Management of Rural Snakebite: Lessons from Papua New Guinea by David Williams - CEO Global Snakebite Initiative

1. Management
of
Rural
Snakebites:
Lessons
from
Papua
New
Guinea
David
Williams
Charles
Campbell
Toxinology
Centre
School
of
Medicine
&
Health
Sciences
University
of
Papua
New
Guinea
CEO,
Global
Snakebite
IniGaGve
18/11/2012
1

2. PAPUA NEW GUINEA
Port Moresby
AUSTRALIA
18/11/2012
2

3. Charles
Campbell
Toxinology
Centre
• Mul*-­‐focal
applied
research
with
strong
focus
on
improving
the
clinical
management
of
snakebite
in
a
resource-­‐relevant
manner.
• Combines
clinical
research
with
applied
field
and
laboratory
studies,
health
worker
training
and
community
educa*on.
• Developing
capacity
for
local
an*venom
produc*on
• Developing
na*onal
treatment
protocols
and
clinical
guidelines.

9. 18/11/2012
9

13. Photo: Dr Wolfgang Wüster

14. Photo: Dr Wolfgang Wüster

15. Photo: Dr Wolfgang Wüster

16. Photo: Dr Wolfgang Wüster

17. Snakebite
in
remote
areas
• Many
rural
health
facili*es
are
not
in
a
posi*on
to
manage
snake
bite
pa*ents
because
of
a
lack
of
drugs,
equipment,
skills
and
specific
knowledge
• They
can
poten*ally
apply
good
first
aid,
provide
emergency
treatment
for
shock,
and
if
necessary
provide
suppor*ve
care
and
non-­‐invasive
airway
management
• In
these
situa*ons
pa*ents
will
need
to
be
sent
to
another
hospital
for
defini*ve
treatment
• All
health
centres
should
develop
and
maintain
a
clear,
pre-­‐exis*ng
plan
for
how
pa*ents
will
be
transported,
and
to
which
hospital
they
will
be
sent
18/11/2012
17

27. Successful
early
snakebite
management
• Excellent
outcomes
can
be
achieved
in
even
the
most
basic
care
environments.
• Snakebite
can
treated
in
remote
loca*ons
by
nurse
prac**oners.
• Medical
evacua*on
should
not
need
to
be
an
automa*c
process.
• Intensive
care
admission
is
avoidable.
• Training,
educa*on
and
appropriate
basic
resources
are
the
basic
requirements.

29. Be
prepared
for
snakebite
• Having
a
protocol
in
place
that
is
known
to
all
personnel.
• Stocking
adequate
appropriate
an*venom
if
possible.
• Have
an
organised
emergency
room.
• If
you
are
going
to
seek
advice
from
an
external
consultant,
have
their
details
in
a
place
where
anyone
can
find
them.
• Plan
early:
if
evacua*on
is
necessary
you
should
organise
it
sooner
rather
than
later

30. Have
a
protocol
in
place
• Systema*c
and
sequen*al
inves*ga*ons.
• Immediate
assessment
of
ABC.
• Thorough
history.
• Good
clinical
examina*on
to
demonstrate
specific
life-­‐
threatening
deficits:
– Threats
to
airway
and
breathing
(neurotoxic
signs)
– Bleeding
(seen
and
unseen)
– Other
defects
(severe
cytotoxicity,
shock)
• 20WBCT
• Be
realis*c
about
who
to
treat
and
who
to
refer.

