🔘 SNAKE BITE

SNAKE BITE:

👉🏻 Introduction:-

- India estimates approx 2,00,000 bites and 35-50,000 snake bite deaths/year

- No reliable National statistics are available

- Males 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, result in negligible envenomation.

👉🏻Snake bite An occupational disease:-

- Farmers

- Snake charmers

- Plantation work

- Hunter

- Workers at site

- Fisherman

👉🏻 Classification of snakes:-

1) Poisonous

2) Non-Poisonous

1. Poisonous:-

a) Elapids:-

- Cobra

- King cobra

- Common krait

- Banded krait

- Coral

b) Vipers:-

- Common green pit

- Russell's viper

- Saw scaled viper

c) Sea snakes:-

- Hydrophiids

- Laticaudids

- Acrochordids

- Homalopsids

- Natricids

2. Non-Poisonous

👉🏻Type of snake:-

- In India, >200 species of snakes, only 52 are Poisonous.

- The bites of saw scaled viper and Russel's viper are of 70-80% Hemotoxic/Vasculotoxin

- Common krait and Indian cobra bites are mostly Neurotoxic(20-30%).

👉🏻 Venomous and Non venomous snakes:-

1) Venomous:-

- Triangle shaped head

- Elliptical pupil

- Pit

- Fangs

2) Venomous:-

- Rounded head

- Round pupil

- No fangs

👉🏻Local Sympotoms and signs in the bitten part:-

- Fang marks

- Local pain

- Local Bleeding

- Brushing

- Lymphangitis

- Lymph node enlargement

- Inflammation (swelling, redness, heat)

- Local infection, abscess formation

- Necrosis

👉🏻Haematological sign:-

- Necrosis of muscle tissue.

- Muscle tissue will begin to die throughout the body, a condition known as rhambdomyolysis.

- Dead muscle cells may even clog the kidney which filters out proteins. This, couoled with hypotension, can lead to acute renal failure, and if left untreated eventually death.

👉🏻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.

- The muscles flexing the neck may be paralyzed.

- A common symptom of a bite from a venomous snake is the presence of two puncture wounds from the animal's fangs.

👉🏻Do's and Don'ts:-

1) Do's:-

- Immobilize the affected limb.

- Apply basic first aid (wash the wound with soap and water).

2) Don'ts:-

- Take the patient to a tantrik or a snake charmer for treatment

- Suck the wound

- Cut the wound open

👉🏻 Medicolegal:-

- 39 code of Criminal procedure under:- Constitution of India article 21

- MLC to be initiated.

👉🏻Fatal dose and period:-

1) Fatal dose:-

- Dried form:-

Cobra:- 15mg

Krait:- 6mg

Viper:- 20mg

Saw scaled viper:- 8mg

- Quantity injected in one bite:-

Cobra:- 200-350mg

Krait:- 20mg

Viper:- 150-200mg

Saw scaled viper:- 25 mg

2) Fatal period:-

- Cobra:- Few minutes to few hours

- Viper:- Few day

- Sea snake:- Not fatal

👉🏻ASV:-

- ASV is Ig purified from the serum/plasma of a horse/sheep immumised with the venoms of one or more species of snake

- Monovalent/Polyvalent

- The ASV in India is a polyvalent type which is active against the commonly found snakes in India including the four.

- Average dry weight of venom injected:- 63+/-7 mg by Russell's viper or cobra

- Each vial neutrilises the venoms of:-

• 6 mg cobra

• 6 mg Russell's viper

• 4.5 mg of Krait

• 4.5 mg of Saw scaled viper

- Initial dose should be 8-12 vials

- Snake inject same amount of venom into children dose of ASV is same as adults.

🔘FOOD POISONING

 *Food  Poisoning* 

👉🏻 *Introduction* :-

Food - poisoning is an acute gastro-enteritis caused by the ingestion of the food or drink contaminated with either living bacteria or their toxins or inorganic chemical substances and poison delivered from the plant and animals

👉🏻 *Aetiology* :-

1- Poisoning due to bacterial & Toxic.

2- Poisoning due to vegetable origin

Mushrooms (Poisonous) Lathyrus sativa (Khesari dal)etc.

