HANDBOOK ON TREATMENT GUIDELINES FOR SNAKE BITE AND SCORPION STING 2008 - TNHSP PUBLICATION

HANDBOOK ON TREATMENT GUIDELINES FOR SNAKE BITE AND SCORPION STING

Tamil Nadu Health Systems Project Health and Family Welfare Department Government of Tamil Nadu, Chennai.

2008

Tamil Nadu Health Systems Project 7th Floor, DMS Building, Chennai - 600 006. Tel. Off : (91-44) 2434 5997 Fax : (91-44) 2434 5997 Email : [email protected]

Dr. S. VIJAYA KUMAR I.A.S., Special Secretary to Government Health & Family Welfare Dept., & Project Director

INTRODUCTION The Tamil Nadu Health Systems Project formed a snake bite task force in 2006 to try and understand the staggering Þgures that were surfacing on snake bite and scorpion sting cases in Tamil Nadu. During the effort, it was apparent that despite morbidity and mortality, an evidence based handbook on treatment guidelines was not available to medical ofÞcers as a ready reckoner in dealing with affected persons. A committee was then formed to prepare guidelines to treat snake bite and scorpion sting with the assistance of the Health & Family Welfare department and in particular the Poison Control, Training and Research Treatment Centre in Government General Hospital, Chennai. The Committee has prepared this Handbook after several rounds of discussion and has also subjected this document to a peer review. This handbook will help to redeÞne patient care for those who suffer from snake bite and scorpion sting and will be useful for health care providers, patients and policy makers. Information provided in the following pages range from epidemiological issues, clinical features, treatment modalities, management of complications, referral aspects medical audit, research areas and so on. With this handbook, we hope to ensure that a major information gap is adequately plugged so as to ensure rational medical treatment and appropriate quality of care for snake bite and scorpion sting victims.

November 2008

Dr. S. VIJAYA KUMAR

Chennai.

iii

EDITORIAL COMMITTEE Chair Person : Thiru.Dr.S.Vijaya kumar, I.A.S., Project Director and Special Secretary to Government, Tamil Nadu Health Systems Project, Chennai – 6.

Members: Dr. (Capt.) M.Kamatchi, Expert Advisor, TamilNadu Health Systems Project (TNHSP), Chennai. Dr. P. Thirumalaikolundusubramanian, Former Director, Professor and Head, Institute of Internal Medicine, Madras Medical College and Emeritus Professor, The Tamil Nadu Dr.M.G.R. Medical University, Chennai. Mr. Ian D. Simpson, Consultant, Member of Tamil Nadu Snake Bite Task Force and Snake bite advisor to Pakistan Medical Research Council Dr. C. Rajendiran, Director, Professor and Head, Institute of Internal Medicine, Madras Medical College and Physician i/c, IMCU & Poison Control, Training and Research Centre, Government General Hospital, Chennai. Dr. P. Ramachandran, Pediatrician, & Registrar, Institute of Child Health & Hospital for Children, Madras Medical College, Chennai. Dr. C. Ravichandran, Asst. Professor, Institute of Child Health & Hospital for Children, Madras Medical College, Chennai. Mrs. Beaula Indrani, Public Health Nurse, Reproductive & Child Health, Chennai. Dr. G. Sasikala, Editorial Assistant, TNHSP, Chennai. iv

ACKNOWLEDGEMENT Tamil Nadu snakebite task force team and staff Tamil Nadu Health Systems Project (TNHSP), Chennai thank the Ministry of Health and Family Welfare, Health & Family Welfare Department, State Government of Tamil Nadu, Chennai, India and Madras Medical College, Chennai for making arrangements to prepare the treatment guidelines for snakebite and scorpion sting; and also thank the Ministry of Health & Family Welfare, Government of India, New Delhi, for considering the treatment guidelines prepared from Tamil Nadu for Snake bite favourably. The encouragement provided by Thiru .V.K. Subburaj, I.A.S., Principal Secretary to Government, Health & Family Welfare Department, Government of Tamil Nadu, Chennai; Ms. Supriya Sahu, I.A.S., former Additional Secretary, Tamil Nadu Health Systems Project, Chennai; Thiru. P.W.C. Davidar, I.A.S., Former Project Director & Special Secretary to Government, Tamil Nadu Health Systems Project, Chennai; and Thiru. Muthiah Kalaivanan, I.A.S., former Project Director, Reproductive and Child Health (RCH), Chennai, for the preparation of the treatment guidelines for snakebite and scorpion sting is gratefully acknowledged. The support provided by former Director of Medical Education, Dr. Vijayalakshmi, former Director of Medical and Rural Health Services, Dr. N. Kalyanasundaram and former Director of Public Health and Preventive Medicine, Dr. S.Murugan are duly acknowledged. The services rendered by Dr. P. Padmanabhan, Director of Public Health and Preventive Medicine, Chennai; Dr.V.K. Rajamani, Professor of Medicine, and Dr. Saradha Suresh, Director and Superintendent, Professor and Head of Pediatrics, Madras Medical College, Chennai; Dr. S. Shivakumar, Professor and Head of Medicine, Stanley Medical College, Chennai; Dr. A. Ayyappan, Professor and Head of Medicine and Dr. M.L. Vasanthakumari, Professor of Pediatrics, Madurai Medical College, Madurai; Dr. S. Muthukumaran, Professor and Head of Medicine, Thanjavur Medical College, Thanjavur; Dr. Vasantha Elango, Professor and Head of Community Medicine, and Dr. K.Umakanthan, Professor and Head of Medicine, Coimbatore Medical College, Coimbatore; Dr. K. Sathyamoorthy, Professor and Head of Medicine, Government M.K. Medical College, Salem; and Dr. R.A. Sankaramanian, Professor of Pediatrics, Government Theni Medical College, Theni in reviewing the manuscript and offering suggestions are greatly appreciated.

v

STATEMENTS 1. For private circulation, not for sale 2. Acknowledging the source permits copying or translating the material 3. This module is designed to give concise information for medical practitioners and not intended to provide comprehensive scientiÞc information 4. For detailed and up to date information as well as to know the current developments, users are requested to go through the original articles, review papers, case reports, related publications, websites etc., 5. For administration of each drug, users are informed to go through the latest product information leaßets provided by the manufacturers 6. Users are reminded to recall the contraindications before using any drug. 7. Users have been motivated to make use of their experience and knowledge of patients before deciding the dosage and treatment of each patient 8. The hand book has been revised as on November 2008 9. The publishers, Tamil Nadu Health Systems Project, Health and Family Welfare Department, Chennai, Tamil Nadu, Funding agency, the contributors and reviewers do not assume liability for any injury and / or any damage to persons or property arising out of this publication 10. Readers are requested to submit their suggestions, views, feed back and their experience on snakebite / scorpion sting to the following mail address [[email protected]] which will be helpful for modifying / revising future editions.

