Managing snakebite

Characteristics of snakebite patients due to Naja samarensis in the Philippines: a prospective hospital-based study

BACKGROUND

Little is known about snakebites by Naja samarensis, a species unique to the Philippines. The aim here is to describe the clinical and epidemiological characteristics of patients bitten by this medically important cobra in the Eastern Visayas.

METHODS

A hospital-based prospective study analysed the features of snakebite patients attending Eastern Visayas Medical Center between June 2022 and May 2023. Logistic regression analysis identified the factors associated with severity.

RESULTS

A total of 175 snakebite patients with five fatalities were included. Naja samarensis was most commonly implicated (n=49, 28.0%), although it could be definitively identified, by examining photographs of the snake responsible, in only four cases. The N. samarensis bites occurred in grass or rice fields, in daytime, and during farming activities, but the people bitten were most frequently students (34.7%) who were bitten at home (36.7%). Patients bitten by N. samarensis often presented with cytotoxic (63.3%) and neurotoxic signs (46.9%). Traditional remedies were common, resulting in delayed presentation to the hospital. Bites by N. samarensis, and older age (>44 y) were independently associated with severity (adjusted OR of 10.33 and 7.89, respectively).

CONCLUSION

Naja samarensis is a major cause of severe snakebites in this region. Pre-hospital treatment frequently involves wasted time and unproven traditional methods. Enhancement of public awareness is urgently needed. Development of a diagnostic test for species identification is warranted to improve future surveys and management.

Snakebite-associated acute kidney injury in South Asia: narrative review on epidemiology, pathogenesis and management

Snakebite-associated acute kidney injury (AKI) poses a significant health burden in the South Asia region, resulting in considerable morbidity and mortality. Multiple factors contribute to the pathogenesis of AKI following snakebites, including hypotension, intravascular haemolysis, disseminated intravascular coagulation, rhabdomyolysis, thrombotic microangiopathy (TMA) and direct nephrotoxicity. Clinical features manifest as anuria, oliguria, haematuria, abdominal pain and hypertension. Diagnosis is supported by elevated serum creatinine levels and urine output monitoring. Renal histology studies revealed a spectrum of lesions, including acute tubular necrosis, renal cortical necrosis, glomerulonephritis and TMA. Management strategies centre around timely administration of antivenom, fluid and electrolyte balance and dialysis to improve renal outcomes. While dialysis has demonstrated efficacy in reducing AKI-related mortality rates, the use of fresh frozen plasma and therapeutic plasma exchange may be the subject of some controversy. Understanding the pathophysiological link between coagulopathy, TMA and AKI is important for tailoring effective treatment approaches. Species-specific randomized controlled trials are imperative to evaluate targeted interventions. In tackling the complexities of snakebite-associated AKI and chronic kidney disease, a multidisciplinary approach integrating clinical management with rigorous research efforts is essential. This collaborative endeavour aims to confront the challenges posed by these conditions and improve patient outcomes in the affected regions.

Medically important snakes in Sudan: an overview of distribution, clinical features and present challenges

Snakebite envenomation (SBE) is a neglected tropical disease. It causes substantial morbidity and mortality in Sudan. Despite its endemicity, there is a substantial lack of up-to-date data on venomous snakes and their geographical distribution in Sudan, with most information dating back to the early twentieth century. To address this gap, we conducted a narrative review of the literature on snakes and SBE in Sudan. This review involved systematic searches of databases, historical publications and online resources from 1908 to 2024. Integrating literature findings with personal field experiences to provide a comprehensive overview of the SBE situation in Sudan, we identified 19 medically significant snake species in Sudan from four families. These species exhibit a range of venom types and clinical effects, including neurotoxic, hemotoxic and cytotoxic envenomation. The most dangerous and important species are the carpet viper (Echis pyramidum), the Nubian cobra (Naja nubiae) and the Sudan burrowing asp (Atractaspis phillipsi). Challenges in snakebite management include the non-availability of specific antivenoms, inadequate healthcare infrastructure and reliance on traditional medicine. We recommend establishing a national snakebite registry, improving healthcare infrastructure, developing training programs for healthcare professionals and increasing public awareness. Strengthening international collaborations for antivenom production and investing in molecular research are also crucial for reducing the severity and associated morbidity of SBE in Sudan.

