Snake envenomation in a north Indian hospital

Use of antivenoms for the treatment of envenomation by Elapidae snakes in Guinea, Sub-Saharan Africa

Background

In Guinea Elapids are responsible for 20% of envenomations. The associated case fatality rate (CFR) ranged 15-27%, irrespective of treatment.

Results

We studied 77 neurotoxic envenomations divided in 3 groups: a set of patients that received only traditional or symptomatic treatments, and two other groups that received either 2 or 4 initial vials of Antivipmyn® Africa renewed as necessary. CFR was 27.3%, 15.4% and 17.6%, respectively. Although antivenom treatment was likely to reduce CFR, it didn’t seem to have an obvious clinical benefit for the patients, suggesting a low treatment efficacy. Mean delay to treatment or clinical stages were not significantly different between the patients who recovered and the patients who died, or between groups. Interpretation of these results is complicated by the lack of systematic studies under comparable conditions. Of particular importance is the absence of assisted ventilation, available to patients in all the other clinical studies of neurotoxic envenomation.

Conclusion

The apparent lack of clinical benefit may have several causes. The hypothesis of a limited therapeutic window, i.e. an insufficient formation of antigen-antibody complexes once toxins are bound to their targets and/or distributed beyond the reach of antivenom, should be explored.

Retrospective analysis of snake victims in Northern India admitted in a tertiary level institute

Context:

Snake bites are the common cause of morbidity and mortality in tropical countries.

Aims:

To analyze the outcome of snake bite victims

Settings and Design:

Retrospective analysis of data from Intensive care unit, Department of Anesthesiology.

Materials and Methods:

All the patients admitted in the intensive care unit for snake bite management during the year May 2004 - April 2009 were retrospectively reviewed. The data included age, sex, month and time of incident, site of bite, dose of anti--snake venom, time of anti--snake venom, administration, duration of mechanical ventilation, complications and death of a victim.

Statistical analysis used:

Pearson's correlation test, paired samples t-test.

Results and Conclusions:

113 patients reported to the Accident and Emergency with history of snake bite. 26 patients were referred to other hospital, 17 patients were brought dead, and 70 patients were admitted to the intensive care unit. In 59 snake-bite victims, maximum data could be recovered. Krait was the most common type of snake bite reported. There was a male preponderance (69.4%) with age ranging between 20 and 40 years (52.5%). The mean lag time (time elapsed between bite and first dose of anti--snake venom) was 5.3 ± 1.4 h and the mean anti-snake venom dose was 12.3 ± 2.4 vials. There was a positive and significant correlation between lag time and total dose of anti--snake venom (correlation coefficient =0.956, P<0.0001). Overall 72.9% patients required mechanical ventilation with a mean duration of 56.2 ± 16.1 h. 10.2% patients sustained cardiac arrest, 8.7% patients developed ventilator associated pneumonia, 6.7% suffered mild anti-snake venom reaction, 6.7% had hypotension and 5.1% patients developed renal failure. The overall mortality was 5.1%.

Incidence of snake bites in kashan, iran during an eight year period (2004-2011)

Background:

Snake bites are one of the significant health problems in the tropical and subtropical regions. Snake bite is a common medical emergency in Iran, and the epidemiological features and management of such cases vary from region to region.

Objectives:

This present research study was conducted to obtain new information about the epidemiology of snake bites in the region of Kashan, located in the central part of Iran.

Patients and Methods:

This research was a descriptive retrospective study. Data from 2004 to 2011 of snakebite cases were collected from case reports. Information included; age and sex of the victim, district, month of incident, mortality, and time of bite.

Results:

The results of this study showed that the majority of snake bite patients were male (96%). The age distribution of patients indicated that the greatest rate of snake bites occurred among the 15-24 year old group. Data collected in this study revealed that the highest incidence of snake bite cases took place in summer (60%) and the lowest number occurred in winter, with no snake bite cases being recorded. The peak number of snakebite cases was seen during June-September.

Conclusions:

It was concluded that snake bite cases in Kashan are similar to other areas in Iran from an epidemiological point of view, including; age distribution rates, gender and site of the bites. The existence of Macrov ipera lebetina, a dangerous venomous snake, can cause a range of clinical effects among residents in central parts of Iran, such as Kashan area.