vi

ABBREVIATIONS •

AS

–

Anti Snake Venom

•

AT

–

Antithrombin

•

BP

–

Blood Pressure

•

CT

–

Computerised Tomography

•

DIC

–

Disseminated Intravascular Coagulation

•

FFP

–

Fresh Frozen Plasma

•

Hg

–

Mercury

•

HR

–

Heart Rate

•

HCL

–

Hydrochloride

•

ICP

–

Intra Compartment Pressure

•

IM

–

Intramuscular

•

IV

–

Intravenous

•

LAB

–

Laboratory

•

PHC

–

Primary Health Centre

•

PIM

–

Pressure Immobilisation Method

•

PR

–

Pulse Rate

•

RR

–

Respiratory Rate

•

SD

–

Standard Deviation

•

WBCT –

Whole Blood Clotting Test

•

WHO –

World Health Organisation

vii

List of Tables, Figures, Pictures and Plates List of Tables Table 1: Statistics on clinical aspects of snake bites and outcome Table 2: Categorisation of snakes (W.H.O.1981) Table 3: Snakes, clinical aspects and therapeutic response Table 4: Details of local envenomation Table 5: 20 Minutes Whole Blood Clotting Test (20WBCT) Table 6: Currently recommended First aid Table 7: Principles involved in the management Table 8: Manifestations of immediate reactions to ASV Table 9: Dosage of adrenaline for adults and children Table 10: ASV – Risk and Wastage (Ian D.Simpson Model) Table 11: Surgical issues: assessment and action required. Table 12: Initial evaluation - No systemic envenomation Table 13: Haemotoxic envenomation Table 14: Neurotoxic envenomation Table 15: Referral aspects for snake bite Table 16: Distinguishing features of lethal and non-lethal scorpion Table 17: Inßuencing factors for symptoms and signs Table 18: Local effects at the site of sting. Table 19: Systemic signs of scorpion sting. Table 20: Non-neurological signs Table 21: Measures to be adopted while using Prazosin Table 22: Initial evaluation of scorpion sting without systemic envenomation Table 23: Evaluation of scorpion sting with systemic envenomation Table 24: Referral aspects for scorpion sting Table 25: Responsibilities of health care providers viii

Table 26: Levels of analysis Table 27: Formula to calculate case fatality rate at different levels Table 28: Snake bite cases reported and ASV vials used in secondary care hospitals (district wise) Table 29: Fluid requirement chart for children Table 30: Normal Respiratory Rate (per minute) by age. Table 31: Normal Heart Rate (per minute) by age Table 32: Normal Blood Pressure in children by age Table 33: Hypotension by systolic Blood Pressure and age

List of Figures Figure 1: Grading of scorpion envenomation Figure 2: Nervous system signs

List of Pictures Picture No. 1: Snakes of Medical Importance in Tamil Nadu Picture No. 2: Typical signs of local envenomation Picture No. 3: Cellulitis with compartmental syndrome Picture No. 4: Showing bilateral ptosis with overaction of frontalis Picture No. 5: Showing ophthalmoplegia

List of Plates Plate No. 1: Snake IdentiÞcation Plate No. 2: Important Venomous Snakes of India Plate No. 3: Primary / Community Health Care Centre - Snake bite Treatment Guidelines Plate No. 4: Secondary Health Care Centre - Snake bite Treatment Guidelines

ix

CONTENTS 1.

INTRODUCTION

iii

2.

EDITORIAL COMMITTEE

iv

3.

ACKNOWLEDGMENT

v

4.

STATEMENTS

vi

5.

ABBREVIATIONS

vii

6.

LIST OF TABLES, FIGURES, PICTURES AND PLATES

viii

7.

SECTION I:

SNAKEBITE

8.

SECTION II:

SCORPION STING

9.

SECTION III:

MISCELLANEOUS

10.

SECTION IV:

ANNEXURES

SECTION - I

SNAKE BITE Titles

Page

1.1 General • Introduction • Magnitude of the problem • Epidemiology of snake bite • Ecological aspects

1

1.2 Classification of snakes • Snakes of Medical Importance in Tamilnadu Distinguishing features

4

1.3 Clinical aspects of snake bite • Pathophysiology • Symptoms and signs • Criteria for diagnosis • Complications and outcome • Investigations

7

1.4 Treatment • First aid for snake bite • Traditional methods followed for treating snake bite • Newer methods - pressure pad or Monash technique • Principles involved in the management • Pharmacological aspects of Anti Snake Venom • ASV Administration criteria dosage administration • Facts to be remembered before / while using Inj.ASV • ASV reactions • Prevention of ASV reaction(s) – prophylactic regimens

14

Titles • • • • •

Page Repeat doses of ASV in Anti haemostatic envenomation Recurrent envenomation Anti-hemostatic maximum ASV dosage Recovery phase ASV risk and wastage

1.5 Clinical issues in Snakebite • Hypotension • Persistent or severe bleeding • Renal failure • Surgical issues • Use of Heparin and Botropase

29

1.6 Snake Bite in special situations • Victims requiring life saving surgery • Victims arriving late • Snake bites again! • Pregnancy and lactating women • Others

32

1.7 Management at Primary Health Care Centres and Block PHC

33

1.8 Referral aspects

36

1.9 Welfare measures

38

1.10 Occupational risk for snakebite

38

1.11 Preventive measures and health education

39

1.12 Resource material

39

Treatment Guidelines for Snakebite and Scorpion sting - 2008

1.1 General Introduction In many parts of India, snake is worshipped and in some areas special prayers are performed. In Northern India on Naga Panjami day people worship snake idol. In certain areas of Maharashtra and Goa the live snakes, rarely live cobras are brought for worship. Snake charmers carry snakes especially cobra, door to door for worship. At every house the snake’s mouth is forced open and some milk is poured down in its throat though milk is not snake food. It is also believed that snakes bite people who harmed them in their previous birth. When snakes are killed, people offer special prayers and bury them. People also believe that snakes take revenge against those who harmed them. In view of their strong beliefs and many associated myths, people resort to magicoreligious treatment for snake bite thus causing delay in seeking proper treatment. As a result, valuable time is lost in some of the deserving cases. It is poignant to note that some of the cinema and TV serial stories even now propagate non-scientiÞc ideas on snakes and snakebites, and display traditional treatment. Hence, there is a need for the health department to disseminate the scientiÞc aspects related to snakebites to the community.

Magnitude of the problem Recently global burden of snake bite was assessed using available published data and modeling technique. From that it is estimated that 4,21,000 envenomations and 20,000 deaths occur annually. These Þgures may be as high as 18,41,000 envenomation sand 94,000 deaths. Snake bites contribute to health problem in India and continue to be a major medical concern. India alone contributes to 81,000 envenomations and 11,000 deaths annually. Based on the above statistics, it appears that every 10 seconds one individual is envenomed and one among four dies due to snake bite. Many deaths occur before the victim reaches the hospital. Actually up-to-date national data, on the morbidity and mortality due to snakebite is not available. Moreover there is no national snake bite registry in India. So the available statistics is incomplete and not systematically collected. In 1972, Dr. Sawai and Dr. Homma of the Japan Snake Institute studied snakebite in about 10 hospitals in India. They reported that about 10% of snakebite deaths are among the victims who come to the hospital and about 90% die outside, having gone for other remedies like mantra, magic, and so on. However things are very different now, after 35 years. Government General Hospital, Chennai, from January to December 2006 has treated 281 cases of snakebites. Among them, there were 182 males and 99 females. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

1

Treatment Guidelines for Snakebite and Scorpion sting

94 were referred after treatment in different hospitals and 187 were brought to the hospital directly. 274 (97.5%) survived and 7 died due to various complications of snakebite while they were in the hospital. The details on the type of snakes, clinical signs, complications, number referred, number who received supportive therapy and death are provided below (Table no.1). Table No. 1: Statistics on clinical aspects of snake bites and outcome*