Treatment and treatment outcomes of snakebite envenoming in Uganda: a retrospective analysis

BACKGROUND

Snakebite envenoming is a neglected tropical disease that causes significant morbidity and mortality in rural sub-Saharan Africa. However, there is a notable lack of data concerning the management and treatment outcomes for those affected. This study addresses this gap by examining the management and treatment outcomes of snakebite victims in Uganda.

METHODS

We reviewed retrospective data of 532 snakebite cases attending 16 Ugandan health facilities from January 2017 to December 2021. Demographic characteristics and clinical data were extracted from patient records and summarized using descriptive statistics.

RESULTS

The snakebite victims had a median age of 26 y, most were male (55.3%) and had bites of unidentified snake species (92.3%). Among the 465 treated patients, 71.6% received antibiotics, 66.0% hydrocortisone, 36.3% analgesics and only 6.9% antivenom. No adverse antivenom reactions were documented. The majority (89.5%) were discharged; 1.3% died and 5.5% had unknown outcomes.

CONCLUSIONS

These results suggest that snakebite envenoming affects vulnerable Ugandans, particularly young males and children. Treatment is primarily supportive, with antibiotic overuse and infrequent antivenom administration. Health provider training on appropriate snakebite management is needed to optimize outcomes.

Health-seeking behaviours and traditional healer practices for snakebite in rural and tribal communities in southern India

BACKGROUND

Nearly 60 000 Indians die of snakebite envenoming each year. Most deaths occur in rural communities and remote tribal settlements. We describe snakebite-related epidemiology and health-seeking behaviours in a rural (Timiri) and remote tribal block (Jawadhu Hills) in Tamil Nadu, India.

METHODS

This cross-sectional survey used structured questionnaires for information pertaining to snakebites and their treatment in the preceding year. Treatment-seeking behaviour from the moment reported until recovery was mapped. Traditional healers residing in the two blocks were also surveyed.

RESULTS

Snakebite incidence and mortality were 174/100 000 population and 2.7/100 000 population in Jawadhu Hills and 194/100 000 population and 2.6/100 000 population in Timiri, respectively. More snakebite victims applied tourniquets in Jawadhu Hills (90%) than in Timiri (69%). Traditional healers were the first contact for 64% in Jawadhu Hills. Ambulances and buses were reported as unavailable in Jawadhu Hills. Traditional healers in Jawadhu Hills did not refer snakebite victims to hospitals.

CONCLUSIONS

Three challenges to snakebite mitigation in Indian rural and tribal communities highlighted in this study are potentially harmful first aid, a disconnect between traditional healers and the public health system and a lack of emergency transport to health facilities. Addressing these challenges would necessitate community awareness, traditional healer engagement and improved means of public transportation.

Treatment response and clinical features of snakebite envenomation in Alborz province, Iran: A cross-sectional study

Background

Snakebite envenomation is a significant yet neglected public health burden. Our aim was to investigate the clinical and demographic factors of snakebite envenomation, as well as the factors associated with its severity and response to treatment, in Alborz province, northern Iran.

Methods

In this cross-sectional study, we included 50 patients diagnosed with snakebite envenomation, referring to the Poison Control Centre of Alborz University of Medical Sciences. The presenting signs and symptoms, demographic data, treatment dose, response to treatment, complications, laboratory findings, and snakebite severity scale (SSS) were collected.

Results

Forty-six patients (92%) were men, the total mean age was 31.7 ± 12.06 years, and mean SSS was 6.54 ± 3.39. The patients were admitted for a median of 2 days, and 11 patients needed ICU admissions. The majority of snakebites were in upper extremities (60%) and they mainly occurred in summer (56%). SSS was significantly associated with response to treatment, ICU admission, gastrointestinal adverse events, thrombocytopenia, and length of stay. Similarly, response to treatment was significantly related to the history of snakebite, ICU admission, gastrointestinal adverse events, thrombocytopenia, length of stay, and SSS.

Conclusion

Gastrointestinal symptoms, higher severity scores, and longer hospital stays were associated with poor treatment response. Importantly, no mortality was observed in this cohort. Further research is needed to confirm these findings and optimize treatment strategies for snakebite management.

