Meet the Expert - The Association of Physicians of...

Dr. D.P. PundeM.D. (Medicine)

Punde Hospital, Mukhed, Dist. Nanded (M.S.)

e-mail:[email protected] 2008Kochi

Meet the ExpertManagement of

Snake Bite

11th January, 2008

Hall H

17.00 to 18.30 hrs.

Contents

1. Snake Bite ......................................................................................................................... 5

Meet the ExpertManagement of

Snake Bite

• Snakebite isaacute life threatening time limitingmedicalemergencyaoccupationalhazardoftenfacedbyfarmlabourersandfarmers.ItisinendemicformallovertropicalcountrieslikeIndia.

• SnakebiteisaforgottentopicinIndia.

Gravity• 2.5lakhssnakebitesperyearinIndia.

• 35,000to50,000deathsperyearduetosnakebiteinIndia.

• HighmortalityinMaharashtra,upto2000deathsperyear

• Highmortalityinruralpopulation.

• Deathfiguremaybehigh.

• 3000speciesofsnakesaredistributedworldwide.500arevenomousspecies52venomousspeciesarefoundinIndiansubcontinent.

Poisonous Snakes

Elapids Neurotoxic :

Cobra, King Cobra, common krait, banded krait, coral, Spitting cobra & Mamba.

Vipers Vasculotoxic :

Pitless -Russell’sViper&Saw-scaled

Pit -Bamboopitviper,Hump-nosedpitviper,Malbarpitviper

Sea snakes Myotoxic

Bigfour

Cobra Predominantlyneurotoxic

Krait Predominantlyneurotoxic

Russell’sViper Predominantlyvasculotoxic

Saw-scaledviper Predominantlyvasculotoxic

Cobra : (NajanajanajaorNag):-foundallover India,upto6 feet in length ,Wheatyorblackishcolored,formsahoodbearingaspectaclemark(Bicyelet,MonocyeletorAcyelet),bitescommoninmorning&evening&predominantlyneurotoxic.

Common Krait (BungarauscaeruleusorcommonkraitorManyar):-FoundalloverIndia,upto3feetinlength.glistening black, having white bands darker towards tail, central hexagonalscales,nocturnal,predominantlyneurotoxic,Suryakandar.

Russell’s Viper (Daboiarussellii,Ghonus,Parad):-FoundalloverIndia,upto5.5feetinlength,Stout,Brownorbuffcoloured&hasthreerowsofblackdiamondshapedspotsonback,triangularheadwithvmark,itmakesaterrifichissingsoundwhenabouttobite&bitemaybeindayornighthours,predominantlyvasculotoxic

Snake Bite

6 APICON 2008 Kochi

Saw-scaled viper (EchiscarinatusorphoorsaorJilebiSnake):-FoundalloverIndia,upto1.5feet,Brownishcoloured,triangularheadwithwhitearrowmark,bitemaybeindayornighthours,predominantlyvasculotoxic.

Non-poisonous Snakes

01.RatSnake(Colubermucosus) 02. Trinket(Elaphe helena)

03.CommonWolfSnake(Lycodon aulicus) 04.WaterSnake(CheckeredKeelBack)

05.Python(Python molurus molurus) 06.EarthBoa(Eryx johnii)

07.CommonSandBoa(Eryx conicus) 08.GrassSnake(Macropisthodonplumbicolor)

09.Bronzebacktreesnake(Dendrelaphis tristis) 10.BandedRacer(Argyrogenafasciolatus)

11. Common cat snake (Boigatrigonata) 12. Common kukri snake (Oligodonamensis)

13.Strippedkeelback(Amphiesmastolata) 14.VineorWhipsnake(Ahaetulla)

Anatomy of the snake

Snakeisavertebrate,coldbloodedreptile,hastwoeyeswithouteyelids,twonostrils,noears,biprongedtongue,70–80teeth&twofangsinvenomoussnakes,100-200vertebrae&200-400ribs,lungs,kidneys,testis,etc.,Nodiaphragm,heart3chambered,nosweatglands.

Fangs of Snakes

Cobra & Krait Short,2-4mm&grooved,erected

Viper Long,12-15mm&canalisedlikehypodermicneedle,folded

Snake Venom

Containsnumberof toxinsandenzymes.It isaclear transparent,amber tinted fluidandcontains.

