Syndromes
- •Suggested Reading
- •Website
- •Suggested Reading
- •25: Aortic Dissection
- •Suggested Reading
- •26: Cerebrovascular Accident
- •Suggested Reading
- •Websites
- •27: Subarachnoid Hemorrhage
- •Suggested Reading
- •Websites
- •28: Status Epilepticus
- •Suggested Reading
- •29: Acute Flaccid Paralysis
- •Suggested Readings
- •30: Coma
- •Suggested Reading
- •Suggested Reading
- •Websites
- •32: Acute Febrile Encephalopathy
- •Suggested Reading
- •33: Sedation and Analgesia
- •Suggested Reading
- •Websites
- •34: Brain Death
- •Suggested Reading
- •Websites
- •35: Upper Gastrointestinal Bleeding
- •Suggested Reading
- •36: Lower Gastrointestinal Bleeding
- •Suggested Reading
- •37: Acute Diarrhea
- •Suggested Reading
- •38: Acute Abdominal Distension
- •Suggested Reading
- •39: Intra-abdominal Hypertension
- •Suggested Reading
- •Website
- •40: Acute Pancreatitis
- •Suggested Reading
- •Website
- •41: Acute Liver Failure
- •Suggested Reading
- •Suggested Reading
- •Websites
- •43: Nutrition Support
- •Suggested Reading
- •44: Acute Renal Failure
- •Suggested Reading
- •Websites
- •45: Renal Replacement Therapy
- •Suggested Reading
- •Website
- •46: Managing a Patient on Dialysis
- •Suggested Reading
- •Websites
- •47: Drug Dosing
- •Suggested Reading
- •Websites
- •48: General Measures of Infection Control
- •Suggested Reading
- •Websites
- •49: Antibiotic Stewardship
- •Suggested Reading
- •Website
- •50: Septic Shock
- •Suggested Reading
- •51: Severe Tropical Infections
- •Suggested Reading
- •Websites
- •52: New-Onset Fever
- •Suggested Reading
- •Websites
- •53: Fungal Infections
- •Suggested Reading
- •Suggested Reading
- •Website
- •55: Hyponatremia
- •Suggested Reading
- •56: Hypernatremia
- •Suggested Reading
- •57: Hypokalemia and Hyperkalemia
- •57.1 Hyperkalemia
- •Suggested Reading
- •Website
- •58: Arterial Blood Gases
- •Suggested Reading
- •Websites
- •59: Diabetic Emergencies
- •59.1 Hyperglycemic Emergencies
- •59.2 Hypoglycemia
- •Suggested Reading
- •60: Glycemic Control in the ICU
- •Suggested Reading
- •61: Transfusion Practices and Complications
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Website
- •63: Onco-emergencies
- •63.1 Hypercalcemia
- •63.2 ECG Changes in Hypercalcemia
- •63.3 Superior Vena Cava Syndrome
- •63.4 Malignant Spinal Cord Compression
- •Suggested Reading
- •64: General Management of Trauma
- •Suggested Reading
- •65: Severe Head and Spinal Cord Injury
- •Suggested Reading
- •Websites
- •66: Torso Trauma
- •Suggested Reading
- •Websites
- •67: Burn Management
- •Suggested Reading
- •68: General Poisoning Management
- •Suggested Reading
- •69: Syndromic Approach to Poisoning
- •Suggested Reading
- •Websites
- •70: Drug Abuse
- •Suggested Reading
- •71: Snakebite
- •Suggested Reading
- •72: Heat Stroke and Hypothermia
- •72.1 Heat Stroke
- •72.2 Hypothermia
- •Suggested Reading
- •73: Jaundice in Pregnancy
- •Suggested Reading
- •Suggested Reading
- •75: Severe Preeclampsia
- •Suggested Reading
- •76: General Issues in Perioperative Care
- •Suggested Reading
- •Web Site
- •77.1 Cardiac Surgery
- •77.2 Thoracic Surgery
- •77.3 Neurosurgery
- •Suggested Reading
- •78: Initial Assessment and Resuscitation
- •Suggested Reading
- •79: Comprehensive ICU Care
- •Suggested Reading
- •Website
- •80: Quality Control
- •Suggested Reading
- •Websites
- •81: Ethical Principles in End-of-Life Care
- •Suggested Reading
- •82: ICU Organization and Training
- •Suggested Reading
- •Website
- •83: Transportation of Critically Ill Patients
- •83.1 Intrahospital Transport
- •83.2 Interhospital Transport
- •Suggested Reading
- •84: Scoring Systems
- •Suggested Reading
- •Websites
- •85: Mechanical Ventilation
- •Suggested Reading
- •86: Acute Severe Asthma
- •Suggested Reading
- •87: Status Epilepticus
- •Suggested Reading
- •88: Severe Sepsis and Septic Shock
- •Suggested Reading
- •89: Acute Intracranial Hypertension
- •Suggested Reading
- •90: Multiorgan Failure
- •90.1 Concurrent Management of Hepatic Dysfunction
- •Suggested Readings