Snakebite Management: The Need of Reassessment, International Relations, and Effective Economic Measures to Reduce the Considerable SBE Burden

The sole treatment for snakebite envenomation (SBE), the anti-snake venom (ASV), suffers from considerable drawbacks, including side effects and limited species specificity. Additionally, despite its existence for more than a century, uniform availability of good quality ASV does not yet exist. The present review describes the journey of a SBE victim and highlights the global crisis of SBE management. A detailed analysis of the current ASV market has also been presented along with the worldwide snake distribution. The current production of country specific licensed ASV throughout the globe along with their manufacturers has been examined at the snake species level. Furthermore, a detailed analysis of on-ground situation of SBE management in antivenom manufacturing countries has been done using the most recent literature. Additionally, the export and import of different ASVs have been discussed in terms of procurement policies of individual countries, their shortcomings, along with the possible solution at the species level. It is interesting to note that in most countries, the existence of ASV is really either neglected or overstated, implying that it is there but unsuitable for use, or that it is not present but can be obtained from other countries. This highlights the urgent need of significant reassessment and international collaborations not just for development and production, but also for procurement, distribution, availability, and awareness. A PROMISE (Practical ROutes for Managing Indigenous Snakebite Envenoming) approach has also been introduced, offering simple, economical, and easy to adopt steps to efficiently alleviate the worldwide SBE burden.

Snake diversity, occupancy, and detection on Thailand's largest university campus

More than 240 species of snake have been described from Thailand, yet basic natural history and ecology for this group of animals remains scarce in human disturbed environments despite conservation and human medical significance of them in these habitats. We studied snake diversity at Walailak University from March to December 2023, the largest university campus in Thailand (1525 hectares) through standardized walking surveys, opportunistic notifications and observation, road surveys, and traps and evaluated diversity using the Shannon diversity index (H), Pielou's evenness of species (J), detection probabilities (p), and occupancy probabilities (ψ). We observed 195 snakes (21 species, 7 families) at Walailak University and overall snake diversity (H = 2.60) and evenness (J = 0.85) were quite high, although specific site diversity (range H = 0-1.94) and evenness (range J = 0.67-0.91) within the university were variable. The probability of detecting snakes (range p = .10-.40) increased with increasing humidity and decreased with increasing amount of rain, temperature, and wind; site occupancy probability decreased with increased canopy height and increased with increased distance to buildings, increased canopy height loss, increased distance to roads, and increased distance to water. Our findings of relatively high snake diversity, presence of snake species potentially dangerous to humans (six species), and protected snake species (Thailand WARPA and international CITES, five species) suggest significant potential for conservation and further research at Walailak University and other campuses in Thailand.

Metabolomic analysis of Agkistrodon haly venom poisoning mouse treatment by Jidesheng snake pill based on GC-MS

Introduction

Snakebites are acute systemic toxic diseases caused by snake venom entering the body through wounds. Failure to use antivenom immediately and difficulty in obtaining antivenoms are frequently responsible for worsening disease. Traditional Chinese medicine is commonly used to supplement and replace antivenom in treating snakebites. The Jidesheng snake pill (JDS) is a widely used traditional Chinese medicine that has achieved good clinical therapeutic effects; however, its mechanism remains unclear. Therefore, metabolomics techniques were employed to explore the pathophysiological mechanisms of JDS treatment of Agkistrodon halys (Ah) snake venom-poisoned mice.

Methods

The Ah group mouse model was established by intramuscular injection of Ah venom into the hind legs of the mice. The Ah venom + JDS group model was established using JDS after the affected area was treated with Ah venom. Hematoxylin and eosin (HE) staining was used to evaluate the severity of gastrocnemius injury. Quantitative polymerase chain reaction (qPCR) was utilized to detect the mRNA expression of vascular cell adhesion molecule-1 (VCAM-1), muscle-specific creatine kinase (CKM), thrombin antithrombin complex (TAT), and tumor necrosis factor-alpha (TNF-α). Gas chromatography-mass spectrometry (GC-MS) was performed with multivariate statistical analysis to provide new insights into the global metabolic profile of Ah venom-poisoned mice.