Type of snake Cobra Krait Russell’s viper Humpnosed viper Saw scaled viper Sea snake Non poisonous

Number Local treated signs

Supportive Neuro Hemo. Number Toxicity Toxicity Mechnical Expired Hemo- Fasciotomy. ventilation Dialysis 118 90 2 51 82 60 3 2

118 82

80 -

42

42

-

42

6

23

1

1

4

4

-

4

-

4

-

1

16

16

-

16

-

3

-

1

3

3

-

-

-

-

-

-

16

6

-

-

-

-

-

-

*Government General Hospital, Chennai (Jan – Dec 2006). An equal or more number of snake bite cases were admitted and treated at other Government Medical College Hospitals. Patients go to private hospitals mostly for Þrst aid purposes. Very few get adequate treatment in these hospitals. In Tamil Nadu the total number of snake bite cases admitted (and expired) in the secondary care hospitals alone during 2005 - 2006 and 2006 -2007 were 19321(85) and 20677(75) respectively. The total number of ASV vials used in these hospitals during the respective periods were 94481 and 96800 (Annexure I). Over all analysis revealed that the snakebites and ASV usage in West, North, East, Central, South zone of Tamil Nadu were 13, 17, 20, 24 and 26% respectively. The Government is spending a huge sum of money in procuring and supplying anti snake venom. On an average, Government hospitals spend a minimum of Rs.5,000/- per case of Snake bite and patient spends an equal amount for socio-cultural and magicoreligious aspects. The money lost due to loss of job and earning as well as loss of lives is huge, and thus has an impact on the national economy. Deaths due to snakebite can 2

Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.


be prevented, if some simple Þrst aid measures are undertaken by the public and / or by the health care providers. So, there is an urgent need to take effective steps to contain these issues. Many of the Þrst aid measures carried out at present are ineffective and dangerous. The research also concluded that the other traditional methods followed for snake bite are not appropriate. It is gratifying to note that the traditional snake catchers in Tamil Nadu, the Irulas with their own sophisticated herbal medicine system, have now understood the problems? They know that the snake injects venom which goes deep into the system and this can be neutralised only by injection of Anti snake venom (ASV) and not by oral or locally applied remedies, no matter how famous. But this information needs to reach other communities also. Hence, the need to recommend the most effective Þrst aid to the victims bitten by snakes and to recommend effective steps in the management of this problem. Poisoning due to cobra and viper groups are seen frequently in the state of Tamil Nadu. Very rarely sea snakebite cases are reported. Hence, this hand book focuses on the Þrst two. Though the speciÞc antidote is not available for sea snake, the same general principles for other snakebites are applicable here too.

Epidemiology of snakebite Snakebite is observed all over the country with a rural / urban ratio of 9:1. They are more common during monsoon and post monsoon seasons. Snakebites are seen often among agricultural workers and among those going to the forest. Many of the susceptible populations are poor living below poverty line, living in rural areas with less access to health care. The male / female ratio among the victims is approximately 3:2. Majority are young and their age is between 25 to 44 years. Most of the bites (90 to 95%) are noticed on the extremities (limbs). The hospital stay varies from 2 to 30 days, with the median being 4 days. The in-hospital mortality varies from 5 to 10%, and the causes are acute renal failure, respiratory failure, sepsis, bleeding and others.

Ecological aspects: By destroying forests for creating agricultural land, the prey base of the snake (that is frogs and rats) has increased. The rice Þelds, which harbour millions of rats attract a lot of snakes. The number of snakes per acre in a rice Þeld is abnormally high when compared to the natural population in the forest. Humans go into the Þeld every morning and come out in the evening, just the time when snakes are active. Thus, the chance of an encounter between farmer and snake is very high. As more areas are inhabited at the periphery of towns, even there the chances of human / snake interaction increase. Cobras ßourish as long as there are rice Þelds; there they feed mainly on the mole rat (varapu eli in Tamil), live and lay their eggs in the rat burrow networks. Kraits also get by very well in rice Þelds because they like the plentiful small rodents such as the Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

3


Þeld mouse (sundeli in Tamil) and rock mouse (kallu eli in Tamil). Kraits are also found in the mounds of earth and rubble near wells. The Russell’s viper lives in the rocky outcrops and hedgerows of cactus and other bushes which often form the boundaries of agricultural land. There, on the high ground, they have a plentiful supply of common gerbil (velleli in Tamil) which are also attracted to the wealth of food humans provide by their farming activities! But thanks to snakes, we are not overrun by rodents.

1.2 Classification of Snakes: There are more than 3000 species of snakes in the world. For the purpose of clinical practice, snakes are classiÞed into poisonous (venomous) and non-poisonous (non venomous) snakes. Poisonous snakes are classiÞed into three families and they are • • •

Cobra group [Elapidae] Viper group [Viperidae] Sea snake group [Hydrophidae]

For many decades, the concept of the “Big 4” snakes of medical importance has reßected the view that 4 species and responsible for Indian snakebite mortality. They are - the Indian cobra (Naja naja), the Common Krait (Bungarus caeruleus), the Russell’s viper (Daboia russelii) and the Saw scaled viper (Echis carinatus). However, recently another species, the Hump-nosed pit viper (Hypnale hypnale), has been found to be capable of causing lethal envenomation, and that this problem had been concealed by systematic misidentiÞcation of this species as the saw-scaled viper. The concept of the “Big 4” snakes has failed to include all currently known snakes of medical signiÞcance in India. This has a negative effects on clinical management of snakebite and the development of effective snake anti venoms In 1981, the W.H.O. developed the following deÞnition of snakes of medical importance (Table No.2). This model is more accurate and useful than deÞnitions such as the ‘Big 4’ that are inaccurate and misleading to doctors and more importantly to ASV manufacturers. Table No. 2: Categorisation of snakes (W.H.O. 1981) Class Details I Commonly cause death or serious disability II Uncommonly cause bites but are recorded to cause serious effects (death or local necrosis) III Commonly cause bites but serious effects are very uncommon. 4

Name of the snakes Russells viper / Cobra / Saw scaled viper Krait / Hump-nosed pit viper / King cobra / Mountain pitviper Water snakes, Green snake



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<0!2$/%'1%=$>.?!#%@AB'-+!0?$%.0% !A.#%&!>C%D%E./+.0,C./F.0,%1$!+C-$/ Picture No.1 Tamil Nadu Snakes of Medical Importance

Snakes of Medical Importance in Tamil Nadu - Distinguishing features A great deal is written concerning the problem of how to identify medically signiÞcant species from non signiÞcant ones. A large amount of space is devoted, in both medical and toxicology textbooks, to the problem of how to identify venomous snakes. The problem with this information is that it is complex (involves counting of scales) and not deÞnitive (the identiÞcation of pre or post maxillary teeth) and of no use to a doctor in a medical situation. On the question of description, it is worth remembering that the least reliable means of identifying a particular species of snake is to use colour. Virtually every species of venomous snake has a huge range of colour manifestations and even the markings can be subjected to major variations. What is important therefore is to focus on the key aspects of identiÞcation that enable the medical professional to rapidly identify whether they are dealing with a venomous species, and what that species might be. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

5


There are six medically important species in Tamil Nadu shown above. Readers are informed to get familiarised with the pictures given at the end of Hand-book. Further details of some of the poisonous snake are provided in the ensuing paragraphs.