Bite-to-hospital time and morbidity in victims of viper bite in a rural hospital in Nigeria

Background: Mortality amongst in-hospital patients bitten by carpet viper in northern Nigeria has reduced, related to use of a monospecific ovine Fab snake antivenom. However, many victims survive with temporary or permanent morbidity. Objectives: Study objectives were to: (1) determine and score the morbidity caused by carpet viper bite; and (2) find the relationship between bite-to-hospital time and morbidity amongst victims of carpet viper bite.Method: A prospective study was conducted in a rural hospital in north-central Nigeria. The morbidities scored were oedema, tenderness, prolonged whole-blood clotting time, blister, ulcer, need for blood transfusion, coma, hypotension, convulsion, length of hospital stay, need for disarticulation, and need for skin graft. A score of one was given to each objective sign. The bite-to-hospital time of 233 subjects was obtained. Descriptive and inferential statistical analysis was done.Results: Most of the subjects (150 or 64%) came to the hospital within 6 hours of the snake bite, with 2 (1%) arriving within 1 hour. The median bite-to-hospital time was 5 hours, with a range of 0.5–216 hours. Major morbidities were oedema, seen in 212 (91.0%; 95% CI 86.6–94.3%); incoagulable blood, seen in 205 (88%; 95% CI 83.1–91.9%), and tenderness, seen in 201 (86.3%; 95% CI 81.2–90.4%). The mean morbidity score was 8 ± 4. For every unit increase in logged bite-to-hospital time, the morbidity score increased by 1.85 (p < 0.001).Conclusion: Morbidity caused by carpet viper bite is high in Zamko, north-central Nigeria, and correlates with increasing bite-to-hospital time.

Consequences of neglect: analysis of the sub-Saharan African snake antivenom market and the global context

BACKGROUND

The worldwide neglect of immunotherapeutic products for the treatment of snakebite has resulted in a critical paucity of effective, safe and affordable therapy in many Third World countries, particularly in Africa. Snakebite ranks high among the most neglected global health problems, with thousands of untreated victims dying or becoming permanently maimed in developing countries each year because of a lack of antivenom-a treatment that is widely available in most developed countries. This paper analyses the current status of antivenom production for sub-Saharan African countries and provides a snapshot of the global situation.

METHODS

A global survey of snake antivenom products was undertaken in 2007, involving 46 current and former antivenom manufacturers. Companies producing antivenom for use in sub-Saharan Africa were re-surveyed in 2010 and 2011.

RESULTS

The amount of antivenom manufactured for sub-Saharan Africa increased between 2007 and 2010/11, however output and procurement remained far below that required to treat the estimated 300,000-500,000 snakebite victims each year. Variable potency and inappropriate marketing of some antivenoms mean that the number of effective treatments available may be as low as 2.5% of projected needs. Five companies currently market antivenom for sale in Africa; three others have products in the final stages of development; and since 2007 one has ceased production indefinitely. Most current antivenom producers possess a willingness and capacity to raise output. However inconsistent market demand, unpredictable financial investment and inadequate quality control discourage further production and threaten the viability of the antivenom industry.

CONCLUSION

Financial stimulus is urgently needed to identify and develop dependable sources of high-grade antivenoms, support current and emerging manufacturers, and capitalise on existing unutilised production capacity. Investing to ensure a consistent and sustainable marketplace for efficacious antivenom products will drive improvements in quality, output and availability, and save thousands of lives each year.

Surgery in management of snake envenomation in children

BACKGROUND

Snakebite is common in children especially in the developing countries. This study was undertaken to determine the role of surgery in the treatment of venomous snake bite in pediatric patients.

METHODS

The clinical data of 58 pediatric patients aged 0-16 years who had been treated for venomous snakebite from January 1999 to December 2008 were analyzed.

