Snake bite....

I was covering for the ED in the afternoon... the emergency dispatch center informed us that the 911 is sending over a snake bit patient, ETA (estimate arriving time) was 20 minutes. The ED was not busy then... A 14 y/o girl was sent in. 2 teacher accompanied her to the ED. She appeared frightened. Her left wrist was bandaged but not splint. The teacher told me that it was Green bamboo silk snake(青竹絲) - Trimeresurus stejnegeri. There were lots of snake in our area, especially in the mountain. We get a snake bite every 1 -2 months.

There were 2 kind of green snake in our region. 1 non-venomous and the other is venomous. The non-venomous carried a strong smell and it was name as smelly green mother ( 臭青母) aka King Rat Snake ( Elaphe carinata). The venomous one is this T. Stejnegeri and it produced hemorrhagic venom. The bite is less striking than the cobra (neuro-toxin) which may lead to respiratory failure. However the swelling of bitten region is frightening.

The girl entered our ED at + 40 min. She was nausea and vomited in ED. It is common for patient to had GI upset following bite. But when I saw the vomitus, I was worried, She had vomited blood clot. 6 bite hole was noted over her left wrist around the ulna artery site. The wound was oozing when I took off the bandage. I asked my team to move fast and called my nephrologist cum toxicologist H down. He was preinformed about this case before her arrival. He was worried as well as the course was too fast. An allergy test was done to see if any allergy present. Usually if allergy is noted, the case would be transferred to a medical center and venom were given there. ( some venom was given actually but if any complication occured the family wont raise any arguement...). Luckily there was no allergy noted. But I had decided to give the anti-venom anyway even if allergy had occured. The hardest part was the girl was staying with her granny and her parents was in Taipei. I ordered 2 vial of anti-venom stat and admitted her to ICU. H checked the drug storage and found that we had 7 bottle of hemorrhagic anti-venom left. He told me to passover not to intake anymore similiar snake bite case as he expect a full dose of 8 vial of anti-venom would be needed. I concurred with his suggestion. A third vial was infused later in the ICU as hematuria was noted. Her parent was called and informed about her situation. I left the ED 2 hrs later and her forearm swelling had started to swell. I told the on call doctor to give a 3-4 more vials as needed. I arrived in the ICU the next day and found that she was transferred out to the nearest univeristy hospital under the request of her uncle. Later that day, the nurse would accompanied her over told me that the swelling had worsen later and the uncle had insisted a transfer. The transfer was done against advice. As the ED of university hospital had told us that no bed (not even a strecther) was available. Our nurse had to stay there for another extra 1 hour as no bed for her in the ED(she had to lay on our trolley) instead. However the nurse told me that a ortho consult was done stat and she was sent to OT stat as compartment syndrome was noted. I was worried when I heard such news - no fasciotomy should be done until haemostatic abnormalities have been corrected as recommened by the The Clinical Management of Snake Bites in the South East Asian Region(edited by WHO). Well, I called up the university hospital ICU today , and asked about her condition. Fasiotomy - yes , Oozing was noted for the first 2 days and now better total antivenom used 3 + 10 vial Yes - she is currently stable... Thank god, she is stable at the moment....13 vial of antivenom used , more than 8 as recommended. But the challange is not over yet as the venom would be re-released from soft tissue few days later and further bleeding maybe noted later. Frankly said, no patient had died in our hospital because of T.stejnegeri bite. Most of them recovered without complication, unlike bite by cobra where tissue necrosis would be noted.

I had a dicussion with H later and he told me that the snake might be a mutant variant and the venom is super toxic...

I was covering for the ED in the afternoon... the emergency dispatch center informed us that the 911 is sending over a snake bit patient, ETA (estimate arriving time) was 20 minutes.
The ED was not busy then... A 14 y/o girl was sent in. 2 teacher accompanied her to the ED. She appeared frightened. Her left wrist was bandaged but not splint. The teacher told me that it was Green bamboo silk snake(青竹絲) - Trimeresurus stejnegeri. There were lots of snake in our area, especially in the mountain. We get a snake bite every 1 -2 months. There were 2 kind of green snake in our region. 1 non-venomous and the other is venomous. The non-venomous carried a strong smell and it was name as smelly green mother ( 臭青母) aka King Rat Snake ( Elaphe carinata). The venomous one is this T. Stejnegeri and it produced hemorrhagic venom. The bite is less striking than the cobra (neuro-toxin) which may lead to respiratory failure. However the swelling of bitten region is frightening.
The girl was entered our ED at + 40 min. She had nausea and vomited in ED. It is common for patient to had GI upset following bite. But when I saw the vomitus, I was worried, She had vomited blood clot. 6 bite hole was noted over her left wrist around the ulna artery site. The wound was oozing when I took off the bandage. I asked my team to move fast and called my nephrologist cum toxicologist H down. He was preinformed about this case before her arrival. He was worried as well as the course was too fast. An allergy test was done to see if any allergy present. Usually if allergy is noted, the case would be transferred to a medical center and venom were given there. ( some venom was given actually but if any complication occured the family wont raise any arguement...). Luckily there was no allergy noted. But I had decided to give the anti-venom anyway even if allergy had occured. The hardest part was the girl was staying with her granny and her parents was in Taipei.
I ordered 2 vial of anti-venom stat and admitted her to ICU.  H checked the drug storage and found that we had 7 bottle of hemorrhagic anti-venom left. He told me to passover not to intake anymore similiar snake bite case as he expect a full dose of 8 vial of anti-venom would be needed. I concurred with his suggestion. A third vial was infused later in the ICU as hematuria was noted. Her parent was contacted and informed about her situation.
I left the ED 2 hrs later and her forearm swelling had started to worsen. I told the on call doctor to give  3-4 more vials pending her condition.

 I arrived in the ICU the next day and found that she was transferred out to the nearest univeristy hospital under the request of her uncle. Later that day, the nurse who accompanied her during the transfer told me that the swelling had worsen later and the uncle had insisted a transfer. The transfer was done against advice. As the ED of university hospital had told us that no bed (not even a strecther) was available. Our nurse had to stay there for another extra 1 hour as no bed for her in the ED(she had to lay on our trolley instead.) However the nurse told me that a ortho consult was done stat and she was sent to OT stat as compartment syndrome was noted. I was worried when I heard such news - no fasciotomy should be done until haemostatic abnormalities have been corrected as recommened by the The Clinical Management of Snake Bites in the South East Asian Region(edited by WHO).
Well, I called up the university hospital ICU today , and asked about her condition.
    Fasiotomy - yes , Oozing was noted for the first 2 days and now better
    total antivenom used 3 + 10 vial
    Yes - she is currently stable...

Thank god, she is stable at the moment....13 vial of antivenom used , more than 8 as recommended. But the challange is not over yet as the venom would be re-released from soft tissue few days later and further bleeding maybe noted later. Frankly said, no patient had died in our hospital because of T.stejnegeri bite. Most of them recovered without complication, unlike bite by cobra where tissue necrosis would be noted.

I hate snake ......