Results

HE staining revealed increased red cell necrosis, local hemorrhage, and neutrophil infiltration in the Ah venom group than in the control group. Several compounds were identified, including lipids, amino acids, peptides, and organooxygen. Eighty differential metabolites were screened between the control group and the Ah venom group, and 24 were screened between the Ah venom and JDS groups. The mechanism of Ah venom poisoning in mice may involve aminoacyl-tRNA biosynthesis, various amino acid metabolism disorders, tricarboxylic acid circulation disorders, and abnormal fatty acid metabolism. JDS may reduce symptoms by affecting long-chain fatty acid and amino acid metabolism and promoting nicotinamide-nicotinamide metabolism.

Conclusion

Our results suggest that metabolomics has huge prospects for elucidating the pathophysiology of Agkistrodon haly venom poisoning and therapeutic mechanisms of JDS.

Neurotoxic snakebite envenomation treated with Philippine cobra antivenom in the eastern Visayas: a descriptive study between 2016 and 2020

Introduction

There is a significant shortage of observational studies on neurotoxic snakebite envenomation in the Philippines. This lack of data, especially concerning treatment using Purified Cobra Antivenom (PCAV), has prompted the initiation of this foundational study.

Methods

The target population included snakebite patients admitted to the Eastern Visayas Medical Center and treated with PCAV between 2016 and 2020. A retrospective chart review was conducted for data collection. The investigation analyzed the hospital stay and patient features of individuals who were administered either lower or higher doses of PCAV.

Results

Eighty-two patients were identified during the study. Of these, 27 (33%) were under 20 years of age and 50 (61%) were male. Most patients, totalling 75 (92%) were hailed from rural areas. Of the 82 patients, 59 (72%) received one or two ampoules of PCAV during the course. However, patients who received more than two ampoules had a longer median hospital stay than those who received less than three ampoules [96 h (interquartile range, IQR 66-122) vs. 125 h (IQR 96-218), P = 0.038]. The study reported five in-hospital mortalities (6.1%).

Conclusions

The individuals who needed a high dosage of PCAV tended to have more extended hospital stays, yet over 70% of the patient population required a lower dosage. To gain a clearer understanding of the burden of neurotoxic snakebites and determine the optimal PCAV dosage based on disease severity in the area, a more comprehensive, prospective study is recommended.

A Guide to the Clinical Management of Vipera Snakebite in Italy

The genus Vipera encompasses most species of medically significant venomous snakes of Europe, with Italy harbouring four of them. Envenomation by European vipers can result in severe consequences, but underreporting and the absence of standardised clinical protocols hinder effective snakebite management. This study provides an updated, detailed set of guidelines for the management and treatment of Vipera snakebite tailored for Italian clinicians. It includes taxonomic keys for snake identification, insights into viper venom composition, and recommendations for clinical management. Emphasis is placed on quick and reliable identification of medically relevant snake species, along with appropriate first aid measures. Criteria for antivenom administration are outlined, as well as indications on managing potential side effects. While the protocol is specific to Italy, its methodology can potentially be adapted for other European countries, depending on local resources. The promotion of comprehensive data collection and collaboration among Poison Control Centres is advocated to optimise envenomation management protocols and improve the reporting of epidemiological data concerning snakebite at the country level.

Attitudes towards snakebite health education and associated factors among residents in China: A national cross-sectional study

Background

This study aimed to investigate attitudes towards health education on snakebites and to identify the influencing factors among Chinese residents. Additionally, we proposed effective health education strategies for snakebite management.

Methods

Between May 2022 and February 2023, we conducted a nationwide cross-sectional questionnaire survey using a multistage sampling method with supplementary snowball sampling. We used descriptive analysis, χ2 tests, and univariable and multivariable binary logistic regression models to analyse the data.

Results

We included 56 669 respondents in the analysis. The average score for snakebite knowledge was 12.13 ± 5.26 points, with a maximum score of 28. Among the respondents, 72.66 and 63.03% of the residents believed that it was necessary to disseminate knowledge about snakebites and expressed a willingness to receive snakebite training, respectively. Respondents from the northeast region, respondents with a higher education level, and respondents with higher scores for snakebite knowledge, health knowledge, health skills, and social-psychological adjustment skills exhibited more positive attitudes towards snakebite knowledge dissemination and training. Conversely, respondents from eastern or southern China, respondents older than 60, and respondents who lived in rudimentary housing conditions showed a lower perception of the need for snakebite knowledge dissemination and were less willing to participate in snakebite knowledge and skill training.