1. Neurotoxin (Predominant in Elapids)

2. Cholinesterase (Predominant in Elapids)

3. Haemolysins (PredominantinViper)

4. Thromboplastin (PredominantinViper)

5. Fibrinolysins

6. Proteolysins

7. Cardiotoxin

8. Agglutinins

9. Coagulase,Hyaluronidaseetc.

• 10outof26ineachvenomwithseasonal(Venomismorelethalinwinterthansummer)&Regionalvariationsinpotency.

Factors Affecting Snake Bite

1. Site:-Bitesaremorecommoninlower&upperlimbs,bitesclosertobrainaremoredangerous.

Factors Affecting Snake Bite

2. Occupation:BitesaremorecommoninFarmers&Labourers

3. Time of bite :-Nocturnalbitesareserious.Cobra:-Morningandevening,Krait:-Night,Vipers:-day&nighthours.

4. Size of the snake :-Newbornsofsnakesareequallydangerouslikeadults.

7Snake Bite

Pathophysiologic basis of clinical spectrum in ophitoxemia

Snake bite

Venom

Systemic absorption via lymphatics

Spread facilitated by hyaluronidase

Venom in blood stream (Ophitoxemia) Pooling of blood Activation of Directo cytolytic Alteration of in microcirculation kinin & bradykinin action coagulation system activity Ischaemia fibrinolysis Haemolysis

capillary permeability Loss of plasma OEDEMA Local necrosis & blood

circulating vol. 2°Infection Bleeding Shock

DEATH

Venom in blood stream (Ophitoxemia) Neurotoxin Cardiotoxin Myotoxin Nephrotoxin Selective Cardiac arrest K+ Myoglobulinuria ARF Neuromuscular release block

Paralysis

Respiratory Arrest DEATH

8 APICON 2008 Kochi

5. Condition of the snake:-Ifrecentlycastedsevereenvenoming.

6. Type of fangs :- More venom is injected in vipers.

7. Size of the pt.:- Severe envenoming in children due to less body surface area.

8. Clothes, shoes:- Less envenoming.

9. Sleep :- Slow envenoming.

10. Primary aids :- If received less mortality & if not high mortality.

11. Bite Time since :- If delayed admission high mortality.

Diagnosis of Snake Bite

• H/osnakebite-seeforA,B,Cofthept.Ask3questionstopt.–

• Whichisthesiteofbite?,Whatistimesincebite?,whethersnakeisseenornot?

• UnknownbitetoS/osnakebite

• Examofkilledsnake,showingspecimen.

Observed Bite Marks Variations

Poisonous :

1. Twofangmarksonlywithorwithoutoedema

2. TwoFangmarks+othermultipleteethmarks+oedema

3. Singlemarkonlywithorwithoutoedema

4. Onlyabrasion

Distribution of Total Bite Cases as per Site of BiteSite Neurotoxic Vasculotoxic Non Poisonous Unknown Total % Fatal

Upperlimbs 48 126 83 127 384 43.24 9

Lowerlimbs 51 182 123 126 482 54.28 10

Trunk 1 2 0 Nil 3 00.34 Nil

Head&Neck 2 3 Nil 1 6 00.67 1

Penis 2 Nil Nil Nil 2 00.23 Nil

Glutelarea Nil 1 Nil 1 2 00.23 Nil

Site Not Detected 9 Nil Nil Nil 9 01.01 Nil

Total 113 314 206 255 888 100.00 20

*ManagementofSnakebiteinruralMaharashtra:A10yearexperience,D.P.Punde,NMJI,VOL18,No.2,2005,71-75

Occupationwise Distribution of Bite CasesNo.of total cases 888

Sr Occupation Poisonous Non Poisonous Unknown Total % of Total Cases

1 Child 12 4 6 22 2.48

2 Labourer 119 72 68 259 29.17

3 HouseWife 117 58 99 274 30.86

4 Farmer 159 69 80 308 34.68

5 Student 16 3 1 20 2.25

6 Service 1 0 1 2 0.23

7 Business 3 0 0 3 0.34

Total 427 206 255 888 100.00


9Snake Bite

5. Twoabrasionswithorwithoutoedema

6. Onlyecchymoticpatch

7. Localbloodoozing

8. Nomarksseen

Observed Bite Marks Variations

Non-poisonous :

1. Multiple teeth marks

2. Singlemark

3. Onlyabrasion

4. Multipleabrasions

Clues for Diagnosis

Non-poisonous : (Snakenotbrought)

H/osnakebite,NoS/oenvenoming,Poisonous:(H/osnakebitebut Snakenotbrought&S/oenvenoming)

Saw scaled Localoedema+bleedingrare.