31. Treatment
or
Referral
• Need
to
decide
as
quickly
as
possible
if
it
is
possible
to
treat
the
pa*ent
locally,
or
if
they
will
require
referral
to
hospital
elsewhere:
– Bites
with
no
signs,
or
minimal
local
swelling
and
no
other
signs
may
not
need
referral
– Bites
with
extensive
local
swelling
(>50%
limb)
or
very
severe
localised
swelling
(e.g.:
fingers/hands/toes/feet),
or
with
bleeding,
paralysis
should
be
referred
to
hospital
without
delay
• Referrals
need
to
be
well
planned
and
consequences
carefully
considered.
18/11/2012
31

32. Key
consideraHons
• There
should
always
be
a
clear
reason
for
pa*ent
referral,
and
this
should
be
recorded
in
both
the
pa*ent’s
notes,
and
in
the
referral
le^er.
• Pa*ent
transport
should
not
put
the
pa*ent
at
addi*onal
risk
or
reduce
the
level
of
pa*ent
safety
• Referral
should
be
to
a
facility
that
provides
a
higher
level
of
care
• Pa*ents
at
risk
of
life-­‐threatening
problems
such
as
bleeding,
neurotoxicity,
shock
or
renal
failure
should
always
be
accompanied
by
medical
staff
trained
in
basic
emergency
life
support
18/11/2012
32

33. Timing
of
medical
referrals
• A
pa*ent
who
needs
referral
should
be
send
onward
as
soon
as
possible
• Don’t
wait
for
complica*ons
to
occur!
• Specific
*ming:
– aaer
first
aid
(immobilisa*on
or
PIB)
applied
– once
you
have
resuscitated
Airway,
Breathing
and
Circula*on,
in
that
order,
to
the
best
of
your
ability
&
resources
• Do
not
wait
un*l
the
pa*ent
has
deteriorated
before
ini*a*ng
referral
or
they
may
die
enroute
• Early
referral
saves
limbs
and
saves
lives!
18/11/2012
33

34. Types
of
transport
• Carried
by
stretcher
• Private
vehicles:
– Motorcycles
– Ca^le-­‐drawn
carts
– Tractors
– Cars
and
trucks
• Ambulances
• Government
vehicles
• Boats
• Aerial
retrieval
in
rare
situa*ons
(i.e.:
military)
18/11/2012
34

35. Criteria
for
referral
(1)
• Does
the
health
facility
have
the
resources
to
treat
the
pa*ent?:
– Essen*al
drugs
and
medical
supplies
– Equipment
(diagnos*c,
treatment
delivery
and
life
support)
– Staff
with
the
necessary
knowledge
and
experience
to
provide
treatment
and
make
informed
decisions
• If
the
answer
to
any
of
these
points
is
no,
then
early
referral
to
a
be^er
facility
should
be
a
priority
once
the
pa*ent
is
stabilised
18/11/2012
35

36. Criteria
for
referral
(2)
• Will
referral
of
the
pa*ent
result
in
a
significant
improvement
in
pa*ent
care,
or
provide
access
to
an
essen*al,
but
locally
unavailable
medical
service?
– If
the
answer
is
yes,
then
referral
is
appropriate
– If
the
answer
is
no,
reconsider
referral
of
this
pa*ent
18/11/2012
36

37. PaHent
safety
(1)
• Will
the
safety
of
the
pa*ent
be
compromised
by
a^emp*ng
to
transport
them
to
another
facility?:
– Is
the
pa*ent
clinically
unstable?
• Is
there
severe
bleeding?
• Is
the
pa*ent
shocked?
• Does
the
pa*ent
has
airway
and
breathing
problems?
– Will
it
be
possible
to
provide
emergency
treatment
to
the
pa*ent
in
the
type
of
transport
that
is
available?
• If
not,
are
there
any
alterna*ves
available?
– Are
the
road
condi*ons
suitable
to
ensure
that
the
pa*ent
can
reach
the
referral
hospital?
• Is
there
a
risk
of
the
vehicle
gefng
bogged
or
stopped
by
floods
18/11/2012
37

38. PaHent
safety
(2)
• A
clinically
unstable
pa*ent
should
not
be
moved
un*l
the
immediate
risk
has
reduced:
– Shocked
pa*ents
or
those
with
severe
bleeding
require
adequate
fluid
resuscita*on
to
maintain
cerebral
perfusion
(i.e:
a
minimum
BP
of
80/60)
– Airway
and/or
breathing
support
for
paralysed
pa*ents
• Obtain
qualified
medical
advice
from
an
expert
– Consider
the
need
to
have
the
pa*ent
retrieved
by
ambulance
and
a
medical
team
• Is
it
safer
to
delay
referral
un*l
the
pa*ent
is
more
stable,
or
is
it
a
case
of
‘now
or
never’?
18/11/2012
38