RESULTS

Of the 58 patients, 43 (74.6%) were male. Peak age incidence was around 2-3 years (28.8%). The majority of envenomations occurred in the summer and rainy seasons, especially in the latter, during flooding. The bites occurred during 6 pm to 12 pm in 27 patients (49.0%). The main bite site was the lower extremities in 49 patients (83.9%). The main species of the snake were Malayan pit viper (Calloselasma rhodostoma) in 28 patients (47.5%) and cobra (Ophiophagus hunnah or Naja spp.) in 21 patients (35.6%). Soft tissue necrosis occurred more in cobra bites (47.6%) than viper bites (3.6%). The most common organism identified in necrotic tissue was Morganella morgagnii. Four patients with cobra bite had respiratory failure that required ventilatory support. Compartment syndrome was suspected in 2 patients. Surgical intervention was necessary in 13 patients. Most procedures involved serial wound debridement, followed by skin grafting. One case needed a toe amputation because of necrosis. The average length of hospital stay in patients who needed surgical management was 18.8 days (range: 12.1-25.5 days). There were no mortalities.

CONCLUSIONS

Surgery plays an important role in the management of snakebite patients, especially for those with cobra bite with tissue necrosis.

Brain death--think twice before labeling a patient

Brain death is defined as the cessation of cerebral and brainstem function. A 12-year-old boy presented with alleged history of snake bite. He was brain dead with Glasgow Coma Score of 3 and absent corneal reflexes. However, it was only neuroparalytic effect of the venom, which improved in due course of time with antivenoms. This case highlights the occurrence of both internal and external ophthalmoplegia, which would mimic brain death in many ways, thus prompting an intensivist to consider withdrawing ventilatory support, which would be disastrous.

Clinical profile of venomous snake bites in north Indian Military Hospital

Snakebite is an environmental hazard associated with significant morbidity and mortality. We report a case series of venomous snakebites in a military operational area of north India. Of 33 cases of snake bites presenting to the military hospital, 21 patients were envenomated. The median age of patients was 24 years; all were men. All of the envenomations were neurotoxic in nature. Abdominal pain (91%), headache (86%), dysphagia (86%), ptosis (77%), diplopia (72%), blurred vision (72%), dyspnea (67%), and vomiting (62%) were the predominant clinical presentation. Polyvalent AntiSnakeVenom (ASV) [mean 180 ml; range 90-320 ml] was given to all patients with systemic manifestations, and repeated as needed. Eleven (52%) patients received neostigmine with glycopyrrolate to counter cholinergic effects. Two patients were given ventilatory support. The average time of recovery from envenomation was 16 hours after administration of ASV. All patients recovered without sequelae. Soldiers during military exercise are vulnerable to snakebites. Neurotoxic snakebites predominate in our study and usually present with autonomic features along with headache, abdominal pain, ptosis, diplopia and dysphasia. Preventive measures to minimize snake bites and planned treatment regimens should be emphasized among medical and military personnel deployed in the field operations.

Emergency treatment of a snake bite: Pearls from literature

Snake bite is a well-known occupational hazard amongst farmers, plantation workers, and other outdoor workers and results in much morbidity and mortality throughout the world. This occupational hazard is no more an issue restricted to a particular part of the world; it has become a global issue. Accurate statistics of the incidence of snakebite and its morbidity and mortality throughout the world does not exist; however, it is certain to be higher than what is reported. This is because even today most of the victims initially approach traditional healers for treatment and many are not even registered in the hospital. Hence, registering such patients is an important goal if we are to have accurate statistics and reduce the morbidity and mortality due to snakebite. World Health Organization/South East Asian Region Organisation (WHO/SEARO) has published guidelines, specific for the South East Asian region, for the clinical management of snakebites. The same guidelines may be applied for managing snakebite patients in other parts of the world also, since no other professional body has come up with any other evidence-based guidelines. In this article we highlight the incidence and clinical features of different types of snakebite and the management guidelines as per the WHO/SEARO recommendation.

Herpes labialis in patients with Russell's viper bite and acute kidney injury: a single center experience

Snake bite is an important health hazard in tropical countries and is associated with significant morbidity and mortality. Herpes labialis is a common ailment caused by the Herpes simplex virus. There is no published data showing any association between the snake bite and development of Herpes labialis. Here, we present a series of patients who developed Herpes labialis after Russell's viper bite and had acute kidney injury. We attempted to find whether snake bite is an immunosuppressed state and whether it could have pre-disposed the patients to the development of these lesions.