- •91: Central Line Placement
- •Suggested Reading
- •92: Arterial Catheterization
- •Suggested Reading
- •93: Pulmonary Artery Catheterization
- •Suggested Reading
- •Website
- •Suggested Reading
- •95: Temporary Pacemaker Insertion
- •Suggested Reading
- •96: Percutaneous Tracheostomy
- •Suggested Reading
- •97: Thoracentesis
- •Suggested Reading
- •98: Chest Tube Placement
- •Suggested Reading
- •99: Pericardiocentesis
- •Suggested Reading
- •100: Lumbar Puncture
- •Suggested Reading
- •Website
- •101: Intra-aortic Balloon Pump
- •Suggested Reading
- •Appendices
- •Appendix A
- •Appendix B
- •Common ICU Formulae
- •Appendix C
- •Appendix D: Syllabus for ICU Training
- •Index
Snakebite |
71 |
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Dhruva Chaudhry, Inder Paul Singh, and Surcharita Ray
A 20-year-old male patient presented with history of diffuse abdominal pain, myalgias, difficulty in swallowing, and pooling of secretions. He also complained of difficulty in breathing and diplopia with acute onset drooping of eyes. He was conscious, oriented to time and space, with a respiratory rate of 12/min and a single breath count of 12. The power in all limbs was 4/5, but all reflexes were absent. He had ptosis, and the rest of the general and systemic examination was normal. He was absolutely normal the previous night, when he had slept on the floor.
Some snakebites result in envenomation. Most of the snakes are nonvenomous. The outcome of snakebite depends on numerous factors which include species of snake, the area of the body bitten, and the amount of venom injected.
Step 1: Initial resuscitation and assessment
Airway
•Management of airway is very important in snakebite.
•The patient should be assessed for any pooling of secretions or respiratory depression with a single breath count of less than 10 and if present should be immediately intubated following the general indications of intubation.
D. Chaudhry, M.D., D.M. (*)
Department of Pulmonary & Critical Care Medicine, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
e-mail: dchaudhry@sify.com
I.P. Singh, M.D., D.N.B.
Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, New Delhi, India
S. Ray
Department of Medicine, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach, |
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DOI 10.1007/978-81-322-0535-7_71, © Springer India 2012 |
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Breathing
•The patient’s oxygenation status can be monitored with a bedside pulse oximeter.
•When the patient is in respiratory distress and not able to maintain oxygenation, he/she should be put on assisted ventilation.
Circulation
•Obtain a good peripheral line and start intravenous fluids.
•Be careful while venipuncturing in patients with coagulopathy.
Step 2: Take detailed history
•Detailed history such as the type of the snake color, length, timing of bite, provoked or unprovoked bite, and first-aid measures done should be taken.
•Patients with snakebite usually present with history of sudden onset of generalized weakness, with diplopia, difficulty in swallowing, pooling of secretions, ptosis, abdominal pain, and diffuse myalgias.
•Ask for local swelling or pain in the body and bleeding from any site including cardiovascular collapse.
Step 3: Perform physical examination
•A comprehensive general physical and neurological examination should be performed in all patients with suspected snakebite.
•The examination may reveal generalized motor weakness with sluggish deep tendon reflexes.
•There may be ptosis and both internal and external ophthalmoplegia giving a false impression of brain stem dysfunction. However, the patient responds to commands by using the frontalis muscle and orbicularis oculi.
•Usually, there are no local reactions in neuroparalytic snake envenomation (krait); however, in cobra bite, severe local reaction can be seen.
•The differential diagnosis of any patient presenting with sudden onset of neurological deficit with respiratory compromise is enumerated in Table 71.1.
