Efficacy of a low dose of antivenom for severe neuroparalysis in Bungarus caeruleus (common krait) envenomation: a pilot study

Introduction

Despite the widespread use of antivenom for the treatment of snakebite envenoming in the Indian subcontinent, the ideal dose of antivenom has been a point of contention. Low-dose regimens can economize on a scarce resource in low- and middle-income countries. This study assessed the effectiveness of a low-dose (10 vials) antivenom regimen compared to the usual 20 vials in patients with krait bite neuroparalysis requiring mechanical ventilation.

Methods

This study was a prospective controlled pilot study conducted in a tertiary-care hospital in north India. Participants were eligible if they were ≥12 years old, had krait bite neurotoxicity, showed severe paralysis requiring mechanical ventilation, and had access to antivenom therapy within 24 h of the bite. The primary outcome was the duration of mechanical ventilation, and the secondary outcomes were the length of hospital stay and in-hospital survival.

Results

Fifteen patients received 10 vials of antivenom, and 25 received 20 vials. The two treatment groups had similar baseline demographics, clinical and laboratory features, snakebite severity scores, and median time from snakebite to initiation of antivenom therapy. The low-dose regimen was as effective as the standard dose concerning the median duration of mechanical ventilation (41 h vs. 55 h, P = 0.094), the median length of stay (78 h vs. 85.5 h, P = 0.360), and in-hospital deaths (1 vs. 3, P = 1.000). The incidence of ventilator-associated pneumonia was similar between the two groups (1 vs 3, P = 1.000).

Conclusion

A low dose of antivenom effectively treats patients with severe krait bite neuroparalysis.

A Case of Keraunoparalysis: A Bolt from the Blue

Keraunoparalysis is a catastrophic but fortunately totally reversible neuroparalysis of the limbs occurring due to a lightning strike. One such case with transient right hemiparesis along with a brief account of the pathophysiology of this unique neurologic problem has been presented here.

Predictors of mortality in patients of poisonous snake bite: Experience from a tertiary care hospital in Central India

Background and Aims:

This study was undertaken, to assess the clinical parameters in patients of poisonous snakebite, complications which occurred in them, their outcome and to evaluate various clinical predictors of mortality

Materials and Methods:

Four hundred and thirty-two patients of snake bite were admitted, of which 172 did not show any signs of envenomation and excluded. Two hundred and sixty patients had signs of local or systemic envenomation and included. Complete clinical examination, blood counts, kidney function tests, serum electrolytes, coagulation profile was done in all patients. All received tetanus toxoid and anti-snake venom (ASV). Appropriate supportive treatment was given. Clinical and laboratory parameters were compared between patients who were discharged (Group A) and those who expired (Group B). All data analysis was performed by using stata software version 10 [StataCorp LP, Texas, USA] and SPSS version 11 [SPSS Inc, Chicago, USA].

Results:

Out of 260 patients, 58 died and 202 survived. Mean age was 34.97 ± 14.07 years. One hundred and eighty-six (71.5%) patients were from rural areas and 74 (28.5%) from urban. 63.4% of bites occurred during rainy season. One hundred and ninety-seven (75.8%) had bite on lower limb and 62 (23.8%) on upper limbs. All 260 patients (100%) had pain at site of bite, local swelling in 252 (96.9%) and blackening of skin, blebs in 18 (6.9%). Seventy-seven (29.6%) had bleeding tendencies. Ptosis was present in all the 65 patients with signs of neuroparalysis. Eighty (30.8%) patients had acute renal failure. The mean duration of stay in survivors was 7.50 + 4.13 days and in non-survivors it was 3.45 + 3.02 days. Out of 58 who died 18 (31%) patients, succumbed within 24 hrs. On multivariate analysis, significant predictors o mortality were bleeding tendency (P = 0.013), mean PTTK (sec) (P = 0.047), respiratory failure (P = 0.045), shock (P = 0.013), mean ASV dose (cc) (P < 0.001).

Conclusions:

Mortality in patients with snake bite can be predicted by simple variables like presence of bleeding tendencies, respiratory failure, and shock. These parameters can help the doctors at peripheral health centers to predict outcome, so that such high risk cases can be referred to higher centers for expertise management without wasting time.

Indian common krait envenomation presenting as coma and hypertension: A case report and literature review

Neuroparalytic snake bite is a common emergency situation encountered in India. Common krait (Bungarus caeruleus) and cobra (Naja naja) are important snakes causing neuroparalysis in North India. Despite severe neuroparalysis, patients who receive antivenin and ventilator support in time recover completely. Autonomic disturbances resulting in resting tachycardia, labile hypertension and sweating have been described in common krait envenomation. We present a case of common krait (B. caeruleus) envenomation presenting in the locked-in state and severe hypertension that remained in such a state for over 96 h before a gradual and sustained recovery.