Ending the drought: new strategies for improving the flow of affordable, effective antivenoms in Asia and Africa

The development of snake antivenoms more than a century ago should have heralded effective treatment of the scourge of snakebite envenoming in impoverished, mostly rural populations around the world. That snakebite still exists today, as a widely untreated illness that maims, kills and terrifies men, women and children in vulnerable communities, is a cruel anachronism. Antivenom can be an effective, safe and affordable treatment for snakebites, but apathy, inaction and the politicisation of public health have marginalised both the problem (making snakebite arguably the most neglected of all neglected tropical diseases) and its solution. For lack of any coordinated approach, provision of antivenoms has been pushed off the public health agenda, leading to an incongruous decline in demand for these crucial antidotes, excused and fed by new priorities, an absence of epidemiological data, and a poor regulatory framework. These factors facilitated the infiltration of poor quality products that degrade user confidence and undermine legitimate producers. The result is that tens of thousands are denied an essential life-saving medicine, allowing a toll of human suffering that is a summation of many individual catastrophes. No strategy has been developed to address this problem and to overcome the intransigence and inaction responsible for the global tragedy of snakebite. Attempts to engage with the broader public health community through the World Health Organisation (WHO), GAVI, and other agencies have failed. Consequently, the toxinology community has taken on a leadership role in a new approach, the Global Snakebite Initiative, which seeks to mobilise the resources, skills and experience of scientists and clinicians for whom venoms, toxins, antivenoms, snakes and snakebites are already fields of interest. Proteomics is one such discipline, which has embraced the potential of using venoms in bio-discovery and systems biology. The fields of venomics and antivenomics have recently evolved from this discipline, offering fresh hope for the victims of snakebites by providing an exciting insight into the complexities, nature, fundamental properties and significance of venom constituents. Such a rational approach brings with it the potential to design new immunising mixtures from which to raise potent antivenoms with wider therapeutic ranges. This addresses a major practical limitation in antivenom use recognised since the beginning of the 20th century: the restriction of therapeutic effectiveness to the specific venom immunogen used in production. Antivenomic techniques enable the interactions between venoms and antivenoms to be examined in detail, and if combined with functional assays of specific activity and followed up by clinical trials of effectiveness and safety, can be powerful tools with which to evaluate the suitability of current and new antivenoms for meeting urgent regional needs. We propose two mechanisms through which the Global Snakebite Initiative might seek to end the antivenom drought in Africa and Asia: first by establishing a multidisciplinary, multicentre, international collaboration to evaluate currently available antivenoms against the venoms of medically important snakes from specific nations in Africa and Asia using a combination of proteomic, antivenomic and WHO-endorsed preclinical assessment protocols, to provide a validated evidence base for either recommending or rejecting individual products; and secondly by bringing the power of proteomics to bear on the design of new immunising mixtures to raise Pan-African and Pan-Asian polyvalent antivenoms of improved potency and quality. These products will be subject to rigorous clinical assessment. We propose radically to change the basis upon which antivenoms are produced and supplied for the developing world. Donor funding and strategic public health alliances will be sought to make it possible not only to sustain the financial viability of antivenom production partnerships, but also to ensure that patients are relieved of the costs of antivenom so that poverty is no longer a barrier to the treatment of this important, but grossly neglected public health emergency.

Role of neostigmine and polyvalent antivenom in Indian common krait (Bungarus caeruleus) bite

Bungarus caeruleus (Indian common krait) bite during monsoons is common in Northwest India. This study was undertaken to find the effectiveness of neostigmine and polyvalent antivenom in improving neuromuscular paralysis following bite. All the consecutive patients admitted between June 2007 and December 2008 with common krait bite, identified either from brought snake or circumstantial evidence were studied. Ten vials of polyvalent antivenom and three doses of 2.5 mg neostigmine at 30 min intervals after administration of 0.6 mg of atropine were administered I.V. and patients were assessed for any improvement in neuroparalysis. Seventy-two patients were admitted during the study period. All the patients except two came from rural areas and were brought between June and September. Sixty-two patients were bitten during the day while clearing bricks, cutting grass or walking. The mean time interval between bite and arrival to hospital was 4.5 h. None of the patients showed any improvement following treatment and all patients developed respiratory paralysis, requiring assisted ventilation. Seventy survived and two died. Neostigmine is ineffective in reversing or improving neuroparalytic features in patients with B. caeruleus bite even at higher dose than normally recommended.