3- Poisoning due to Animal origin.

4- Chemical: Accidentally or intentionally added poisonous

chemical products 

on radio nucleotide.

👉🏻 *Food Poisoning is* *Characterised by-* 

1- Simultaneous illness of many persons at the same time.

2- History of common food intake by all patient.

3- Common signs & symptoms in all patient.

👉🏻 *Bacterial Food* *poisoning* :-

Bacterial Food

poisoning is of

three types

 1- Infection type

2- Toxic type

3- Botulish

👉🏻 *Infection type* 

Infection type of food poisoning result from ingestion of microorganism that multiply in the gastrointestinal tract.

e.g. Salmonella & Shigella group.

👉🏻 *Signs & Symptoms:-* 

1- Nausea

2- Vomiting

3- Abdominal pain

mucus

4- Watery diarrhoea stained with blood or

Diarrhea vs Dysentery

5-Muscular weakness

6-Fever

👉🏻 *Toxic type :-* 

Toxic type of food poisoning occurs by a strain of organism that produce enterotoxin, e.g. Staphylococci, proteus vulgaris,

Streptococcus viridians,Clostridium welchii etc.

Food such as milk, custard, egg & previously prepared meat dishes are the chief sources.

👉🏻 *Sign and symptoms :-* 

1- Salivation.

2- Acute gastroenteritis.

👉🏻 *Treatment* 

1- Gastric lavage

2- Liquid paraffin 15-30ml/day,

3- Lactulose 15ml/day

4- Glucose saline infusion to eliminate toxics from the system.

5- Antibiotics are given depending upon causative organism.

e.g. Salmonella group-Chloramphenicol 1-3gm daily four divided doses.

5- The rest of the treatment is symptomatic.

👉🏻 *Post-mortem* *appearances* :-

1- the mucosa of the alimentary canal is inflamed,congested & ulcerated.

2- Fatty degeneration of liver.

3- Internal organs may be congested.

4- the causative organism can be isolated from the blood viscera.

👉🏻 *Botulism* :-

Botulism type of food poisoning is caused by the ingestion of exotoxins of the clostridium botulinum contained in the

undercooked food, potted meats, tinned fish, canned acidic, vegetables & fruits etc.

Action: the toxic inhibits acetylcholine & paralyses the muscles by blocking the nerve impulse at the myoneural junction.

👉🏻  *Signs & Symptoms* :-

Dry throat

Difficulty in swallowing & speech

Diplopia

Constipation

Hypothermia

Respiratory insufficiency.

Urinary Retention

The patient is conscious till death

The gastrointestinal symptoms like nausea, vomiting, abdominal pain are rare in

botulism type of poisoning.

Diagnosis : Diagnosis of botulism can be made by the isolation of

the bacillus from food patients vomit, faeces or viscera.

*Fatal dose :* 5gm or even less.

 *Fatal period :* 24-48 hours.

 👉🏻 *Treatment* :-

1- Gastric lavage

2- Polyvalent botulism antitoxic (type A,B & E) one vial by slow 1.V.

in normal saline one vial I.M.

 It should be repeated at 2-4 hours

intervals I.V.

3- 50ml Botulism immune globulin (BIG) 1.V. daily. Till the patient

recovers.

4- Liquid paraffin 15-30ml/day, Lactulose 15ml/day.

5- maintain fluid

6- Artificial respiration. If needed.

👉🏻 *Post-mortem* *appearances* :-

1- Congestion & hemorrhage in kidney, liver & meninges

2- Degenerative changes in the liver & kidneys.

3-Histological examination of the organs may show thrombosis.

4- The causative organism can be isolated from viscera.

The golden rules for prevention of food

poisoning

1-Choose foods processed for safety.

2-Cook food thoroughly.

3-Eat cooked food immediately.

4-Store cooked food carefully.

5- Reheat cooked food thoroughly.

6-Avoid contact between

cooked and raw food.

7-Wash hands repeatedly

using lots of friction.

8-Keep all kitchen surfaces

always clean. Wash dishes

and cutting board after

contact with raw meat or

eggs.

9- protect foods from

insects, rodents and

other animals.

10-use safe water.