Handling serums

▶️ Vaccine: ​ It is the antigens in the form of a suspension of the microbe, whether it is alive or weakened.

▶️ Serums represent an important part of immunity, called passive immunity , which is used or resorted to when active immunity is not available , or in the event of an epidemic, and there is not enough time to acquire immunity, or the vaccination against this epidemic has not been taken before.

· Some of them are prepared in horses, after injecting them with the microbe, then the antibodies are extracted from the plasma, purified and packaged.

· Some serums may be prepared in volunteers, after conducting the necessary tests to ensure that they are free of diseases.

· The antibody used in serums is called globulin , and there are three main types: human, highly immune, and intravenous.

Human Immune Globulin

• This type of serum is prepared from serum or plasma extracted from a number of volunteers. It contains concentrated immunoglobulin of the IgG type, along with IgM and IgA, but in small amounts.

• It is stored at a temperature of 4°C.

• It starts to be effective in the body 48 hours after injection, and its effectiveness lasts for about three weeks.

• This serum is primarily used for the prevention of the following diseases: Hepatitis A, chickenpox, and rubella, particularly for pregnant women in the first three months of pregnancy. One of the drawbacks of this serum is that it provides temporary immunity, its effectiveness may vary from one type to another, it causes pain during intramuscular injection, and in some cases, it can cause severe allergic reactions.

Hyper immune globulin

• This type of serum is prepared from individuals who have a high level of antibodies specific to a particular disease. It is obtained from these patients during the recovery phase. It can also be prepared by stimulating the immune system of healthy individuals by giving them the vaccine for the disease. Examples of this type of serum include:

• Rabies serum, Hepatitis B serum, Tetanus serum, and Varicella-Zoster serum. One of its drawbacks is that it is painful during intramuscular injection, and it can also be accompanied by severe allergic reactions.

Intravenous Immune Globulin  (IVIG)

• This type of serum is characterized by being administered via intravenous injection rather than intramuscular, which helps in giving large and repeated doses of the serum without causing pain. • For this reason, it is considered the best drug of choice for treating premature infants, those with low weight and growth, from bacterial and viral infections such as meningitis or AIDS.

• Despite the absence of pain during injection, the potential for allergic reactions remains a drawback of this serum.

An important case for using serums is food poisoning (Botulism), for which a serum called "Botulinum Antitoxin" is used. The treatment using serums prepared by modern immunization methods for snake, scorpion, spider bites, and others is called "Venom Immunotherapy," which is a safe and effective treatment, especially in cases where there is a reaction or allergy to the serum itself before immune treatment, or during pregnancy. The use of serums, due to the antibodies they contain to prevent certain infectious diseases, is called "Immunoprophylaxis."

Antisnake Venom Serum

It is worth noting that snake venom is 50% poisonous and 50% non-poisonous 

The patient is initially evaluated in the hospital in an observation room where symptoms, if present, are divided into

·  Snake bite causing bleeding - Haemorrhagic

·   Paralytic snake bite

haemorrhagic snake bite

Clinical  picture

Laboratory tests

➡️ The following tests are performed on the patient urgently 

(Complete blood count, kidney function, blood sugar, prothrombin time and concentration - INR)

Complete bleeding profile: It is done for the patient every 104 hours regularly and includes:

• Platelet count.

• INR.

• Prothrombin time and concentration.

• Fibrinogen level.

Medical Management

First: Minimal cases

·  The patient is placed under medical observation for 24 hours

·  The above-mentioned laboratory tests are performed, with a warning to perform a complete  bleeding profile.

·  The affected limb  (the site of the sting)  is monitored every hour, and it is examined gently and carefully, and the size of the swelling and redness at the site of the sting is determined with each time the examination is performed

·  Alert to deal with the development of the condition if it deteriorates to  Mild - Moderate Severe) by giving the necessary intravenous solutions and also giving the anti-venom serum as will be mentioned later

·  Symptomatic cases that include (Sever-Moderate Mild)

·  The affected limb should be  fully extended and elevated to avoid increased swelling

·  Adequate  intravenous satanic crystalloid is given to support circulation and maintain  urine output at least 1 ml/kg/hr.