Conclusions

Generally, Chinese residents have positive attitudes towards snakebite knowledge dissemination and training. However, the public lacks sufficient knowledge about snakebites. Therefore, we should pay close attention to areas south of the Yangtze River to strengthen snakebite health education using engaging formats that align with residents' interests, such as short videos or television programmes, in an attempt to and ultimately improve health literacy and prevention awareness.

Effect of Envenomation on Serum Hepatic Biomarkers in Snake (Echis Ocellatus) Bitten Individuals in Zamko Comprehensive Health Centre of the Jos University Teaching Hospital, North Central Nigeria

Background

Snake bite is a neglected public health issue in many tropical and subtropical countries of the world. About 5.4 million snakebites occur each year, resulting in 1.8 to 2.7 million cases of envenomation yearly. Hepatic markers have been reported to rise 3-6 hours after injection of venom in experimental animals. This study aims to biochemically assess ALT, AST and GGT levels as biomarkers of Echis ocellatus envenomation in victims of snake bite presenting at JUTH Comprehensive Health Centre Zamko 6hours post-bite and compare with values in those bitten by non-venomous snakes.

Methodology

The study was a comparative cross-sectional study where serum levels of AST, ALT and GGT were compared between the study group and the control group.

Results

Of the 150 respondents, 75 from each study group, 90(60.0%) were Male while 60(40.0%) were Female, with a Male to Female ratio of 1.5:1. The most predominant age group was 20-29 years 57(38.0%), the mean age was 39 years. The most predominant occupation was farming 82(54.7%). The majority 82(54.7%) had a secondary level of education. 91(60.7%) were married. A large majority of 123(82.0) had Christianity as their religion. We found a significant increase in the levels of AST (47.45IU/L) and GGT (61.62 IU/L) in the study group compared to AST (25.88IU/L), GGT (29.61IU/L) in the control group at p<0.05, while the level of ALT was similar in both groups at p>0.05.

Conclusion

This implies that serum levels of AST and GGT can be used to diagnose envenomation in snakebite patients.

Incidence and Risk Factors for Wound Infections after Trimeresurus stejnegeri Snakebites in Taiwan

Snakebite envenomation is a neglected tropical disease. Taiwan, with its subtropical and Southeast Asian environment, provides suitable habitat for several venomous snake species. Trimeresurus stejnegeri, an arboreal pit viper, is the most common cause of venomous snakebite in Taiwan. Trimeresurus stejnegeri envenomation can cause local swelling, occasional ecchymosis, and wound infection. The primary treatment of T. stejnegeri envenomation is the binary antivenom, vacuum freeze-dried F(ab')2 fragments of equine antibodies, against T. stejnegeri and Protobothrops mucrosquamatus. This study aimed to analyze the incidence of post-envenomation wound infections caused by T. stejnegeri based on data collected over a decade from institutions affiliated with the Chang Gung Memorial Hospital in Taiwan. A total of 254 patients were enrolled in this study. Clinical and laboratory data, treatment information, and patient outcomes were extracted from electronic medical records. Wound infection was associated with delay in antivenom initiation (adjusted odds ratio: 3.987; 95% CI: 1.406-11.302). The infection rates were 20.5%, 12.5%, 31.3%, and 48.1% for antivenom administration within 2 hours, 2-4 hours, 4-6 hours, and > 6 hours, respectively. Therefore, early initiation of antivenom treatment (within 6 hours) is recommended. Morganella morganii was cultured from wounds of the patients, whereas Enterobacter cloacae and Enterococcus faecalis were cultured from both the oral cavity of snakes and the wounds of the patients. For post-envenomation patients who develop a local infection, empiric antibiotics such as third-generation cephalosporins, quinolones, and piperacillin/tazobactam are recommended because snakebite wound infections are often polymicrobial in nature.