R. viper Local+bleedingdiathesis

Krait Minimalornolocalsigns+slowneuroparesis

Cobra Local+fastneuroparesis

Clues for Diagnosis

UnknownBite: H/ounknownbite,Observe(24to48hrs.)

* IfS/osnakeenvenoming.-snakebite

*NoS/osnakeenvenooming.-unknownbite.

Dry Bite : H/osnakebite,NoS/oenvenoming,bittensnakeispoisonous

Clinical Syndromes

Syndrome 1- Local envenoming (swelling etc) with bleeding/Clotting disturbances –Viperdae (all species)

Syndrome 2

- Localenvenoming(swellingetc)withbleeding/clottingdisturbances,Shockorrenalfailure–Russell’sviper(andpossiblysaw-scaledviper–echisspecies–insomeareas.

- Withconjunctivaloedema (chemosis) andacutepituary insufficiency–Russell’sviper,Myanmar,NEIndia

- Withptosis,externalopthalmoplegia,facialparalysisetcanddarkbrownurine–Russell’sviper,SriLankaandSouthIndia

Syndrome 3 –Localenvenoming(swellingetc)withparalysis–CobraorKingcobra

Syndrome 4 –Paralysiswithminimalornolocalenvenomingbiteonlandwhilesleepingoutside– Krait.Biteinthesea–seaSnake

Syndrome 5 –Paralysiswithdarkbrownurineandrenalfailure:

-Biteonland(withbleedingandclottingdisturbance)–Russell’sviper,SriLanka/SouthIndia

10 APICON 2008 Kochi

-Biteinthesea(nobleeding/clottingdisturbances)–SeaSnake

Cobra bite - Symptoms & Signs

Majority of pts. Present within one hr.

Giddiness,Localoedema,Ptosis,Ophthalmoplegia,Heavinessinlimbs,Dysarthria,Dysphagia,Abd.Pain,Convulsions,Quadriparesis,Respiratoryparalysis,Death.

Note : fast development of signs (10 min to 2 hours) and fast recovery

Krait bite - Symptoms & Signs

Minimalorno local signs ,Abd.Pain (High indexof suspicion shouldbe there),Ptosis,Dysarthria,Dysphagia,Chestpain,Quadriparesis,Respiratoryparalysis,death.

Note :

1. Slowdevelopmentofsignsgenerallywithin3to4hrs.butdelayedsignsobservedupto56hrs.

2. Slowrecovery

3. Worsttypeofsnakebite,moredangerousthancobra.

Russell’s Viper bite - Symptoms & Signs

• Sev.Localpain,localbleedingstartssoonafterbite.

• Rapidlyprogressiveoedema,regionaltenderlymphadenopathy

• Nausea,vomiting

• Collapse,shock

• Bleeding-gum,tongue,Haematemesis,Hemoptysis,P/R,P/V,intracranial,petichae,purpura,echymoses,conjunctival,oldwounds,venepuncturesitesbleeding.

• S/oneuroparesisinfewcases

• Convulsions,coma

• DVT

• Renalfailure

• Death

Saw-Scaled Viper bite Symptoms & Signs

• Localslowprogressiveoedema

• Systemicsignsrare

• Bleedingrare

• Mortalityless

Sea Snake

• Usuallypainlessbiteandteetharefrequentlypresentinthewound

• Nolocalswellingorinvolvementoflocallymphnodes.

• Headache,thirstgeneralizedaching,stiffness,tendernessofmusclesandtrismus.

• Generalizedflaccidparalysislikeelapidneurotoxicity

• Generalizedrhabdomyolysis.

• Myoglobinemiaandmyoglobinuriaafter3to8hours.

• Serum/PlasmaappearsbrownishandUrinedarkreddishbrown(Coca-cola)colored.

11Snake Bite

• ARF,Hyperkalemiaandcardiacarrest.

Complications of Snake Bite

Respiratoryparalysis :Cobra&KraitFastinCobra

Shock&Bradycardia :Mainlyinvipers

Bleedingdiathesis&ARF :Russell’sviper,rareinsaw-scaledviper(inMarathwada,M.S.)

Non-healingulcers :Cobra&viper

Delayed :Pituitarydysfunction,persistenceofswellinginvipers.