Russell’s Viper (Daboia russelii) The Russell’s Viper is a stout bodied snake, the largest of which grows to approximately 1.8 meters in length. Like all the vipers it is a nocturnal snake, but unfortunately for humans, during the daytime it rests up under bushes, at the base of trees and in leaf litter. It is therefore frequently encountered by rural workers, as they are carrying out general agricultural activities. There are two key identiÞcation features that are worth noting. The Þrst is a series of chain-like or black edged almond shaped marks along the snakes back and ßanks. The second distinguishing mark is a white triangular mark on the head with the apex of the triangle pointing towards the nostrils.

Saw scaled Viper (Echis carinatus) The southern Indian Saw Scaled Viper is a small snake, usually between 30 and 40 centimetres long. The northern Indian species (Echis sochureki) is much larger, with an average size of 60 centimetres. It inhabits mainly dry arid climates but can also be found in scrubland. One of the key identiÞcation features of this species is the posture it adopts when it is agitated. It moves its body into a Þgure of eight like arrangement with its head at the centre. It rapidly moves its coils against each other and produces a hissing like sound which gives its name of ‘Saw Scaled’. In addition, there are often wavy hoop like markings down both sides of the Saw Scales body. On the head, there is usually a white or cream arrow shaped mark, pointing towards the front of the head, often compared to the shape of a bird’s foot.

The Hump-nosed Pit viper (Hypnale hypnale) The Hump-nosed pit viper is one of India’s tiniest venomous snakes, its total length ranging from 28.5 to 55cm. Its distinctive features include the presence of Þve large symmetrical plate scales on the top of the head in addition to the smaller scales typical of all vipers. There are heat sensitive pits between the nostril and the eye.

Spectacled Cobra (Naja naja) The Spectacled Cobra, is probably India’s most well recognised snake. The hood markings of the spectacle like mark, distinguishes this snake from other species, and its habit of rearing up when alarmed makes it distinctive but not deÞnitive as other 6



species do this, notably the Trinket Snake. The Cobras coloration may vary from pale yellow to black.

Common Krait (Bungarus caeruleus) The Common Krait is a nocturnal snake which usually grows to approximately 1.0 to 1.2 metres in length. Its primary diet is other snakes. It can be found all over Peninsular India and often seeks habitation near human dwellings. During the day it rests up in piles of bricks, rat burrows or other buildings. The Common Krait is the most poisonous snake in India and its venom is pre-synaptic neurotoxic in nature. There are a number of key identiÞers which are worth remembering. The Krait is black, sometimes with a bluish tinge, with a white belly. Its markings consist of paired white bands which may be less distinct anteriorly. These paired white bands distinguish the snake from another black nocturnal snake, the Common Wolf Snake. The Wolf Snake’s white bands usually are thicker and are singular bands equidistant from each other. The second useful distinguishing feature is a series of hexagonal scales along the top of the snakes back. This feature is really useful if the dead snake has been brought to the hospital and examined.

King Cobra (Ophiophagus hannah) The King Cobra is the least medically signiÞcant of the venomous snakes in India in terms of both bites and fatalities. Hence, descriptive features of this are not provided here.

1.3 Clinical aspects of Snake Bite Pathophysiology: Snake venom is mostly watery in nature. It consists of numerous enzymes, proteins, aminoacids, etc., Some of the enzymes are proteases, collagenases, arginine ester hydrolase, hyaluronidase, phospholipidase, metallo-proteinases, endogenases, autocoids, thrombogenic enzymes, etc., These enzymes also act like toxins on different tissues of the body, and are grouped under neurotoxins, nephrotoxins, hemotoxins, cardiotoxins, cytotoxins etc., resulting in organ dysfunction / destruction. Enormous clinical and experimental works have been published on the pathophysiology of snake bite in relation to different species of snakes. The quality and quantity of enzymes and other clinical constituents vary with species and subspecies, and the response of the victims to those substances are also variable, thus resulting in dissimilar features in different individuals. For example hyaluronidase allows rapid spread of venom through subcutaneous tissues by disrupting mucopolysaccharides, and phospholipase A2 has esterolytic effect on the red blood cell membrane and causes hemolysis. It also promotes muscle necrosis. Thrombogenic Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

7


enzymes promote formation of weak Þbrin clot, which activates plasmin and results in consumptive coagulopathy and hemorrhagic consequences. Venom of some snakes causes neuromuscular blockade at pre or post synaptic level. In addition to above it causes endothelial cell damage which results in increased vascular permeability. In short, snake venom acts on various parts / systems / organs of the body. Venom also causes endothelial cell damage which results in increased permeability.

Symptoms and signs: An international expert on snakebite, the late Dr. Alistair Reid of the Liverpool School of Tropical Medicine found out that only 10 to 15% of venomous bites end in death. The possibility of survival, even without treatment, is incredibly good in 80-90% of cases. One of the reasons for this is that many snakebites are by nonvenomous snakes. Secondly, a large percentage of venomous snakebites are dry bites i.e., the snake does not always inject venom. Sometimes, it might inject only a tiny quantity of venom. The snake can inject the quantity of venom it wants. This is an entirely voluntary process. Hence, one can never know how much venom was injected except by observing the progression of the symptoms. In other words the recovery in snakebite without even treatment is great. Every traditional healer uses this fact to his / her advantage and propagates his / her own method to treat snakebite viz., herbal details, “snakestone” or mantra, or plain soda water and most villagers would be happy to go to him. Also, every one should remember the systemic action of venom and the extent varies from one snake to another. Complications and outcome due to snakebite may also vary from each other and can’t be predicted by any means. Moreover, the status of poisoning cannot be judged by the bite mark, reaction to envenomation, size or the type of snake. Hence, one has to observe for signs and symptoms which may develop within 24 to 48 hours. The symptoms and signs of Viperine and Elapid envenomation as well as lateonset envenomation are listed below.

General symptoms and signs of Viperine envenomation Local effects • • • • 8

Swelling and local pain with or without erythema or discoloration at the site of bite Tender enlargement of local lymphnodes as large molecular weight Viper venom molecules enter the system via the lymphatics. Effects due to coagulopathy and hemorrhagic consequences Bleeding from the gingival sulci and other oriÞces. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.


• • • • • • • •

Epistaxis. The skin and mucous membranes may show evidence of petechiae, purpura and ecchymoses. The passing of reddish or dark-brown urine or declining or no urine output. Lateralising neurological symptoms and asymmetrical pupils may be indicative of intra-cranial bleeding. Vomiting. Acute abdominal tenderness which may suggest gastro-intestinal or retro peritoneal bleeding. Hypotension resulting from hypovolaemia or direct vasodilation. Low back pain, indicative of early renal failure or retroperitoneal bleeding.

Other effects • •

Muscle pain indicating rhabdomyolysis. Parotid swelling, conjunctival oedema, sub-conjunctival haemorrhage.

General symptoms and signs of Elapid envenomation Local effects • •

Swelling and local pain with or without erythema or discoloration at the site of bite (Cobra). Local necrosis and / or blistering / bullae (Cobra).

Neurotoxic effects •

• • • • •

Descending paralysis, initially of muscles innervated by the cranial nerves, commencing with ptosis, diplopia, or ophthalmoplegia. The patient complains of difÞculty in focusing and the eyelids feel heavy. There may be some involvement of the senses of taste and smell. Problems of vision, breathing and speech. Paralysis of jaw and tongue may lead to upper airway obstruction and aspiration of pooled secretions because of the patient’s inability to swallow. Numbness around the lips and mouth, progressing to pooling of secretions, bulbar paralysis and respiratory failure. Hypoxia due to inadequate ventilation can cause cyanosis, altered sensoriun and coma. This is a life threatening situation and needs urgent intervention. Paradoxical respiration, as a result of the intercostal muscles paralysis is a frequent sign.