The Chinese guideline for management of snakebites

In 2009, the World Health Organization included snakebite on the list of neglected tropical diseases, acknowledging it as a common occupational hazard for farmers, plantation workers, and others, causing tens of thousands of deaths and chronic physical disabilities every year. This guideline aims to provide practical information to help clinical professionals evaluate and treat snakebite victims. These recommendations are based on clinical experience and clinical research evidence. This guideline focuses on the following topics: snake venom, clinical manifestations, auxiliary examination, diagnosis, treatments, and prevention.

Biochemical and hemostatic description of a thrombin-like enzyme TLBro from Bothrops roedingeri snake venom

Objective: The current study's objective is to characterize a new throm-bin-like enzyme called TLBro that was obtained from Bothrops roedingeris snake from a biochemical and hemostatic perspective. Methodology: One chromatographic step was used to purify it, producing the serine protease TLBro. Molecular mass was estimated by SDS-PAGE to be between reduced and unreduced by 35 kDa. Tryptic peptide sequencing using Swiss Prot provided the complete amino acid sequence. Expasy.org by conducting a search that is limited to Crotalinae snake serine proteases and displaying a high degree of amino acid sequence. Results: Ser (182) is inhibited by phenylmethylsulfonyl fluoride (PMSF), and TLBro demonstrated the presence of Asp (88) residues. It also deduced the positions of His (43) and Ser (182) in the set of three coordinated amino acids in serine proteases. It was discovered that this substrate had high specificity for BANA, Michaelis-Menten behavior with KM 0 point85 mM and Vmax 1 point89 nmoles -NA/L/min, and high stability between temperatures (15 to 70°C) and pHs (2 point0 to 10 point0). According to doses and incubation times, TLBro degraded fibrin preferentially on the B-chain; additionally, its activities were significantly diminished after preincubation with divalent ions (Zn2 and Cd2). When incubated with PMSF, a particular serine protease inhibitor, enzymatic activities and platelet aggregation were inhibited. Conclusion: The findings revealed distinct structural and functional differences between the serine proteases, adding to the information and assisting in the improvement of the structure-function relationship.

Clinical Risk Factors Associated with Poor Outcomes in Snake Envenoming: A Narrative Review

Snakebite-related fatalities disproportionately affect populations in impoverished socio-economic regions, marked by limited access to adequate healthcare and constrained antivenom availability. Early medical intervention is pivotal in mitigating mortality and morbidity associated with snakebite envenoming (SBE). While clinical assessment remains fundamental in treating SBE, this review aims to spotlight objective parameters that could also affect outcomes. Selected studies that identify factors associated with poor outcomes are predominantly region-specific, single-site, and observational, yet collectively reveal similar findings. They consistently report factors such as treatment delays, susceptibility in vulnerable groups such as children and pregnant women, as well as various biochemical and haematological abnormalities. Acute kidney injury (AKI), low platelets, leucocytosis, abnormal coagulation, and elevated creatine kinase (CK) all show an association with poor outcomes. Furthermore, recognising rare and unusual SBE presentations such as adrenal insufficiency, severe hypertension, intracranial haemorrhage, acute angle closure glaucoma, and bowel ischaemia also has a bearing on outcomes. Despite the integration of these parameters into clinical decision tools and guidelines, the validation of this evidence is limited. This review underscores the imperative for high-quality, multi-centre studies aligned with consensus-driven Core Outcome Sets (COS) and Patient-Reported Outcome Measures (PROMS) to validate and strengthen the current evidence.

Barriers and opportunities for improving management of snakebites: Perspectives of healthcare workers in Northern Uganda

BACKGROUND

Snakebites are a neglected public health problem that pose a significant burden on affected individuals and communities in many sub-Saharan African countries, including Uganda. However, the barriers and facilitators to snakebite management within healthcare settings are not as well understood and well-documented. The aim of this study was to explore the experiences and perspectives of healthcare workers involved in handling snakebite incidents at individual and health system levels in Arua and Gulu districts in Northern Uganda. We sought to understand how healthcare workers manage snakebite cases, what challenges they encounter, and what opportunities they perceive for improvement.

METHODS

We conducted a qualitative study using in-depth interviews with 18 healthcare workers from different cadres, seniority levels, and facility types. We used iterative thematic analysis to explore the management procedures, challenges, and opportunities for snakebite management. Using thematic analysis, we identified the overarching themes and subthemes related to snakebite management and associated barriers and opportunities.