Analysis of Poisonous Snake Bite Cases at Punde Hospital, Mukhed, Nanded (M.S.),

Total Cases = 427

Period 1992 to 2001 (Retrospective Study)Type of Snake No. of Cases Respiratory

Paralysis ARF ASV Anaphylactic ASV Dose Referred

Cases Death

Cobra 71 36(50.71%) Nil 12 40to320(156) 10 13

Krait 42 13(30.95%) Nil 08 40to250(154) 08 03

Russell’s

Viper40 Nil 12

(30%) 08 20to250(126) 20 04

Echis 274 Nil Nil 22 20to240(040) 08 Nil

Total 427 49 12 50(11.71%) 46 20(4.7%)

Complications of Snake BiteComplication Type of snake-bite Total

Neurotoxic (n=113) Vasculotoxic (n=314)

Acute

Respiratory paralysis 49 0 49

Cardiac complications

Shock 2 20 22

Bradycardia 3 9 12

Pulmonary oedema 3 0 3

Bleedingdiathesis 0 18 18

Acuterenalfailure 0 12 12

Gangrene 0 1 1

Subcutaneousemphysema 1 0 1

Therapy-related

Antisnakevenomanaphylaxis 11 39 50

Severe 8 28 36

Delayed

Non-healingulcer 25 6 31

Contracture 2 0 2

Vocal cord adhesions 1 0 1


Investigations

CBC,BT,CT-20minWBCT,Urine,ECG,Bl.Grouping,LFT,Bl.Urea,Sr.creatinine,Sr. Na+, Sr. K+, X-ray chest, Coagulation profile (at higher center), Blood gas analysis (at higher center).


WBCT (Cont..) 20 Min WBCT (Whole blood clotting time) WHO/SEARO Guidelines

• Simple,bedsidegoldstandardtesthavingdiagnosticvalue.

• Draw2ccvenousbloodofpt.&placeinanewtesttube.

• Leaveundisturbedfor20mins.atambienttemp.

• Tipthetubeonesafter20mins.

• Ifthebloodisstillliquid(unclotted)andrunsout,thepatienthashypofibrinogenaemia(“incoagulableblood”)asaresultofvenom-inducedconsumptioncoagulopathy.

• IntheSoutheastAsianregion.Incoagulablebloodisdiagnosticofaviperbiteandrulesoutanelapidbite.

WBCT 20 Min WBCT (Whole blood clotting time) WHO/SEARO Guidelines

• Warning!Ifthevesselusedforthetestisnotmadeofordinaryglass,orifithasbeenusedbeforeandcleanedwithdetergent,itswallmaynotstimulateclottingofthebloodsampleintheusualwayandtestwillbeinvalid.

• If there is anydoubt repeat the test induplicate includinga “control” (blood fromahealthy person).

• Performtestonadmission&6hrly.

• Change in WBCT is observed within 30 min or upto 6 hrs due to initial hepaticcompromise.

• ASVmonitoringisdonewiththehelpofWBCT.

Management

Difficultinruralset-up

Due to :

• Lackoffacilities,equipments&trainedstaff

• llliteracy,misbeliefs,quacks&poverty

• Improperprimaryaid

• Delayinadmissions

• Highcosttherapy(400to500Rs/Vial)

Management - Primary Aids

• Immobilisationofpt.-Avoidfright&flight

• Keepbittenpartbelowheartlevel

• Allayofanxiety(Lessinpaedatricgroup)

• Tourniquet,Pressureimmoblisation(CrepeBandageinKraitbite)

• Careofthewound

• Shiftingofpt.toproperhospital

• VitaltimeshouldnotbewastedwithMantriks&Quacks.

Be AlertTourniquetshouldnotbereleasedimmediatelybeforeadministrationofASVbecausepatientmaydevelopfast&severeenvenoming.

13Snake Bite

Management - General T/t

• I.V.line

• TT,antibiotics,anti-inflammatory,anxiolytics,don’tallowpt.tosleep

• Observationminimumfor24hrsineverycase,ifdoubtobserveupto48hrs.

• Dieticadvise:-Normaldietifnocomplications,NBMifpt.hasvomitings,GIbleedingorneuroparesis,lowK+&calculatedfluidsifrenalfailure.

Management - Specific ASV Schedule

• IVrouteonly,polyvalentfromHaffkin,SerumInstitute.

• DoseofASVisstillempirical.

• PreviousMortalitywas4.7%&nowitisless.