9


•

Krait bites often present in early morning with paralysis that can be mistaken for a stroke. Stomach pain which may suggest submucosal haemorrhages in the stomach.

Other effects • •

Stomach pain which may suggest submucosal haemorrhages in the stomach (Krait). Eye pain and damage due to ejection of venom into the eyes by spitting cobra (as observed in Africa)

[If features of renal failure are noted search for other causes / mechanisms]

Late-onset envenomation The patient should be kept under close observation for at least 24 hours. Many species, particularly the Krait and the Hump-nosed pit viper are known for the length of time it can take for symptoms to manifest. Often this can take between 6 to 12 hours. Late onset envenoming is a well documented occurrence. This is also particularly pertinent at the start of the rainy season when snakes generally give birth to their young. Juvenile snakes (young ones), 8-10 inches long, tend to bite the victim lower down on the foot in the hard tissue area, and thus any signs of envenomation can take much longer to appear.

Overlapping symptoms and signs Russells Viper envenomation can also manifest with neurotoxic features. This can sometimes cause confusion and further work is necessary to establish how wide this might be. Development of neurotoxic features in Russells Viper bite are believed to be pre synaptic or Krait like in nature. It is for this reason that a doubt is expressed over the response of both species to Neostigmine. Clinical aspects and therapeutic response in relation to some of the poisonous snakes in India is provided in Table no. 3 Table No. 3: Snakes, clinical aspects and therapeutic response Feature Local Pain / Tissue Damage Ptosis / Neurological Signs Haemostatic abnormalities 10

YES

NO

Russells Viper YES

YES

YES

YES!

NO

NO

NO

NO!

YES

YES

YES

Cobras Kraits

Saw Scaled Viper YES

Hump Nosed Viper YES



Renal Complications Response to Neostigmine Response to ASV

NO* YES

NO* NO?

YES NO?

YES

YES

YES

NO* NOT applicable YES

YES NOT applicable NO

[* If features of renal failure are noted search for other causes / mechanisms]

Sea snakes: Sea snake bites are reported rarely among Þshermen and / or their family members living in the seashore area as well as among those who walk on the seashore. To begin with there may be local pain which may be insigniÞcat which appears within 60 to 90 minutes. There may not be obvious local swelling. Systemic manifestations noticed among poisonous sea snake bite are neurological involvement, severe muscle pain, rigidity, renal failure, hyperkalemia and Þnally cardiac arrest.

Criteria for diagnosis An approach to snakebite is provided in Annexures VIII and IX. The criteria to diagnose poisonous snakebite in a given clinical setting are: a. Systemic envenomation in the form of coagulopathy and neurotoxicity. b. Local envenomation (Table no: 4). Features of local envenomation - are grouped under the mneumonic “PONDS”. Table No :4 : Details of local envenomation • • • • •

Pain- pain at the site of bite, swelling and regional lymphnode Oozing- sero / sanguinous oozing from the site of bite Node- development of an enlarged tender lymphnode draining the bitten limb Discoloration- discoloration at the site of bite Swelling – swelling is seen at the site of the bites on the digits (toes and especially Þngers); local swelling develops in more than half of the bitten limb immediately (in the absence of the tourniquet) and swelling extends rapidly beyond the site of bite (eg. beyond the wrist or ankle within a few hours of bites on the hands or feet)


11


%%

Picture No.2

Picture No.3

Typical signs of local envenomation namely edema, blister and joint swelling

Cellulitis with compartmental syndrome

Complications and Outcome Complications in snake envenomation are due to the heterogenous composition of the venom. In addition the quantity and quality of the venom and the response of the individual to the components of venom inßuence the clinical course, complications and outcome. The complications of venom are observed in various systems viz., the hematological, vascular, renal, respiratory, cardiovascular, endocrine, gastrointestinal, muscular and dermatological system. In addition to the anti snake venom, the envenomed individual requires supportive treatment for the complications arising out of snakebite as well as the consequences of the complication. One must also remember to look for complications developing after infusion of Inj.anti snake venom and get prepared to treat them also. The outcome of snakebite depends upon amount of envenomation, bite to needle time, individual’s response to envenomation, the complications that develop following snakebite and response to treatment. Till the patient has recovered, one cannot predict the complications and outcome.

Investigations 20 Minutes Whole Blood Clotting Test (20WBCT) The 20 Minutes Whole Blood Clotting Test (20WBCT) is considered as the most reliable test for coagulation and can be carried out at the bedside without specialised training. It can also be carried out in the most basic settings. It is signiÞcantly superior to the ‘capillary tube’ method of establishing clotting capability and is the preferred method of choice in snakebite. The advantages, requirements and procedure for 20 WBCT are provided in in Table no: 5

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Table No. 5: 20 Minutes Whole Blood Clotting Test (20WBCT) Advantages • The most reliable test of coagulation. • Can be carried out, at the bedside. • Does not require specialised training.

• • • • • •

Requirements Dry glass test tube (clean and new) 2ml disposable syringe Cotton Antiseptic solution Clean gloves (one pair) (The test tube must not have been washed with detergent, as this will inhibit the contact element of the clotting mechanism)

• • •

•

•

• •

Procedure Wash hands with soap and water. Wear the gloves Collect 2ml blood from the peripheral vein of the unaffected limb Remove the needle and pour the blood along the walls of the test tube Keep the test tube untouched and unshaken in a safe place near the patient’s bedside at ambient temperature for 20 minutes Note the time After 20 minutes the test tube is gently tilted and if the blood is still liquid then the patient has incoagulable blood.

If the 20WBCT is normal in a suspected case of poisonous snakebites, the test should be carried out every 30 minutes from admission for three hours and then hourly after that. If incoagulable blood is discovered, the 6 hourly cycle will then be adopted to test for the requirement of repeat doses of ASV. This is due to the inability of the liver to replace clotting factors under 6 hrs. Other Useful Tests: • •

• •

Clinical test: - PR / BP / RR / Postural Blood Pressure Laboratory studies: - Haemoglobin / PCV / Platelet Count/ PT / APTT / FDP / D-Dimer - Peripheral Smear / Blood grouping / Rh typing - Urine Tests for Proteinuria / RBC / Haemoglobinuria / Myoglobinuria - Biochemistry for Serum Creatinine / Urea / Electrolytes / Oxygen Saturation Imaging studies : - X-Ray Chest / CT / Ultrasound (whenever required) Others - Electrocardiogram - Special investigations depending upon clinical status. - Ocular fundus examination


13


1.4 Treatment First aid for snake bite The Þrst aid currently recommended is based around the mnemonic ‘R.I.G.H.T’. The details are provided in Table no.6 . Table No. 6: Currently recommended First aid •

•

• •

R. = Reassure the patient. (70% of all snakebites are from non-venomous species. Only 50% of bites by venomous species actually envenomate the patient) I = Immobilise in the same way as a fractured limb. (Use bandages or cloth to hold the splints, not to block the blood supply or apply pressure. Do not apply any compression in the form of tight ligatures, they don’t work and can be dangerous!) G. H. = Get to Hospital Immediately. (Traditional remedies have NO PROVEN beneÞt in treating snakebite). T= Tell the doctor of any systemic symptoms such as ptosis that manifest on the way to hospital.