RESULTS

The main barriers to snakebite management identified by healthcare workers were inadequate knowledge and skills; limited availability of antivenom; lack of protocols for snakebite management; delayed treatment-seeking for patients; and poor referral systems. The main opportunities for improvement were regular in-service training; increasing public education and awareness about snakebite prevention and management; and increased funding and research.

CONCLUSION

This study highlights the need for interventions to address the identified barriers while leveraging the existing opportunities to enhance snakebite management in Uganda. Specifically, we recommend the provision of regular training and support to healthcare workers, developing clinical guidelines, and improving the availability of antivenoms.

Inflammatory Profile Associated with Secondary Infection from Bothrops atrox Snakebites in the Brazilian Amazon

Bothrops snakebite envenomation (SBE) is consider an important health problem in Brazil, where Bothrops atrox is mainly responsible in the Brazilian Amazon. Local effects represent a relevant clinical issue, in which inflammatory signs and symptoms in the bite site represent a potential risk for short and long-term disabilities. Among local complications, secondary infections (SIs) are a common clinical finding during Bothrops atrox SBE and are described by the appearance of signs such as abscess, cellulitis or necrotizing fasciitis in the affected site. However, the influence of SI in the local events is still poorly understood. Therefore, the present study describes for the first time the impact of SBE wound infection on local manifestations and inflammatory response from patients of Bothrops atrox SBE in the Brazilian Amazon. This was an observational study carried out at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus (Brazil), involving victims of Bothrops SBE. Clinical and laboratorial data were collected along with blood samples for the quantification of circulating cytokines and chemokines before antivenom administrations (T0) and 24 h (T1), 48 h (T2), 72 h (T3) and 7 days after (T4). From the 94 patients included in this study, 42 presented SI (44.7%) and 52 were without SI (NSI, 55.3%). Patients classified as moderate envenoming presented an increased risk of developing SI (OR = 2.69; CI 95% = 1.08-6.66, p = 0.033), while patients with bites in hands showed a lower risk (OR = 0.20; CI 95% = 0.04-0.96, p = 0.045). During follow-up, SI patients presented a worsening of local temperature along with a sustained profile of edema and pain, while NSI patients showed a tendency to restore and were highlighted in patients where SI was diagnosed at T2. As for laboratorial parameters, leukocytes, erythrocyte sedimentation ratio, fibrinogen and C-reactive protein were found increased in patients with SI and more frequently in patients diagnosed with SI at T3. Higher levels of circulating IL-2, IL-10, IL-6, TNF, INF-γ and CXCL-10 were observed in SI patients along with marked correlations between these mediators and IL-4 and IL-17, showing a plurality in the profile with a mix of Th1/Th2/Th17 response. The present study reports for the first time the synergistic effects of local infection and envenoming on the inflammatory response represented by local manifestations, which reflected on laboratorial parameters and inflammatory mediators and thus help improve the clinical management of SI associated to Bothrops SBE.

Clinical Profile and Pharmacological Management of Snakebites in Community Care Units: A Retrospective Study Using Two Military Hospital Databases in South Thailand

Snakebite envenoming is an occupational hazard in remote rural areas of South Thailand, where the highest incidence of snakebites is reported. In this work, a hospital-based retrospective study of snakebite patients from 2012 to 2022 at Fort Wachirawut Hospital and Fort Thepsatrisrisunthon Hospital, located in Nakhon Si Thammarat province, Thailand was conducted. Data from the laboratory investigation, physical examinations of snakebite victims, and clinical management, including pharmacological and non-pharmacological treatments, were evaluated. A total of 54 snakebite victims were included. The median age of patients was 49 years (IQR, 28 to 63). Males accounted for 74.1% of all participants. The majority of patients were bitten by Malayan pit vipers (68.5%), followed by unidentified snakes (18.5%), other non-venomous snakes (7.4%), and cobras (5.6%). The most common clinical manifestations were swelling (90.2%) and local pain (73.2%). One patient experienced respiratory failure following an envenoming by an unidentified venomous snake. No deaths were observed in this study. In total, 24 patients received antivenom administration (44.4%), most of whom were from Fort Wachirawut Hospital. Patients who were administered antivenom showed a median admission duration of three days (IQR, 3 to 4), compared with two days (IQR, one to three) for those who did not receive antivenom treatment (p < 0.001). In addition, paracetamol and prophylactic antibiotics, namely, amoxicillin-clavulanate and dicloxacillin, were the most common pharmacotherapies following snakebites. Overall, it was observed that these two community hospitals undertook appropriate clinical management under the standard guidelines for snakebite patients. This might be due to the effective emergency management, facilities, and clinical consultations. Finally, the management process in the medical teams also plays a crucial role in minimizing the severity of snakebite outcomes.