• Averageyieldofvenomperbite:

Cobra60mg.,R-Viper63mg.,Krait20mg.,Saw-scaled13mg.(Fataldose12mg.,15mg.,6mg.,8mg.Respectively.1mlofPolyvalentASVwillneutralize0.6mgCobra&R-Viper,0.45mgofKrait&Saw-scaledvenom.

Cobra :

• 10vialsin200mlnormalsalineIVdripin1sthrasaloadingdose.

• 2to5vialsaspertheneedbymicrodripinfurtherperiodi.e.24hrsmoreaftercompletereversalofneuroparesistopreventrecurrence.

Krait :

• 10vialsin200mlnormalsalineIVdripin1sthr&

• 2to5vialsinfurther24hrsbymicrodrip.

• Ifpt.isonventilator,Neostigmine&largedoseofASVisnotneeded.

Saw-Scaled Viper :

• 2to4vialsin200mlnormalsalineIVdripin1st hr

• 2vialsinfurther24hrs.bymicrodrip.

• ASVisindicatedonlyifswellingoccurswithin1hr.ofbiteorbloodisincoagulableby20WBCT.

• Ifpt.comeslatewithabnormal20WBCTgiveASV.

Russell’s Viper :

• 10vialsin200mlof5%glucosein30mins.

• Ifactivebleedingdonotstopwithin30mins.give5vialsin200ml5%glucoseover2hrs.

• 5vialsbymicrodripinfurther24hrs.

• Observept.clinically&by20WBCT6hrly.

• Ifbleedingpersistsorbloodisincoagulablegivefreshblood.

• MaintenanceASVshouldbegivenforfurther24hrsafterbloodbecomescoagulabletopreventrecurrence.

ASV Schedule (Contd…)

• Doseinpediatricsissameasadults

• Lowdose&adequatetherapyshouldbeusedduetocost,reactions&shortsupply.


• RegionwisechangeinASVdosesduetovariationinvenomtoxicity

• Doserequiredforsaw-scaledviperinMarathwadaislessascomparedtoKokan&SouthIndia

ASV Sensitivity Test

20to30minpriortotherapy,Notalwaysreliable,Notpossibleinemergency,Manystudieshavenotrecommended.13%anaphylaxisinpersonalexperiencepreviously.

Nowweareusingprophylactic0.25ccsubcut.AdrenalinebeforeASV(ifnotcontraindicated)&observeddrasticreductioninanaphylaxis

ASV Reactions

1. EarlyAnaphylacticReaction

- within10to180mins,mildtosevere

- Treat.–adrenaline(IM),steroids,antihistamincs.

RinsingofemptysyringofadrenalineinIVdripisbeneficialintreatingsevereshock

2. Pyrogenic Reactions.

- within1to2hrs.aftertreat.

3. Late(SerumSickness)Reactions.

- From1to12days,rare

- Treat.Oralsteroids&antihistamincs

ASV Schedule and special situations

• DelayedadmissionwithbleedinggivefulldoseofASV.

• DelayedadmissionnoexternalbleedingbutincoagulablebloodgivefulldoseofASV.

• Ifrecurrenceofsymptoms&signsgive50%ofloadingdoseofASV.

T/t of Neuroparesis

• Duetopre&postsynapticblockadeinKrait&postsynapticblockadeinCobrabite.

• Neostigmine&Atropine-1/2hrly6dosesofneostigmine(50mcg./kg)andAtropineaspertheneedinCobra&Kraitbite

• DrasticimprovementinCobrabite

• NeostigminenotmuchbeneficialinKraitbite.

Kind Attention

Fixed&dilatedpupilinneurotoxicsnakebiteisasignofenvenomingandnotthesign of brain death. Patient may recover totally.

T/t of Respiratory Paralysis

• Intubation&ventilation(AmbuBagorVentilator)

• Oxygenation

• Careoftubeetc.

T/t of Cardiac Complications

Shock : IVfluids,dopamine&dobutamine

Arrythmias : Orciprenalineforsev.bradycardiaifnotrespondingtoatropine(1.2mg.)

Myocardial Infarction : TreatofInfarct.

15Snake Bite

Cardiac arrest : Cardiac resuscitation

T/t of Hyperkalemia S.K+ > 5

• CalciumgluconateIV,Sodiumbicarbonate.

• Dextrose&insulin.,Salbutamolinhalation.

• Dialysis.

T/t of Hypoglycemia

InR.Viperbite-IVglucose&Steroids

T/t of Renal Complications

• Renalangletendernessisaearlysign

• Properhydration

• ProphylacticfrusemideorTorsemide.