This method will get the victim to the hospital quickly, without recourse to traditional medical approaches which can delay effective treatment.

Traditional first aid methods followed for snakebite: The traditional methods such as application of tourniquet, cutting (incision) and suction, washing the wound, snake stone or other methods have adverse effects and hence, they have to be discarded. The mneumonic used to recall some of the traditional methods followed is “WHISTTLE” and these are described below.

Washing the Wound: Victims and bystanders have a tendency to wash the wound to remove any venom on the surface. This should not be done as the action of washing increases the ßow of venom into system by stimulating the lymphatic system.

Household remedies: Various forms of household remedies are applied to the site of bite which may enhance absorption of venom.

14



(Incision) Cutting and Suction: Cutting the site of bite and suctioning incoagulable blood increases the risk of bleeding to death as well as increases the risk of infection. Venom is not cleared or removed from the snakebite site by this method.

Snake stone: Snake stone is applied to the site of bite saying that it will absorb the venom and falls once the venom is absorbed. This contributes to delay in seeking appropriate health care.

Tourniquets: Tight tourniquets made of rope, string and cloth, have been followed traditionally to stop venom ßow into the body following snakebite. The problems noticed with tourniquets are :• Risk of ischemia and loss of the limb • Risk of necrosis • Risk of massive neurotoxic blockade • Risk of embolism if used in viper bites. • Release of tourniquet may lead to hypotension. • Gives patient a sense of false security, which encourages them to delay their journey to hospital

Thermal methods: • •

Cautery treatment is followed in some areas. It is injurious and not beneÞcial Cryotherapy involving the application of ice to the bite was proposed in the 1950’s. It was subsequently shown that this method had no beneÞt and merely increased the necrotic effect of the venom.

Local application of anti snake venom: Local application of anti snake venom has not shown any beneÞcial effects

Electrical Therapy: Electric shock therapy for snakebite received a signiÞcant amount of press coverage in the 1980’s. The theory behind it stated that applying an electric current to Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

15


the wound denatures the venom. Much of the support for this method came from letters to journals and not scientiÞc papers. It has been demonstrated that the electric shock has no beneÞcial effect and hence, it has been abandoned as a method of Þrst aid.

Pressure Immobilisation Method (PIM) PIM was developed in Australia in 1974 by Sutherland and gained some supporters on television and in the herpetology literature. Some medical textbooks have referred to it. Further work done by Howarth demonstrated that the pressure, to be effective, was different in the lower and upper limbs. The upper limb pressure was 40-70mm of Mercury; the lower limb was 55-70mm of mercury. Work carried out by Norris showed that only 5% of lay people and 13% of doctors were able to correctly apply the technique. In addition, pressure bandages should not be used where there is a risk of local necrosis, that is in 4/5 of the medically signiÞcant snakes of India. In view of the difÞculties encountered at every level, Pressure Immobilisation Method cannot be recommended for use at present.

Newer Methods ‘Pressure Pad or Monash Technique’ Initial research has suggested that a ‘Pressure Pad or Monash Technique’ may have some beneÞt in the Þrst aid treatment of snakebite. This method should be subjected to further research in India to assess its efÞcacy. It may have particular relevance to the Indian Armed Forces who carry Shell Dressings as part of their normal equipment, and would thus be ideally equipped to apply effective Þrst aid in difÞcult geographic settings where the need is great.

Treatment: While dealing with a case of snake bite consider the mnemonic ‘RASI’. • • • •

Remember principles ( “12 As” ) Address the problems – clinical and social Seek help from others when required and Inform the patient and / or care givers on the status of illness, clinical course, management, outcome, welfare measures and follow up clearly with empathy.

Principles involved in the management of snake bite The principles while managing cases of snake bite at any Health Centre are clubbed under “12 As”

16



Table No. 7: Principles involved in the management 1. Admit the victim immediately. 2. Ask effectively. 3. Assess quickly. 4. Act swiftly. 5. Administer medication meticulously. 6. Address to the wound properly. 7. Anticipate complications keenly. 8. Avoid errors carefully. 9. Ascertain the status repeatedly. 10. Amicable with patients and care givers and show empathy. 11. Advise on follow up accordingly. 12. Arrange for referral early. 1] Admit all victims of snake bite & Keep the victims under observation for 24 to 48 hours 2] Ask effectively to get the following – a] Ask for the description of the snake, which has bitten the patient. If snake is brought try to identify the snake with the help of snake picture chart. b] Ask for the site of bite and check the site. Never be carried away, by bite marks either for diagnosis or for assessment of severity. c] Ask for the time of the bite and correlate with the progression of symptoms and signs due to snakebite provided in page vide supra. d] Ask for the details of traditional medicines or household remedies used, as it may sometimes cause confusing symptoms or interfere with other drugs to be administered. 3] Assess the following quickly. a] Airway, Breathing and Circulation b] Vitals HR, RR, BP and oxygen saturation by Pulse oximetry (if required) c] Chest expansion, and the ability to put out the tongue beyond incisors and counting the numbers at the bed side. d] Site of snake bite along with regional lymphadenitis clinically from head to foot as well as back e] For associated co-morbid illness[es] f] For consuming any medication[s] g] The status of envenomation - local systemic (neurotoxic, hemotoxic, myotoxic) or a combination of them 4] Act swiftly a] Support Airway, Breathing and Circulation b] Start IV line [ßuid for children refer to Annexure II –Table No.29] Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

17


c] Provide supportive measures depending upon the requirements including blood transfusion / components if required. d] Connect to ventilator if there is a need 5] Administer medications meticulously a] Tetanus Toxoid injection intramuscularly b] Anti snake venum as IV drip if needed – described vide infra (ASV is composed of large molecules (IgG or fragments) and are absorbed slowly via lymphatics, making the bioavailability by this route poor as compared to intravenous administration. Also, intramuscular injections are not preferred as it could cause pain on injection and risk of hematoma formation and sciatic nerve damage in patients with hemostatic abnormalities. Intramuscular injections should only be given in settings where intravenous access cannot be obtained and / or the victim cannot be transported to a hospital immediately). c] Ionotropics as IV drip if required d] Antimicrobials if necessary e] IV ßuids as per need [ßuid for children refer to Annexure II – Table No.29] f] Other supportive medications including medicines to relieve pain (avoid aspirin) as per need. 6] Address to the wound properly Remember the surigcal issues described vide infra and Table 11 in addition to the following. a] Wound following snake bite may show bite marks with or without laceration. b] Sometimes venom may penetrate deep and hence deeper tissues may be damaged which may not be visible during initial examination. c] At the site of bite, bleb or vesicle may develop and end in the form of an ulcer which is a non speciÞc one. (Non-speciÞc ulcers are deÞned as ulcers due to infection of wounds, physical or chemical agents or due to local irritation). d] Consider the following while managing the wound / ulcer. • Minimize unnecessary blood loss • Avoid the formation of a hematoma • Initiate adequate cleaning with normal saline or tap water, debridement, and edema control • Remove debris and necrotic tissue, irrigate gently with water / normal saline • Expose viable tissues, excise eschar after controlling hemotoxic complications • Use topical antibacterial agents • Apply dressings after complete debridement. 18



• • •

• • • • •

Maintain proper wound environment and prevent ischemia. Keep the bacterial count as low as possible. Facilitate healing of acute wound by applying non adherent dressing to ensure adequate epithelialisation and to prevent contamination of the wound. Keep wounds clean and dry. Avoid soaking or scrubbing the wound. Teach & explain the care of wound to the patients. Educate on good personal hygiene and nutrition. Control diabetes if identiÞed.