39. Stabilising
shocked
or
bleeding
paHents
• Pa*ents
bi^en
by
some
species
of
viper
may
present
with
hypovolaemia
and
vasodilata*on
leading
to
hypotension
and
shock
• This
may
be
due
to
migra*on
of
circula*ng
fluid
into
the
swollen
limb,
or
may
be
the
result
of
external
or
internal
haemorrhage
• Emergency
resuscita*on
with
crystalloid
or
colloid
should
be
carried
out.
• Endeavour
to
maintain
a
minimum
blood
pressure
of
80/60
mmHg
18/11/2012
39

40. Stabilising
shocked
or
bleeding
paHents
• If
an*venom
is
available
it
should
be
given
without
delay
to
neutralise
circula*ng
toxins
that
contribute
to
coagulopathy
• Be
careful
not
to
overload
the
pa*ent
with
fluids
as
this
may
lead
to
addi*onal
complica*ons
• Pa*ents
in
whom
increased
capillary
permeability
is
suspected
may
benefit
from
administra*on
of
i.v.i.
dopamine
(2.5-­‐5.0
μg/kg/min)
• When
stable
transport
the
pa*ent
while
con*nuing
to
monitor
bleeding
and
blood
pressure,
and
with
adequate
intravenous
fluid
to
con*nue
treatment
18/11/2012
40

41. Treatment
of
Shock
(1)
• Specific
treatments
– Assess
for
&
treat
Airway
or
Breathing
problem
– Obtain
good,
large-­‐bore
IV
access,
if
not
available
– 20ml/kg
crystalloid,
saline
or
Ringer’s,
as
fast
as
possible
– eg.
a
50kg
person
should
be
given
20x50=1000ml
– eg.
a
15kg
child
should
be
given
20x15=300ml
– Repeat
the
vital
signs
frequently,
e.g.
every
10
minutes
– Give
high
flow
oxygen
(6-­‐15l/min)
– Repeat
the
infusion
if
the
pa*ent
is
s*ll
unstable
– Give
an*venom,
if
available
• Consider
whole
blood
replacement
aaer
40ml/kg
of
crystalloid,
if
there
is
heavy
bleeding
&
no
an*venom
is
available
18/11/2012
41

42. Treatment
of
Shock
(2)
• Specific
Treatments
– Treat
obvious
cause
• If
cause
is
an*venom
reac*on
(adrenaline,
promethazine,
hydrocor*sone)
• If
sep*c
shock,
give
broad
spectrum
IV
an*bio*cs
– Atropine
5-­‐20
mcg/kg
for
bradycardia
– Consider
dopamine
(5-­‐20mcg/kg/min)
18/11/2012
42

43. Treatment
of
Shock
(3)
• Intravenous
access
– Try
to
be
successful
as
soon
as
possible
– As
large
an
IV
cannula
as
possible
– Ideally
2
lines
– Use
femoral,
long
saphenous
or
external
jugular
if
necessary
– Avoid
causing
another
site
of
bleeding
– Intraosseus,
especially
in
child,
if
no
IV
access
in
first
few
minutes
18/11/2012
43

44. PaHents
with
airway/breathing
problems
• Protect
the
airway!
– Posture,
chin
lia
or
head
*lt
to
improve
air
entry
– Guedel’s
airway
devices
– Oropharyngeal
airways
– Laryngeal
masks
– Endotracheal
intuba*on
• Support
breathing
– Supplementary
oxygen
– Ambu
Bag
ven*la*on
– Mechanical
ven*la*on
• Transport
only
if
the
airway
is
secure
and
breathing
can
be
supported
by
trained
staff
18/11/2012
44