• Diuretics–500mgoffrusemidecanbetriedthroughIVdripwithin24hrsinARF

• Dialysis(Haemo/PD)

T/t of Bleeding Complications

• Fluids,ranitidine,sucralfate

• Useofbortrophase&ethamsylate

• Bloodtransfusion,FFP.

• Platelettransfusion.

T/t of Non- Healing Ulcers, Contractures, gangrene

• Surgicaldebridement,amputation

• Proper,asepticdressing

• Skingrafting,plasticsurgery

Pregnancy & Envenoming

• Treatedwithsameprotocol,nomaternal&foetalmortalityinourexperience

Delayed Complications

• Persistenceofswellinginviperbite

• Serumsickness

• Pituitarydysfunction–Sheehan’ssyndromeNotobservedinourstudy.

• Hypothyrodism

Recurrence of Systemic Envenoming

• Seenincobra&viperswithin24to48hoursorevendaysafterinitialresponse.

• Duetoabsorptionofvenomfromthedepotatthesiteofbite.perhapsduetocorrectionofshock,hypovolaemiaetc.

• Aftereliminationofantivenom.HalflifeofIgG35-70hrs,Fab12-18,F(ab)280-100hrs.andvenommayreappearincirculationaslongas130hrs.

• NeedoflongactingmonovalentASV.

Cause of Death

• Prolongedrespiratoryarrestleadingtocerebralanoxia&braindeathinelapidaebite.


Flow Chart of management of snake bite

ASV–antisnakevenom,N-Neostigmine,A-Atropine

RF-Renalfailure,DIC-Disseminatedintravascularcoagulation

History of snake bite

Absent Local edema Present

Floor bed

Abdominal pain

Neuroparalysis

Neuro- paralysis

• Bleed • DIC • Shock • RF

Bleeding +

ASV N+A

ventilator

ASV dialysis blood -

transfusion

ASV Blood

transfusion

ASV ventilator

N+A Management

Krait

Cobra

R.viper

Ecchis

-

• Shock, DIC and ARF in vipers (bite cases referred to tertiary care centre werefollowed).

Analysis of Bite cases from 01-01-2003 to 31-08-2004 Total Bite Cases = 206 ( Snake Bite 144 + Unknown Bite 62 )

Snake Bite Cases = 144 (Poisonous 68 + Nonpoisonous 76) Analysis of Poisonous Snake Bite Cases

Type of Snake

No of Cases

Dry Bite

ComplicationsASV

ScheduleASV

ReactionsVentilation

Time

Referred Cured Death Res. Paraly ARF

Cobra 22 Nil 10(45.45%) Nil 80to340

(145ml.) 02 1to34(6.12hrs) Nil 22 Nil

Krait 09 02 02(22.22%) Nil

120to180

(151 ml.)Nil 24to56

(42.85hrs) Nil 09 Nil

Russell’sViper 15 01 Nil 01

(7.14%)60to200(140ml.) 02 - 02 14 01

Echis 22 02 Nil Nil 20to60(47ml.) 01 - Nil 22 Nil

Total 68 05 12 01 - 05(7.93%) - 02 67 01

(1.58%)

0.25ccsubcutadrenalineusedpriortoASV

17Snake Bite

Analysis of Bite Cases at Punde Hospital, Mukhed, Nanded (M.S.) 1/9/2004 To 31/12/2007

Total Cases = 450 (Snake Bite 382 + Unknown Bite 68) Snake Bite = 382 (Poisonous 205 + Nonpoisonous 177)

Poisonous Snake Bite = 205 (Cobra - 66 / Krait - 19 / Rusell’s Viper - 95 / Echis - 25) Analysis of Poisonous Vasculotoxic Snake Bites (Group-A)

Type of Snake

No. of Cases

Dry Bite ARF

Bite to ARF time interval in hrs.

ASV dose given in

ml

ASV Reactions prior (0.25

cc) sc Adrenaline

given

Time required for

Normalisation of cloting time

in hrs.

Refered

cases

Mortality

Russell’s

Viper95 03 19

(20.66%)12to96(32.11)

60to240(152.10) 09 6to48(16.90) 24 07

Echis Carinatus 25 01 Nil - 40to60

(44.11) 01 12 hrs Nil Nil

Total 120 04 19 10(8.62%) 24(20.68%)07(13.14%)

Analysis of Bite Cases at Punde Hospital, Mukhed, Nanded (M.S.) 1/9/2004 To 31/12/2007

Total Cases = 450 (Snake Bite 382 + Unknown Bite 68) Snake Bite = 382 (Poisonous 205 + Nonpoisonous 177)

Poisonous Snake Bite = 205 (Cobra - 66 / Krait - 19 / Rusell’s Viper - 95 / Echis - 25) Analysis of Poisonous Neurotoxic Snake Bites (Group – B)

Type of Snake

No. of Cases Dry Bite Resp.