7] Anticipate complications keenly. a] Examine the victims at regular intervals for alterations in symptoms and signs b] Observe for anti snake venom related systemic changes and drug toxicity and manage them as described vide infra under treatment for ASV reactions. 8] Avoid errors carefully while assessing the case, investigating the victims, administering medications, following the case at hospital, undertaking any procedures, referring to other specialists or hospital, communicating with patient / and care givers, and planning for discharge as well as preparing reports, Þlling up the forms, reviewing the data and conducting the audit. 9] Ascertain the status repeatedly and provide supportive measures as these cases of snake bite victims may develop covert signs during hospital stay while on treatment. 10] Amicable interaction with patient and care givers with empathy is essential in view of the socio clinical aspects of snake bite. 11] Advise on follow up accordingly in view of the systemic toxicity and the nature of wound following snake bite. Patients may be also motivated to attend the nearest Health centre / Hospital for follow up care. Follow-up checks are required for assessment of long term effects on different organs / systems and for appropriate management wherever required / needed. 12. Arrange for referral early - One should also remember the criteria for referral and provide clear instructions while referring the case. The details on referral aspects of snake bite is provided vide infra in Table 15.

Pharmacological aspects of Anti snake venom The goals of pharmacotherapy with injection Anti snake venom (ASV) are to neutralise the venom, reduce morbidity and mortality, and prevent complications. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

19


Currently available Anti Snake Venom (ASV) in India is polyvalent i.e., it is effective against all the four common species; Russells Viper (Daboia russelii), Common Cobra (Naja naja), Common Krait (Bungarus caeruleus) and Saw Scaled Viper (Echis carinatus). Indian ASV is a F(ab)2 product derived from horse serum and has a halflife of over 90 hours. Though it is puriÞed, it still can be immunogenic. At present, no monovalent ASV is available primarily because there are no objective means of identifying the snake species, in the absence of the dead snake. Moreover it is difÞcult for the physician to determine which type of Monovalent ASV to employ in treating the patient. In addition there are difÞculties to prepare, supply and maintain adequate stock of species speciÞc monovalent ASV. There are other known species such as the Hump-nosed pitviper (Hypnale hypnale) where polyvalent ASV is known to be ineffective. In addition, there are regionally speciÞc species such as Sochurek’s Saw Scaled Viper (Echis sochureki) in Rajasthan, where the effectiveness of polyvalent ASV may be questionable. Further work has to be carried out with ASV producers to address this issue of preparing ASV useful against other poisonous snakes observed in India. In India ASV is manufactured by Bengal Chemicals & Pharmaceuticals, Kolkata; Bharat Serums, Mumbai; Biological Evans, Hyderabad; Central Research Institute, Kausali; Haffkins Pharmaceuticals, Mumbai; King Institute of preventive medicine, Chennai; Serum Institute, Pune and Vins bio-products, Hyderabad. ASV is produced in both liquid and lyophilised forms. There is no evidence to suggest which form is more effective and many doctors prefer one or the other based purely on personal choice. Liquid ASV requires a reliable cold chain and refrigeration and has a 2 years shelf life. Lyophilised ASV, in powder form, requires only to be kept cool and hence, is useful in remote areas where power supply is inconsistent. The details of pre hospital treatment and issues related to ASV may be recorded in the form provided in Annexure IV.

ASV Administration Criteria ASV is prepared from animal and hence, it should only be administered when there are deÞnite signs of envenomation. Anti-Snake Venom carries risks of anaphylactic reactions and should not therefore be used unnecessarily. Unbound, free ßowing venom, can only be neutralised when it is in the bloodstream or tissue ßuid. Also it is a scarce and costly commodity. Hence, ASV may be administered only if a patient develops one or more of the following signs / symptoms.

20



Systemic envenoming •

• • •

Evidence of coagulopathy primarily detected by 20 WBCT or visible spontaneous systemic bleeding, bleeding gums, etc., Further laboratory tests for thrombocytopenia, Hb abnormalities, PCV, peripheral smear etc may provide conÞrmation, but 20 WBCT is paramount. Evidence of neurotoxicity: ptosis, external ophthalmoplegia, muscle paralysis, inability to lift the head etc., Cardiovascular abnormalities: hypotension, shock, cardiac arrhythmia, abnormal ECG. Persistent and severe vomiting or abdominal pain.

Local envenomation (Refer Table No: 4) Purely local swelling, even if accompanied by a bite mark from an apparently venomous snake, is not grounds for administering ASV if a tourniquet or tourniquets have been applied. These themselves can cause swelling. Once they have been removed for 1 hour and the swelling continues, then it is unlikely to be as a result of the tourniquet and administration of ASV may be justiÞed.

Dosage In the absence of deÞnitive data on the level of envenomation, symptomatology is not a useful guide to the level of envenomation. Any ASV regimen adopted is at best only an estimate. What is important is to establish a single guideline which could be adhered to, in order to enable sensitization results to be reliably reviewed. The recommended dosage level has been based on published research that Russells Viper injects on average 63mg (SD 7) of venom. Logic suggests that our initial dose should be calculated to neutralise the average dose of venom injected. This ensures that the majority of victims should be covered by the initial dose and keeps the cost of ASV to acceptable levels. The range of venom injected is 5mg to 147mg. One vial of ASV neutralises 6mg of Russells Viper venom. So, to neutralize 63mg of venom, 10 vials are needed. Not all victims will require 10 vials as some may be injected with less than 63mg. However, starting with 10 vials ensures that there is sufÞcient neutralising power to neutralise the average amount of venom injected and during the next 12 hours to neutralise any remaining free ßowing venom. Warrell et al based on their study have shown that test doses for ASV have no predictive value in detecting anaphylactoid or late serum reactions and should not be used. These reactions are not IgE mediated but Complement activated. They may also pre-sensitise the patient and thereby create greater risk. For Neurotoxic / Anti Haemostatic envenomation, 8 to 10 vials of ASV is recommended to be administered Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 21


as initial dose. Children receive the same ASV dosage as adults, as snakes inject the same amount of venom into adults and children. The ASV is targeted at neutralising the venom.

Administration ASV may be administered in two ways over a period of one hour at a constant speed and the patient should be closely monitored for 2 hours: • Infusion: liquid or reconstituted ASV is diluted in 5-10ml/kg body weight of isotonic saline or glucose and administered as infusion usually. (Fluid requirement for children refer to Annexure II) • Intravenous Injection: Rarely reconstituted or liquid ASV is administered by slow intravenous injection. (2ml / minute). Each vial is 10ml of reconstituted ASV.