Snake bite in South Asia: a review

Snake bite is one of the most neglected public health issues in poor rural communities living in the tropics. Because of serious misreporting, the true worldwide burden of snake bite is not known. South Asia is the world's most heavily affected region, due to its high population density, widespread agricultural activities, numerous venomous snake species and lack of functional snake bite control programs. Despite increasing knowledge of snake venoms' composition and mode of action, good understanding of clinical features of envenoming and sufficient production of antivenom by Indian manufacturers, snake bite management remains unsatisfactory in this region. Field diagnostic tests for snake species identification do not exist and treatment mainly relies on the administration of antivenoms that do not cover all of the important venomous snakes of the region. Care-givers need better training and supervision, and national guidelines should be fed by evidence-based data generated by well-designed research studies. Poorly informed rural populations often apply inappropriate first-aid measures and vital time is lost before the victim is transported to a treatment centre, where cost of treatment can constitute an additional hurdle. The deficiency of snake bite management in South Asia is multi-causal and requires joint collaborative efforts from researchers, antivenom manufacturers, policy makers, public health authorities and international funders.

The global snakebite crisis--a public health issue misunderstood, not neglected

The global problem of venomous snakebite continues to attract attention despite it being described as a "neglected" issue. The current focus of the World Health Organization (WHO) remains anti-snake venom quality, although "availability and sustainability" of supply are consistently described as the key issues. Sustainability of antivenom supply has been elusive, with cost and pricing in developing countries being cited as the major reasons. The current WHO approach fails to explore the cost issue, but rather focuses on quality improvements, which may well adversely affect the costs of a product already perceived to be 'unaffordable.' The reference to cost and price indicates a marketing-based perspective may well give more relevant solutions to the snakebite crisis. This paper introduces a marketing model to examine global snakebite and to identify if the current approach is relevant and effective. The "4 Ps" model examines if the correct products are available, whether sufficient information exists concerning estimated market size, whether the assumptions frequently made about the costs of the product are correct and fully understood, if the product is promoted properly, and whether the method by which the product reaches the end user is optimum. The resulting analysis demonstrates that the current approach is characterized by a misunderstanding of the nature of the global snakebite problem. Further, a lack of implementation of key solutions, such as training doctors in developing countries with relevant protocols, has inevitably led to a lack of improvement in the snakebite arena over the last 30 years.

Community-acquired acute kidney injury in Asia

Asia, the largest continent in the world, is heterogeneous in the ethnic, socioeconomic, and developmental status of its populations. A vast majority of it is poor with no adequate access to modern health care, making an accurate estimation of the nature and extent of acute kidney injury (AKI) difficult. Community-acquired AKI in otherwise healthy individuals is common, and the population developing AKI is younger compared with its counterparts in Europe or North America. The etiologic spectrum varies in different geographic regions of Asia depending on environmental, cultural, and socioeconomic factors. Some of the etiologic factors include AKI in relation to infectious diseases, intravascular hemolysis caused by glucose 6-phosphate dehydrogenase deficiency, poisonings caused by industrial chemicals or copper sulphate, animal venoms, natural medicines, heat stroke, and after complications of pregnancy. Preventive opportunities are missed because of failure to recognize the risk factors and early signs of AKI. Patients often present late for treatment, leading to multi-organ involvement and increased mortality. The exact etiologic diagnosis cannot be established in many instances because of a lack of appropriate laboratory support. Modern methods of renal replacement therapy are not universally available; and intermittent peritoneal dialysis is still widely practiced in many areas.