Paralysis

Bite to Resp.

Paraly-sis time interval in hrs.

ASV dose given in

ml

ASV Re-actions

Mean Ventila-

tion time in hrs.

Time required for re-

versal of Neuropa-ralysis in

hrs.

Ref-ered cases Mortality

Cobra 66 3 24(36.36%)

1/2to4.5(1.37)

100to240(132.25) 03 2to30

(8.33)1to30

(5.0) 1 01

Krait 19 Nil 08(42.11%)

2½to7

(4.0)100to180

(146.31) Nil 14to80(46.37)

8to96(33.55) Nil Nil

Total 85 3 32(39.02%) 3(3.66%) 1(1.22%) 1(1.22%)

Analysis of table A & B

• MortalitywashigherinVasculotoxicthanNeurotoxicgroup.

• BitetoASVintervalwashigherin7fatalcasesofVasculotoxicgroup.(6hr,3hr,12hr,8hr,41/2hr,2hr,4hr)indicatingneedofearlyadministrationofASV.

• CauseofdeathinVasculotoxicgroupwasrefractoryshockleadingtoARFandneedsmoreresearch(referredcaseswerefollowed)Mortalitywasverylowinneurotoxicgroupdue toearlyadmissions, adequateandoptimumASV,anticholinesterasesand timelyartificialventilation.

• Earlyadmissionswereduetocontinuousmassawarenessprogrammesconductedbyusin rural areas.

• Prioruseof0.25ccsubcutaneousadrenalineshowedsignificantreductioninincidenceofASVreactions.

• A&Bgrouptakentogether:

• ASVReaction -6.50%

• Mortality -4.04%


Analysis of A & B groups shows that 80% of Vasculotoxic and 98% of Neurotoxic •snake bite cases can be managed successfully in rural setup.

Health Education

• Responsibilitiesofphysiciansare:

• EducationofGPs

• Educationofsociety

Education of GPs :

• Diagnosis

• Primaryaid

• Educationofbasiclifesupport

• Properreferral

• Commontendencyisnottotreat&onlyrefertoGovt.hospitals.Thisshouldbechanged&primaryT/tshouldbegiven&delayinfurtheradmissions&complicationsshouldbeavoided

Health Education

Education of society About :

• Primaryaid,misbelief,quacks

• Properclothing,wearingshoes.

• Useofstick&torchinnighthrs.

• Sleepinghabits

• Controlofrodents

• Keroseneswabsassnakerepellant

• AdviseaboutRCCconstructionifpossible

• Adviseaboutplanitationaroundhouses

• Killingofsnakes(controversial)

• Carefulhandlingofdeadsnakes

• Masseducationthroughawarenesscampsinruralareas

Conclusions

• Cobra,Krait,R.viper&Saw-scaledviperarepoisonoussnakes

• Mortalityishighduetoilliteracy,misbeliefspovertyetc.

• InviewofCPAriskofASVtherapyshouldbeexplainedtopatientandrelatives.Benefitshould exceed the risk.

• ProphylacticadrenalineifnotcontraindicatedshouldbeusedLowadequateASVtherapyshouldbeappliedconsideringcost&shortsupply.

• Properprimaryaid,earlyadministrationofASV,properuseofanticholinesterases&timelyendotracheal intubationwithAmbubagorventilatorare important for savinglife.

19Snake Bite

Take Home MessageCatchabreath

Savethelife

Recommendations

• Declarationofsnakebiteasanotifiableoccupationaldisease.

• EstablishmentofNationalprogrammeforsnakebite.

• EducationofGPsbyHealthDept.

• EducationofsocietybyNGOs&HealthDept.

• NeedofmoreASVinRuralGovt.HospitalsandfreesupplyofASVtoprivateHospitalsbyGovt.

• Needofvenomdetectionkits(VDK)andmonovalentlongactingASV

• Researchaboutpharmacologicalantidotetovenomandchemicalreceptors.

• Insurance of Labourers & Farmers should be considered & promoted by theGovernment.

• Establishmentofregionalresearch,anti-venom&Snakebitetreatment centre.