46. 15 mm connector
Broad
end
fits
under
pa*ent’s
mouth
Pointed
end
over
the
pa*ent’s
nose
Inflatable cushion

47. PosiHoning
of
the
Mask
Watch the position of the mask regarding the eyes

48. 1.
Place
mask
onto
face
&
spread
your
fingers
as
shown

49. 2.
Place
your
fingers
under
the
jaw
grasping
mandibular
margins-­‐
don’t
push
into
the
soT
Hssues

50. 3.
Double
handed
approach

52. ComplicaHons
of
BMV
• Ineffec*ve
oxygena*on:
hypoxia
• Gastric
infla*on
• Aspira*on
• Compression
of
eyeballs
– re*nal
detachment
• Compression
of
facial
and
infraorbital
nerves
• Complica*ons
related
to
oro-­‐pharyngeal
or
nasopharyngeal
airways
used

53. Laryngeal
Masks
LMA Supreme
Elliptical airway tube
prevents kinking
Tougher tip prevents folding
during insertion.

54. Gastric drainage tube
Securing bar, should be at lips
Bite block
Ventilating tube
18/11/2012
54

55. Reinforced tip
prevents fold over
Epiglottic fins prevent epiglottis
from entering airway
Gastric drainage tube
Cuff must be fully deflated to prevent
bulging here during insertion
18/11/2012
55

56. Laryngeal
Masks
• Advantages:
– Easy
to
insert,
and
it
technique
can
easily
be
taught
to
non-­‐
doctors.
– Be^er
oxygena*on
than
with
use
of
bag/mask
alone.
– Rescue
airway
• Disadvantages:
– Gastric
infla*on
if
not
correctly
posi*oned
– Aspira*on
risk
not
100%
removed
– Cuff
pressure
need
to
be
monitored
– Risk
of
pharyngeal
trauma
is
forcefully
inserted
including
risk
of
hypoglossal
nerve
injury

57. Why
and
when
to
insert
LMA
• Pa*ents
who
can
tolerate
a
Guedel
airway
will
tolerate
an
LMA
equally
well
• LMA
may
not
protect
against
aspira*on
but
very
few
cases
of
aspira*on
have
been
recorded
– but
be^er
protec*on
than
BMV
alone
– increasing
use
in
first
aid
trauma
• Easier
to
insert
than
endotracheal
tube
– Don’t
need
laryngoscope
• Can
insert
while
ECM
being
conducted
– Difficult
to
intubate
in
these
condi*ons

59. Excessive
oral
secreHons
• Oaen
a
serious,
life-­‐threatening
complica*on
of
neurotoxic
snake
bites
(e.g.:
mamba
bites)
• Careful,
regular
suc*oning
of
the
airways
is
essen*al:
– Hand-­‐held
or
foot-­‐operated
suc*on
pumps
available
– Ignored,
death
from
airway
obstruc*on
may
be
very
rapid
• Ancillary
drug
treatment
with
atropine
(0.6
mg/kg)
every
3-­‐4
hours
can
help
to
reduce
secre*on
levels
• Posi*on
the
pa*ent
appropriately:
– Recovery
posi*on
on
their
side
– NEVER
transport
a
neurotoxic
pa*ent
in
supine
posi*on
18/11/2012
59

60. PreparaHon
for
paHent
referral
(1)
• Organise
transport:
– What
type
of
transport
is
necessary?
Is
it
available?
– If
not,
what
are
the
alterna*ves?
– Basics:
vehicle
with
fuel,
driver,
spare
tyre,
mobile
phone
– Check
that
road
condi*ons
&
weather
appropriate
– Who
will
accompany
the
pa*ent?
• Prepare
the
pa*ent:
– First
aid
measures
in
place
and
pa*ent
stable
as
possible
– If
an*venom
is
available,
administer
before
departure
– airway
&
breathing
managed
appropriately
– circula*on:
nil
by
mouth,
IV
line
secured
well,
IV
fluids
18/11/2012
60

