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Lai R, Yan S, Wang S, Yang S, Yan Z, Lan P, Wang Y, Li Q, Wang J, Wang W, Ma Y, Liang Z, Zhang J, Zhou N, Han X, Zhang X, Zhang M, Zhao X, Zhang G, Zhu H, Yu X, Lyu C. The Chinese guideline for management of snakebites. World J Emerg Med 2024; 15:333-355. [PMID: 39290598 PMCID: PMC11402871 DOI: 10.5847/wjem.j.1920-8642.2024.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 08/08/2024] [Indexed: 09/19/2024] Open
Abstract
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.
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Affiliation(s)
- Rongde Lai
- Emergency Department, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Shijiao Yan
- School of Public Health, Hainan Medical University, Haikou 571199, China
| | - Shijun Wang
- Surgery Department of Traditional Chinese Medicine, the Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou 350004, China
| | - Shuqing Yang
- Emergency Department, Chongqing University Central Hospital/Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Zhangren Yan
- Department of Surgery of Traditional Chinese Medicine, Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang 330006, China
| | - Pin Lan
- Department of Emergency Medicine, the Fifth Affiliated Hospital of Wenzhou Medical University/Lishui Central Hospital, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Yonggao Wang
- General Surgery Department, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, China
| | - Qi Li
- Emergency Department, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350001, China
| | - Jinlong Wang
- Emergency Department, Chongqing University Fuling Hospital, Chongqing University, Chongqing 408000, China
| | - Wei Wang
- Emergency Department, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Yuefeng Ma
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Zijing Liang
- Emergency Department, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Jianfeng Zhang
- Emergency Department , Wuming Hospital of Guangxi Medical University, Nanning 530021, China
| | - Ning Zhou
- Emergency Department, Central People's Hospital of Zhanjiang, Zhanjiang 524037, China
| | - Xiaotong Han
- Emergency Department, Hunan Provincial People's Hospital, Changsha 410005, China
| | - Xinchao Zhang
- Emergency Department, National Geriatrics Center of Beijing Hospital, Beijing 100020, China
| | - Mao Zhang
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Xiaodong Zhao
- Emergency Department, the Fourth Medical Center of the PLA General Hospital, Beijing 100048, China
| | - Guoqiang Zhang
- Emergency Department, China-Japan Friendship Hospital, Beijing 100029, China
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, BeiJing 100730, China
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, BeiJing 100730, China
| | - Chuanzhu Lyu
- Emergency Department, Sichuan Academy of Medical Sciences/Sichuan Provincial People's Hospital, Chengdu 610072, China
- Research Unit of Island Emergency Medicine, Chinese Academy of Medical Sciences (No. 2019RU013), Hainan Medical University, Haikou 571199, China
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Gopalakrishnan M, Saurabh S, Sagar P, Bammigatti C, Dutta TK. A simple mortality risk prediction score for viper envenoming in India (VENOMS): A model development and validation study. PLoS Negl Trop Dis 2022; 16:e0010183. [PMID: 35192642 PMCID: PMC8896694 DOI: 10.1371/journal.pntd.0010183] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 03/04/2022] [Accepted: 01/20/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Snakebite is a neglected problem with a high mortality in India. There are no simple clinical prognostic tools which can predict mortality in viper envenomings. We aimed to develop and validate a mortality-risk prediction score for patients of viper envenoming from Southern India. METHODS We used clinical predictors from a prospective cohort of 248 patients with syndromic diagnosis of viper envenoming and had a positive 20-minute whole blood clotting test (WBCT 20) from a tertiary-care hospital in Puducherry, India. We applied multivariable logistic regression with backward elimination approach. External validation of this score was done among 140 patients from the same centre and its performance was assessed with concordance statistic and calibration plots. FINDINGS The final model termed VENOMS from the term "Viper ENvenOming Mortality Score included 7 admission clinical parameters (recorded in the first 48 hours after bite): presence of overt bleeding manifestations, presence of capillary leak syndrome, haemoglobin <10 g/dL, bite to antivenom administration time > 6.5 h, systolic blood pressure < 100 mm Hg, urine output <20 mL/h in 24 h and female gender. The lowest possible VENOMS score of 0 predicted an in-hospital mortality risk of 0.06% while highest score of 12 predicted a mortality of 99.1%. The model had a concordance statistic of 0·86 (95% CI 0·79-0·94) in the validation cohort. Calibration plots indicated good agreement of predicted and observed outcomes. CONCLUSIONS The VENOMS score is a good predictor of the mortality in viper envenoming in southern India where Russell's viper envenoming burden is high. The score may have potential applications in triaging patients and guiding management after further validation.