Snakebite Advice and Counseling From Artificial Intelligence: An Acute Venomous Snakebite Consultation With ChatGPT

BACKGROUND

Snakebites, particularly from venomous species, present a significant global public health challenge. Access to accurate and timely information regarding snakebite prevention, recognition, and management is crucial for minimizing morbidity and mortality. Artificial intelligence (AI) language models, such as ChatGPT (Chat Generative Pre-trained Transformer), have the potential to revolutionize the dissemination of medical information and improve patient education and satisfaction.

METHODS

This study aimed to explore the utility of ChatGPT, an advanced language model, in simulating acute venomous snakebite consultations. Nine hypothetical questions based on comprehensive snakebite management guidelines were posed to ChatGPT, and the responses were evaluated by clinical toxicologists and emergency medicine physicians.

RESULTS

ChatGPT provided accurate and informative responses related to the immediate management of snakebites, the urgency of seeking medical attention, symptoms, and health issues following venomous snakebites, the role of antivenom, misconceptions about snakebites, recovery, pain management, and prevention strategies. The model highlighted the importance of seeking professional medical care and adhering to healthcare practitioners' advice. However, some limitations were identified, including outdated knowledge, lack of personalization, and inability to consider regional variations and individual characteristics.

CONCLUSION

ChatGPT demonstrated proficiency in generating intelligible and well-informed responses related to venomous snakebites. It offers accessible and real-time advice, making it a valuable resource for preliminary information, education, and triage support in remote or underserved areas. While acknowledging its limitations, such as the need for up-to-date information and personalized advice, ChatGPT can serve as a supplementary source of information to complement professional medical consultation and enhance patient education. Future research should focus on addressing the identified limitations and establishing region-specific guidelines for snakebite management.

Application of Sonographic Assessments of the Rate of Proximal Progression to Monitor Protobothrops mucrosquamatus Bite-Related Local Envenomation: A Prospective Observational Study

Patients bitten by Protobothrops mucrosquamatus typically experience significant pain, substantial swelling, and potentially blister formation. The appropriate dosage and efficacy of FHAV for alleviating local tissue injury remain uncertain. Between 2017 and 2022, 29 snakebite patients were identified as being bitten by P. mucrosquamatus. These patients underwent point-of-care ultrasound (POCUS) assessments at hourly intervals to measure the extent of edema and evaluate the rate of proximal progression (RPP, cm/hour). Based on Blaylock's classification, seven patients (24%) were classified as Group I (minimal), while 22 (76%) were classified as Group II (mild to severe). In comparison to Group I patients, Group II patients received more FHAV (median of 9.5 vials vs. two vials, p-value < 0.0001) and experienced longer median complete remission times (10 days vs. 2 days, p-value < 0.001). We divided the Group II patients into two subgroups based on their clinical management. Clinicians opted not to administer antivenom treatment to patients in Group IIA if their RPP decelerated. In contrast, for patients in Group IIB, clinicians increased the volume of antivenom in the hope of reducing the severity of swelling or blister formation. Patients in Group IIB received a significantly higher median volume of antivenom (12 vials vs. six vials; p-value < 0.001) than those in Group IIA. However, there was no significant difference in outcomes (disposition, wound necrosis, and complete remission times) between subgroups IIA and IIB. Our study found that FHAV does not appear to prevent local tissue injuries, such as swelling progression and blister formation, immediately after administration. When administering FHAV to patients bitten by P. mucrosquamatus, the deceleration of RPP may serve as an objective parameter to help clinicians decide whether to withhold FHAV administration.