Table 71.1 Differential diagnosis of acute neurological weakness
Acute inflammatory demyelinating polyradiculoneuropathy (AIDP, i.e., LGB syndrome)
Transverse myelitis
Periodic paralysis (hypokalemic, hyperkalemic, normokalemic)
Acute myasthenic crisis
Organophosphorus poisoning
Hypomagnesemia and hypophosphatemia
Hypoglycemia
Acute intermittent porphyrias
Polymyositis/dermatomyositis
Tick paralysis
Head/spinalcord injury
71 Snakebite |
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569 |
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Table 71.2 Severity of snakebite |
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|
Severity |
Local findings |
Systemic findings |
Nonenvenomation |
None or puncture wounds only |
None |
(dry bite) |
|
|
Mild |
Puncture wounds, pain, soft tissue |
None |
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swelling confined to the bite site |
|
Moderate |
Swelling beyond bite site |
Mild nausea, vomiting or fascicula- |
|
|
tions, paraesthesia, microscopic |
|
|
hematuria |
Severe |
Severe pain and swelling |
Respiratory failure or hypotension |
|
|
or bleeding |
•Look for features of local inflammation and if present on the status of circulation.
•Bleeding from the site may be the first manifestation of envenomation.
•Look for hematuria, epistaxis, hematemesis, and ecchymosis.
•Look for blood pressure and carefully follow and monitor.
Step 4: Severity of snakebite
Once a diagnosis of snakebite is made, the patient should be assessed for the severity, as enumerated in Table 71.2.
Step 5: Order investigations
•Complete hemogram with platelet counts, bleeding time (BT), coagulation time (CT), and clot retraction time (CRT) at 20 min or alternately slide test for observing coagulation of blood.
•Urine examination—RBCs in the absence of gross hematuria.
•Prothrombin time, INR, PTTK, fibrinogen level, creatinine kinase, fibrin degradation product, D-dimer.
•If urine is smoky and RBCs absent, look for myoglobulin to rule out myoglobinuria.
•Blood urea and serum creatinine levels should be regularly monitored in patients with renal failure.
•Serum electrolytes and blood gas analysis.
Step 6: Admit to the ICU
• Indications of ICU admission are mentioned in Table 71.3.
Step 7: General management
•All the patients should receive antitetanus toxoid, and the local wound should be cleansed with soap and water.
•The limb with the bite mark should be immobilized; however, no tourniquet should be tied.
•Keep the bitten limb lower than the heart as far as possible.
•Open the tourniquet, if applied outside, only when resuscitative measures are underway.
•Patients with mild features should be observed for at least 24 h.
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•Do not apply ice to the bite site.
•Routine use of antibiotics is not recommended.
Step 8: Specific management
Antisnake venom
•Antisnake venom (ASV) is prepared from horses’ serum.
•It can be monovalent or polyvalent.
•One milliliter of reconstituted antivenin neutralizes 0.6-mg venom of Indian cobra and Russell’s viper and 0.45 mg of common krait and saw-scaled viper.
•If the patient tolerates the ASV, then patients are usually given 50–100 mL of reconstituted ASV in serious envenomation as an infusion over 1 h, after premedication with chlorpheniramine maleate (5 mg) and ranitidine (50 mg).
•It can also be given as push especially when the patient is bleeding profusely at the rate not more than 2 mL/min.
•Patients with moderate and severe envenomation should be given a test dose of ASV intradermally.
•Patients should be observed for any reaction to the ASV.
•ASV will not have a dramatic effect in neuroparalysis. Low-dose ASV is as effective as high dosage in neuroparalytic snake envenomation.
•ASV will however have dramatic effect in stopping bleeding in coagulation abnormalities.
•The patient should be regularly assessed for any signs of reaction to ASV.
•ASV should be given till the patient has no bleeding manifestation or platelet counts rise above 50,000 and resolution of paralysis.
Step 9: Watch for reaction
•ASV is a foreign protein. Therefore, allergic reactions including anaphylaxis are not unknown.
•An adrenaline syringe should always be kept ready before infusing ASV.
•In case the patient is sensitive to ASV or develops reaction to ASV during infusion, first stop the infusion of ASV.
•It should be followed by adrenaline—usual recommended dosage is 0.5 mg of 1:1,000 dilutions subcutaneously.
•Additional dosages of H1 (chlorpheniramine maleate) and H2 (ranitidine) blockers with hydrocortisone 100 mg, though later will take 4–6 h to act, should be given simultaneously.
•If needed, adrenaline can be repeated up to two to three dosages or an infusion can be started in dilution of 1:50,000.
•Hypotension is treated with fluids. Inotropes may be required in patients who had overt myocardial dysfunction.
Step 10: ICU management
•Initiate mechanical ventilation at appropriate time as it reduces the mortality significantly in neuroparalytic envenomation.