·  Giving antivenom to snakes in the following cases:

• In cases of circulatory collapse and heart rhythm disturbances.
• Severe reduction in platelet count.
• Occurrence of convulsions and muscle disturbances.
• Local deterioration of swelling and redness.
• Moderate-Severe cases with moderate to severe effects.
• Mild cases with local deterioration of the sting or the occurrence of general symptoms or disturbance in previous lab test results.
• Severe bleeding cases.
• Platelet count < 50,000 / mm³.
• INR > 3.
• Prothrombin time and concentration > 50 seconds.
• Fibrinogen level < 75 mg/DL. 

Basic indications for giving serum

• Circulatory disorder.
• Coagulation disorder due to low platelet count.
• Neurotoxic muscle poisoning.
• Development and increase of swelling.
• In moderate to severe cases.
• Mild cases with exacerbation of local injury and abnormal lab results.
• Severe bleeding cases:
• Platelet count > 50,000 / mm³.
• INR > 3.
• Prothrombin time and concentration > 50 seconds.
• Fibrinogen level > 75 mg/DL.

Important note

·  The serum is not given as a preventive measure for normal cases with no or few symptoms .

·  No doses of serum for children and young children

·  A sensitivity test is performed on the serum before it is given

Serum dose

It may be necessary to repeat the dose of the serum, typically ranging from 0.5 to 10 ampoules at once, for the purpose of stabilizing the patient's condition.

A sensitivity test for the serum is conducted before administration. If allergic reactions appear in the patient, corticosteroids and adrenaline are given.

The solution is administered very slowly over a period of 5 hours.

Thirdly, severe bleeding cases

Blood transfusion or its derivatives, such as plasma and platelets, are required as follows:

• Red blood cell transfusion: According to a decrease in hemoglobin levels below 8g/dL, with a therapeutic dose of 105- 1/ kg.
• Fresh frozen plasma transfusion: The recommended therapeutic dose for adults is 15 mL/kg in cases of severe bleeding that cannot be controlled, in addition to prolonged PT+PTT.
• Platelet transfusion: In cases of platelet count below 30,000 platelets.

Secondly, paralytic snake bite:

Clinical picture​

All symptoms are neurological, including:

• Tongue heaviness
• Numbness and tingling
• Double vision
• Difficulty swallowing
• Muscle weakness
• Hoarseness
• Weakness of the eye muscles
• Muscle twitches
• Weakness and paralysis of respiratory muscles

Close medical observation for 24 hours is necessary unless coral snake bite is ruled out.

Medical  Management

• Clean the bite site and perform necessary surgical cleaning.
• Administer necessary antibiotics intravenously.
• Physical therapy in case of joint stiffness in the affected limb.
• The patient may require intubation and placement on a ventilator if respiratory muscles are affected.

Give the serum as follows:

·  The serum is given to patients who have neurological symptoms and signs

·  The vaccine is intended for patients who are suspected of having been bitten by a coral snake, even without symptoms

• The loading dose: 3-5 vials, repeated until reaching 10 vials.

Ant spider Venom Serum

Widow Spider or the  Brown Spider , which secrete neurotoxins like snake venom

Its bite causes pain like pinpricks, and leaves a mark that is a blue bruise and a sore in the middle, surrounded by circles; giving it the shape of a target for shooting training , with muscle cramps in the arm or foot, stiffness in the abdominal muscles, high temperature and pressure, profuse sweating, agitation and vomiting

Treatment protocol for dealing with scorpion stings

First aid:

• Reassure the victim and try to keep them calm.
• Remove the stinger, if present, using a flat object such as a card, not a sharp object. Avoid using tweezers as they can squeeze the sting site, increasing venom secretion into the bloodstream.
• Wash the sting site with soap and water and remove any rings, watches, or jewelry from the affected area as it may swell.
• A gauze bandage can be applied above the sting site, ensuring it is tied lightly to close only the vein, not the artery, to avoid compromising blood flow to the parts below the sting.
• Apply ice wrapped in cloth to the sting site for 10 minutes, then remove it for another 10 minutes. Repeat this to prevent swelling and reduce venom absorption into the bloodstream.
• Do not use painkillers unless advised by a doctor.
• Record the vital signs of the patient, particularly pulse, respiration, and blood pressure.