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Affiliation(s)
- Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences Jodhpur, Rajasthan, India
| | - Suman Saurabh
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pramod Sagar
- Department of Cardiology, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Chanaveerappa Bammigatti
- Department of Medicine, Jawaharlal Institute of Medical Education and Research, Puducherry, India
| | - Tarun Kumar Dutta
- Department of Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
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Sirur FM, Lath V, A S C, Mohan G, Shastry S. A Tropical Kiss by a Malabar Pit Viper. Wilderness Environ Med 2021; 33:116-121. [PMID: 34865965 DOI: 10.1016/j.wem.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/13/2021] [Accepted: 10/01/2021] [Indexed: 11/28/2022]
Abstract
Snakebite in India is often attributed to the "big 4," for which polyvalent anti-snake venom is effective. Also significant and less known is the burden of other venomous snakes, one of which is Trimeresurus malabaricus. We report a bite to the face of a tree climber by Trimeresurus malabaricus in the Western Ghats of India, which caused severe local envenomation in the form of facial edema and systemic signs of envenomation, including coagulopathy and hypotension. We discuss the role of thromboelastogram, infrared thermography, and routine diagnostics in this case, which led to the administration of Indian-made polyvalent anti-snake venom. The patient recovered and was discharged without any clinically evident physiological or physical dysfunction.
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Affiliation(s)
- Freston Marc Sirur
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India.
| | - Vrinda Lath
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Chethana A S
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Ganesh Mohan
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shamee Shastry
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Hamza M, Knudsen C, Gnanathasan CA, Monteiro W, Lewin MR, Laustsen AH, Habib AG. Clinical management of snakebite envenoming: Future perspectives. Toxicon X 2021; 11:100079. [PMID: 34430847 PMCID: PMC8374517 DOI: 10.1016/j.toxcx.2021.100079] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/29/2021] [Accepted: 07/30/2021] [Indexed: 11/18/2022] Open
Abstract
Snakebite envenoming is a major cause of morbidity and mortality in rural communities throughout the tropics. Generally, the main clinical features of snakebites are local swelling, tissue necrosis, shock, spontaneous systemic hemorrhage, incoagulable blood, paralysis, rhabdomyolysis, and acute kidney injury. These clinical manifestations result from complex biochemical venom constituents comprising of cytotoxins, hemotoxins, neurotoxins, myotoxins, and other substances. Timely diagnosis of envenoming and identification of the responsible snake species is clinically challenging in many parts of the world and necessitates prompt and thorough clinical assessment, which could be supported by the development of reliable, affordable, widely-accessible, point-of-care tests. Conventional antivenoms based on polyclonal antibodies derived from animals remain the mainstay of therapy along with supportive medical and surgical care. However, while antivenoms save countless lives, they are associated with adverse reactions, limited potency, and are relatively inefficacious against presynaptic neurotoxicity and in preventing necrosis. Nevertheless, major scientific and technological advances are facilitating the development of new molecular and immunologic diagnostic tests, as well as a new generation of antivenoms comprising human monoclonal antibodies with broader and more potent neutralization capacity and less immunogenicity. Repurposed pharmaceuticals based on small molecule inhibitors (e.g., marimastat and varespladib) used alone and in combination against enzymatic toxins, such as metalloproteases and phospholipase A2s, have shown promise in animal studies. These orally bioavailable molecules could serve as early interventions in the out-of-hospital setting if confirmed to be safe and efficacious in clinical studies. Antivenom access can be improved by the usage of drones and ensuring constant antivenom supply in remote endemic rural areas. Overall, the improvement of clinical management of snakebite envenoming requires sustained, coordinated, and multifaceted efforts involving basic and applied sciences, new technology, product development, effective clinical training, implementation of existing guidelines and therapeutic approaches, supported by improved supply of existing antivenoms.
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Affiliation(s)
- Muhammad Hamza
- Infectious and Tropical Diseases Unit, Bayero University Kano, Nigeria
| | - Cecilie Knudsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | | | - Wuelton Monteiro
- Department of Research, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
- School of Health Sciences, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Matthew R. Lewin
- Center for Exploration and Travel Health, California Academy of Sciences, San Francisco, USA
| | - Andreas H. Laustsen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
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Infrared Thermal Imaging as a Novel Non-Invasive Point-of-Care Tool to Assess Filarial Lymphoedema. J Clin Med 2021; 10:jcm10112301. [PMID: 34070599 PMCID: PMC8198125 DOI: 10.3390/jcm10112301] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 12/13/2022] Open
Abstract
Lymphatic filariasis causes disfiguring and disabling lymphoedema, which is commonly and frequently exacerbated by acute dermatolymphangioadenitis (ADLA). Affected people require long-term care and monitoring but health workers lack objective assessment tools. We examine the use of an infrared thermal imaging camera as a novel non-invasive point-of-care tool for filarial lower-limb lymphoedema in 153 affected adults from a highly endemic area of Bangladesh. Temperature differences by lymphoedema stage (mild, moderate, severe) and ADLA history were visualised and quantified using descriptive statistics and regression models. Temperatures were found to increase by severity and captured subclinical differences between no lymphoedema and mild lymphoedema, and differences between moderate and severe stages. Toes and ankle temperatures detected significant differences between all stages other than between mild and moderate stages. Significantly higher temperatures, best captured by heel and calf measures, were found in participants with a history of ADLA, compared to participants who never had ADLA, regardless of the lymphoedema stage. This novel tool has great potential to be used by health workers to detect subclinical cases, predict progression of disease and ADLA status, and monitor pathological tissue changes and stage severity following enhanced care packages or other interventions in people affected by lymphoedema.
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