Our Experience Analysis of Bite Cases Treated

Table 1

Period Poisonous Snake Bites

Nonpoisonous Snake Bites Unknown Total Death

01/01/1992to31/12/2001 427 206 255 888 20

01/01/2002to31/12/2002 47 34 47 128 0

01/01/2003to31/08/2004 68 76 62 206 01

01/09/2004to31/12/2007 205 177 68 450 08

Total 747 493 432 1672 29


Table 2

TypeofSnakePeriod

Total01/01/1992to31/12/2001

01/01/2002to31/12/2002

01/01/2003to31/08/2004

01/09/2004to31/12/2007

Cobra 71 12 22 66 171

Krait 42 9 9 19 79

Russell’s Viper 40 11 15 95 161

Echis 274 15 22 25 336

Total 427 47 68 205 747

Referred 46 1 2 25 74

Death 20 0 1 8 29

Mortality3.88%.

Acknowledgement• Mypatientswhoshoweddeeptrustinme

• Dr.S.K.Bichile,MyteacherandPresidentAPI

• Dr.H.S.Bawaskar,Mahad

• NeelimkumarKhaire,Herpetalogist,Pune.

• BharatCheda,Herpetalogist,Solapur.

• Dr.ShivajiWadekar,Dr.ArunMannikar,Nanded.

• Dr.SanjayLadke,Dr.V.K.Himgire,Eng.Chitmalwar,Mukhed.

• MedisunPharmaPvt.Ltd.,KrishmedPharma,Nanded.

• Mr.R.B.Deshmukh,ICT,Mukhed.

• StaffofPundeHospital&RuralHospital,Mukhed.

• Mrs.MalaPundemywife,forherstimulativeefforts.

References1. WarrellDA–GuidelinesfortheClinicalManagementofSnakebitesintheSoutheastAsianregion.Southeast–

AsianJTropMedPubHealth1999,30:1-84.

2. BawaskarHS,BawaskarPH–ProfileofSnakebiteenvenominginWesternMaharashtra,IndiaTranRSocTropMedHyg2002,:96:79-84.

3. JosephLMathew–PeadiatricsTodayVolIINo1:January–February1999(PGSeminar)

4. SnakeAFriendofHumanbeing–NeelimkumarKhaire,Pune,Maharashtra,India(MarathiBook)

5. Diagnosis and Management of Snake Venom Poisoning – Dr. J. Jacob, Varghese Publishing House, Bombay1990.

6. ReidHAChanKE.TheanPC.Prolongedcoagulationdefect (defibrination syndrome) inMalayanviperbite.Lancet1963,1:621-26

7. NeuromuscularJunctionPg.139-142fromEssentialsofMedicalPhysiology,secondeditionbyKSembulingam&PremaSembulingam.

8. Indiansnakes-NeelimkumarKhaire,Pune,Maharashtra,India(MarathiBook)

9. Snakebiteposoning,Medicineupdate-2007,349to358,H.S.Bawaskar.

Medicine UpdateVolume 18, 2008

Scientific Committee

S. K. Bichile Chairman, Scientific Committee

R. K. Singal President, Association of Physicians of India

Y. P. Munjal Dean, Indian College of Physicians

A. K. Das Dean-Elect, Indian College of Physicians

Sandhya A. Kamath Hon. General Secretary, Association of Physicians of India

Shashank R. Joshi Hon. Editor, Journal of the Association of Physicians of India

N. N. Asokan Organising Secretary, APICON-2008

MembersN. K. Hase • S. S. Mehta

Advisors

Lekha Adik PathakAK AgarwalJS BajajAK BanerjeeSK BanerjeeBR BansodePM DalalSiddhartha DasAlaka DeshpandeSB GuptaPritam GuptaRohini Handa

V. R. JoshiMA KabeerOP KalraKV KrishnadasAjay KumarSajith KumarRajat KumarHM LalRD LeleM MaiyaPC ManoriaKC Mehta

SR MehtaV MohanSK MukherjeeJ MukhopadhyayA MuruganathanG NarsimuluM PanjaPM ParikhKK PareekD RamaraoBK SahayG. S. Sainani

MA SantwaniSiddharth ShahMP SrivastavaShyam SundarPG TalwalkarK TewaryBB ThakurAK TripathySubhash VermaGS WanderME Yeolekar

Meet the Expert - The Association of Physicians of...

Documents

Transcript of Meet the Expert - The Association of Physicians of...