Assessing the patient's condition in terms of severity:

Notes:

The dose should be increased in the following cases:

·  Head, neck or shoulder injury

·  If the period of time between the infection and the treatment is long, a maximum of 10 ampoules

A skin allergy test must be performed before giving the serum as follows:

➡️ 0.1-0.2 ml of the serum diluted in a ratio of 1:10 is injected into the skin. A positive result appears as a rash that may be surrounded by redness within 30 minutes

➡️ The solvent is stored at the same temperature as the refrigerator, from 2 to 8 degrees

Signs of improvement:-

·  A regularization of rapid heartbeats and their return to their normal rate

·  warmth in cold extremities

·  Restore normal blood pressure

·  Respiratory rate returns to normal

Rabies vaccination is giving the child or patient a dose of the rabies virus, which is a killed virus, so that the child’s immune system recognizes the virus and then quickly controls it and prevents the disease from developing if the child is bitten.

Initial symptoms of rabies:

 Symptoms include fever, pain or tingling at the site of the wound, and as the disease progresses, the patient may experience hallucinations, insomnia or mental disturbance. Generally, the disease appears in the following two forms:

Rabies:

It appears in the form of hyperactivity, agitation, hydrophobia and sometimes aerophobia ,  and death usually occurs as a result of the respiratory muscles stopping after a few days

Paralytic rabies: This is less common, and in it the muscles gradually become paralyzed, starting at the site of the bite or scratch, then slowly progressing to coma and then death

It is worth noting that the World Health Organization's definition of the clinical diagnosis of human rabies is based on the appearance of neurological symptoms  (encephalitis)  in the infected person that develop into coma and death, in addition to a history of being bitten or scratched by an animal suspected of being infected with rabies.

Post-exposure prevention measures:

First : Local treatment of wounds

1-  . good wound washing

The process of wound cleaning for all cases, regardless of the severity of the wound, is considered one of the essential pillars that determine the effectiveness of preventive procedures:

1. Wound Cleaning: The wound should be cleaned as quickly as possible for at least 15 minutes. All wounds should be washed with running water and soap, followed by the application of antiseptic agents (such as Povidone iodine or other virucidal substances). The wound should then undergo regular daily cleaning.

2. Wound Edge Removal or Primary Sutures: It is prohibited to perform wound edge excision or primary suturing, except in cases of life-saving interventions (such as continuous bleeding, reconnecting amputated limbs, or complex fractures).

3. Appropriate Treatment: Administer the appropriate treatment, including analgesics or antibiotics, as per the doctor's recommendations.

4. Tetanus Vaccine: Administer the tetanus vaccine intramuscularly according to the applicable protocol.

Second : Rabies Vaccine

The rabies vaccine currently used in Egypt is a vaccine cultured on vero cells, and it is administered for cases of bites, scratches, or contamination of mucous membranes or compromised skin by saliva from an animal suspected of having rabies.

• Five (5) doses of the vaccine are given by injection according to the following schedule:

• First dose: Day 0 (Day of the bite)
• Second dose: Day 3
• Third dose: Day 7
• Fourth dose: Day 14
• Fifth dose: Day 28

Third : Rabies  Immunoglobulin

Immunoglobulin is given to cases with the following priorities:

1. Bites or scratches accompanied by bleeding on the arms and neck.

2. Deep or lacerated wounds, especially if they are multiple.

3. Bites or scratches from an animal suspected to be infected with rabies.

• Rabies immune globulin is administered (20 international units/kg of body weight, with a maximum of 1500 international units). Half of the dose is injected around the wound site, and the other half is given in the anterolateral aspect of the thigh muscle.

• The immune globulin dose is given once (on the day of the bite) and should not be repeated. It can be administered within a period not exceeding 7 days from the date of the first vaccination dose. It should not be given after that, as administering it after this period will inhibit the production of antibodies.

• Cases where immune globulin should not be given:

1. Bruises, abrasions, or superficial scratches not accompanied by bleeding.

2. Wounds not contaminated by the animal’s saliva (with a barrier like clothing or other material).

3. If it is confirmed that the person bitten has received a full and correct course of post-exposure vaccination in the last five years.

4. If the person visits the bite treatment center after 10 days or more have passed since the bite incident, with no signs of rabies in the biting animal.

Fourth: Patients are asked to follow the following:

•  Care for wounds resulting from bites or scratches and treatment of surgical complications immediately after they occur

•  Notify your doctor of any side effects that occur during treatment

•  Refrain, as much as possible, from taking general anesthesia for surgical operations for at least six months