The management of pit viper envenomation of the hand

Snakebites are common among the rural population of developing countries. The severity of venomous snakebites depends on several factors, including the location of the bite, the amount of venom injected, and the effectiveness of the initial therapy. Snakebites frequently occur in the extremities with approximately two thirds of envenomations occurring in the upper extremities. In this study, we presented 12 cases of hand reconstruction after Vipera snakebites and discussed how to minimize functional loss and maximize hand rehabilitation. Twelve patients bitten by Vipera between 2001 and 2006 were included in this study. Groin flaps were performed in three cases, full-thickness grafts in two cases, thenar flaps in three cases, and cross finger flaps in three cases. With medical management, spontaneous healing occurred in one case. We prefer to use flaps on the volar site of the hand and, if the bone is not exposed, full-thickness grafts on the dorsal site of the hand. We also recommend starting rehabilitation of the hand early.

Snake bite mimicking brain death

A 6 year old girl woke up with pain and increasing swelling over the left hand and difficulty in breathing. On examination, she had swelling of the left forearm and hand, flaccid quadriparesis and was in respiratory failure requiring mechanical ventilation. Two clean puncture wounds were identified on the left thumb. A provisional diagnosis of snake bite with severe envenomation was made and she was given anti snake venom therapy. Over a period of about 4 hours her weakness progressed. She became areflexic, developed internal and external ophthalmoplegia and loss of other brain stem reflexes mimicking brain death. Mechanical ventilation was continued despite features suggestive of brain stem dysfunction. About 36 hours after ventilation she showed a flicker of movement of her fingers and gradually the power improved. She was weaned off the ventilator and extubated after 5 days. External ophthalmoplegia is an established association with cobra envenomation, but, this combination of internal and external ophthalmoplegia can mimic brain death and pose a dilemma to the caregivers regarding continuation of therapy.

Snake antivenom product guidelines in India: "the devil is in the details"

Venomous snakebite continues to exact a tremendous toll in human suffering and mortality in India. Contributing to this problem is the fact that all of the current Indian snake antivenom manufacturers include a great deal of misinformation in the package inserts and guidelines that accompany their products. Examples include erroneous recommendations regarding first aid, misleading information regarding the signs and symptoms to be anticipated after Indian snakebite, and misleading and ambiguous recommendations as to initial dosing and repeat dosing of antivenom. In addition, the significant problem of acute adverse reactions to Indian antivenoms is compounded by a lack of appropriate recommendations regarding prevention, diagnosis, and management of such reactions. It is the intent of this article to point out problems with the current Indian antivenom product guidelines and to encourage these manufacturers to produce new literature to accompany their products based on the best available evidence.

Clinical predictors of in-hospital mortality in patients with snake bite: a retrospective study from a rural hospital in central India

OBJECTIVE

To determine the association between selected admission risk factors and in-hospital mortality in patients admitted with venomous snake bite to a rural tertiary care hospital in central India.

METHODS

Retrospective cohort study of patients aged 12 years or older admitted to a rural hospital in central India between January 2000 and December 2003 with venomous snake bites. The primary endpoint was in-hospital mortality. We used Cox proportional-hazards regression analysis to evaluate the association between risk factors (home-to-hospital distance, bite-to-hospital time, vomiting, neurotoxicity, urine albumin, serum creatinine concentration and whole-blood clotting time) and in-hospital mortality.

RESULTS

Two hundred and seventy-seven patients [mean age 32 (SD 12) years; 188 men (68%)] were admitted with venomous snake bite, 29 patients (11%) died. The probability of survival at day 7 was 83%. Vomiting [hazard ratio 6.51 (95% CI 1.94-21.77), P < or = 0.002], neurotoxicity [hazard ratio 3.15 (95% CI 1.45-6.83), P = 0.004] and admission serum creatinine concentration [hazard ratio 1.35 (95% CI 1.17-1.56), P < or = 0.001] were associated with higher risk of death in the adjusted analysis.

CONCLUSIONS

In our rural hospital setting, the overall mortality rate was 11 per 100 cases of snake bite. Vomiting, neurotoxicity and serum creatinine are significant predictors of mortality among inpatients with snake bite. These predictors can help clinicians assess prognosis of their patients more accurately and parsimoniously and also serve as useful signposts for clinical decision-making.