61. PreparaHon
for
paHent
referral
(2)
• Ensure
staff
are
ready:
– Adequately
trained
&
experienced
to
manage
circula*on
problems,
airway
and
breathing
enroute
– Do
they
have
personal
items
&
money
ready
– Are
their
shias
covered
– Have
arrangements
been
made
for
their
return
– if
you
absolutely
cannot
send
a
staff
member
with
the
pa*ent,
reconsider
the
need
to
refer
the
pa*ent,
or
consider
wai*ng
un*l
you
can
send
a
staff
member
• Drugs
&
equipment
ready
in
box/bag
– Adequate
i.v.
fluids,
sphygmanomometer,
stethoscope
– Airway
equipment,
oxygen,
suc*on
pump
&
a^achments
18/11/2012
Flashlight
or
lantern
(for
night
transfers)
– 61

62. PreparaHon
for
paHent
referral
(3)
• Communica*on
complete:
– Consult
the
referral
hospital
for
advice
before
you
send
the
pa*ent
onwards
– Ensure
that
they
have
the
capacity
and
resources
to
be
able
to
accept
the
pa*ent
– Once
referral
is
confirmed,
prepare
documenta*on
• Documenta*on:
– referral
le^er
– copy
of
notes,
snakebite
admission
sheet
or
snakebite
observa*on
sheet
– Chest
X-­‐Ray
if
available,
especially
for
intubated
pa*ents
18/11/2012
62

63. Referral
leXers
• In
addi*on
to
clinical
notes
that
are
sent
with
pa*ent,
send
a
referral
le^er
that
includes:
– Date
&
*me
– Name
of
referring
person,
referring
facility
– Name
of
the
doctor
the
pa*ent
is
being
referred
to
– Telephone
call
details,
telephone
number
for
feedback
– Name
and
details
of
pa*ent
– Summary
of
history
(bite
history,
symptoms
and
signs),
examina*on,
results
and
*mes
of
inves*ga*ons
– Any
informa*on
about
type
of
snake
suspected
– Summary
of
treatments
given,
*ming
&
response
– Details
of
improvement
or
deteriora*on
– Reasons
for
referral
18/11/2012
63

64. PaHent
care
during
transport
• Posi*on
the
pa*ent
in
a
sifng
posi*on
if
they
have
no
airway
or
breathing
problems
• If
the
airway
is
compromised,
lay
them
on
their
side,
with
the
head
supported
and
*lted
slightly
downwards
to
prevent
aspira*on
of
mucus/saliva
• Hang
the
I.V.
fluid
bag
and
monitor
it
• Staff
member
should
remain
with
the
pa*ent
so
that
emergency
treatment
can
be
given
if
needed
• If
no
staff
member
accompanies
the
pa*ent,
and
the
referral
is
urgent,
then
a
family
member
must
be
taught
to
provide
basic
life
support.
18/11/2012
64

65. Summary
(1)
• Have
a
clear
reason
for
referral
of
the
pa*ent
(i.e.:
to
obtain
an*venom
treatment,
or
gain
access
to
a
ven*lator)
• Be
sure
that
referral
will
result
in
an
improvement
in
care
for
the
pa*ent,
and
that
the
transport
of
the
pa*ent
does
not
place
them
at
greater
risk
• If
referral
is
necessary,
do
it
as
soon
as
possible
• Choose
appropriate
transport
• Ensure
that
the
pa*ent
meets
the
criteria
for
referral
to
another
hospital
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65

66. Summary
(2)
• Do
not
refer
the
pa*ent
un*l
they
are
clinically
stable
in
terms
of
airway,
breathing
and
circula*on
• Be
well
prepared:
– Organise
transport
– Prepare
the
pa*ent
– Ensure
staff
are
ready
to
travel
with
pa*ent
– Assemble
necessary
drugs
and
equipment
– Communicate
with
the
referral
hospital
and
prepare
the
documenta*on
• Care
for
the
pa*ent
during
transport
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66