Facts to be remembered before / while using of Anti Snake Venom (ASV) 1. ASV is available in a polyvalent form and marketed in liquid or lyophilised preparations in 10ml vial / ampoule. 2. Remember to use and maintain cold chain systém for liquid form. Users are informed to ascertain whether the cold chain is maintained. 3. There is no dose adjustment for ASV administration for children. 4. Before administering ASV, health staff should read and check the status of vial or ampoule containing ASV. 5. Elicit history of prior exposure to ASV. If a patient had received ASV earlier and comes back with features of snake envonemation again, he / she has to be considered as a fresh case and treated accordingly. However, care should be taken while administering ASV, since he / she has been sensitised. 6. ASV treatment should not be initiated without adequate agents for managing anaphylaxis or anaphylactoid reaction. 7. Anaphylactic or late serum sickness cannot be determined or prevented by test dose. 8. ASV neutralises the unbound venom, hence give it early. 9. ASV administration should not be delayed or denied on the grounds of anaphylactic reactions to a deserving case. 10. ASV is required only to those who show deÞnite signs and symptoms of envenomation. 11. ASV should not be pushed as IV bolus or IM directly. ASV has to be administered slowly as IV infusion in normal saline or glucose water over a period of one hour. 12. Local administration of ASV near the site of bite has been proven to be ineffective and painful, and raises the intra-compartmental pressure, particularly in the digits. Hence, it should not be adopted. 22



13. There is no prophylactic dose of ASV. 14. Total dose requirement cannot be decided on the basis of (WBCT) Whole blood clotting test (or) clinical signs and symptoms. 15. Even if the patient develops reaction(s), the total dose required should be administered slowly after the patient recovers from the reaction(s). 16. There is no other drug of choice other than ASV for the treatment of poisonous snakebite. 17. The patient has to be closely monitored for manifestations of reactions to ASV for atleast 2 hours continuously. 18. No interaction with ASV has been reported. 19. Fetal risk due to ASV has not been established or studied in humans. 20. Safety status for use of ASV during pregnancy has not been established. 21. Timely administration of ASV will not guarantee the recovery or protect the individual from the venom induced toxicity or complications deÞnitely.

ASV Reactions * Reaction to ASV develop usually within 15 to 30 minutes or within 2 hours. So monitor the case on ASV at 5min. interval for Þrst 30min. and then at 15min. interval for two hours. The details of pre hospital treatment and issues related to ASV may be recorded in the form provided in Annexure IV. * Some times, anaphylaxis (Type I) following ASV may develop rapidly and deteriorate into a life-threatening emergency, and hence anticipate and observe for it in every case. If the correct guidelines are followed, anaphylaxis can be effectively treated. * Therefore get alert if the patient develops of any reactions to ASV as shown in Table no: 8. Table No. 8: Manifestations of immediate reactions to ASV • • • • • • • • •

Itching (often over the scalp) Urticaria, even a single spot Nausea Vomiting Abdominal colic / pain Diarrhoea Tachycardia (PR >120/min) (for children refer age speciÞc chart) Fall in blood pressure Low volume pulse

• • • • • • • • • • •

Dry cough Bronchospasm / rhonchi Stridor (rarely) Angio-oedema of lips and mucous membrane Fever Shaking chills (rigors) Sweating Cold and clammy skin Central cyanosis Febrile convulsions (in children) Anaphylaxis (Type I )


23


Treatment for ASV reactions Discontinue ASV Maintain IV line Administer Inj. Adrenaline 0.5ml of 1:1000 IM, (Adults) / Inj. Adrenaline 0.1ml/Kg body weight of 1:10,000 IM (paediatric dose). Details are provided in Table no.9. (If after 10 to 15 minutes the patient’s condition has not improved or is worsening, a second dose of 0.5 ml of Adrenaline IM is given. This can be repeated for a third and final occasion but in the vast majority of reactions 2 doses of Adrenaline will be sufficient). • • •

Studies have shown that adrenaline reaches necessary blood plasma levels in 8 minutes in the IM route, and in 34 minutes in the subcutaneous route . The early use of adrenaline has been selected as a result of study evidence suggesting better patient outcome if adrenaline is used early. In extremely rare, severe life threatening situations, 0.5mg of 1:10,000 adrenaline can be given IV slowly. This carries a risk of cardiac arrhythmias however, and should only be used if IM adrenaline has been tried and the administration of IV adrenaline is in the presence of ventilatory equipment and ICU trained staff. Table No. 9: Dosage of adrenaline for adults and children Adults Inject adrenaline 1:1000 intramuscularly:

• • •

Weighing < 50 kg give 0.25 ml Weighing 50 -100 kg give 0.50 ml Weighing >100 kg give 0.75 ml

• •

24

*Children (upto 25 kg) Inject adrenaline 1:10,000 dilute 1ampoule (1 ml) of adrenaline 1:1000 with 9ml water for injection or normal saline. Inject intramuscularly 1:10,000 adrenaline according to the guide (approximates to 0.1ml/kg). • 1 year (10 kg) give 1 ml • 3 years (15 kg) give 1.5ml • 5 years (20 kg) give 2ml • 8 years (25 kg) give 2.5ml • Children > 25 kg as for small adults

Approximate body weight for children may be calculated by the formula; 2 x Age + 9 = weight in kg.



•

Start an adrenaline infusion if the patient remains shocked, (preferably via a central venous line), commencing at 0.25 microgram/kg/minute, and titrating as required to restore blood pressure. Large doses of adrenaline may be needed.

Consider additional measures: • •

•

• •

• •

•

Administer Salbutamol or Terbutaline by aerosol or nebuliser (Beta2 agonists) for bronchospasm. Antihistamines: Administer both H1 receptor blockers Inj. Chlorpheniramine maleate 10 - 20mg as IV / intramuscularly or Promethazine 0.5 - 1mg/kg and H2 receptor blockers Inj.Ranitidine 1mg/kg or Famotidine 0.4mg/kg or Cimetidine 4mg/kg slowly intravenously. The dose for children is of Pheniramine maleate at 0.5mg/kg/day IV or Promethazine HCl can be used at 0.3 - 0.5mg/kg IM or 0.2mg/kg of Chlorpheniramine maleate IV, and 2mg/kg of Hydrocortisone IV, antihistamine use in pediatric cases must be deployed with caution. Administer Corticosteroids intravenously: Hydrocortisone 2 - 6mg/kg or Dexamethasone 0.1 - 0.4mg/kg Try nebulised Adrenaline (5ml of 1:1000) in case of laryngeal oedema which often will ease upper airways obstruction. However, do not delay intubation if upper airways obstruction is progressive. IV ßuids should be given for haemodynamic instability. Once the patient has recovered, the ASV can be restarted slowly for 10 - 15minutes, keeping the patient under close observation. Then the normal drip rate should be resumed. Monitor vitals and provide supportive measures

Late Serum sickness reactions (delayed hypersensitivity) to ASV Serum sickness may occur one to two weeks after administration of ASV. Late Serum sickness reactions can be easily treated with an oral steroid such as prednisolone, adults 5mg 6 hourly, paediatric dose 0.7mg/kg/day. (Duration of treatment has to be adjusted with case). Oral H1 Antihistamines provide additional symptomatic relief.

Prevention of ASV Reactions – Prophylactic Regimens The conclusion in respect of prophylactic regimens to prevent anaphylactic reactions, is that there is no evidence from good quality randomized clinical trials to support their routine use. If they are used then the decision must rest on other grounds, such as policy in the case of hospitals, which may opt for a maximum safety policy, irrespective of the lack of deÞnitive trial evidence. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

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Two prophylactic regimens normally recommended are given below: •

•

100mg of Hydrocortisone and H1 antihistamine (10mg Chlorphenimarine maleate; or 22.5mg IV Phenimarine maleate IV or 25mg Promethazine hydrochloride IM) 5minutes before ASV administration. The dose for children is 0.1-0.3mg/kg of antihistamine IV and 2mg/kg of Hydrocortisone IV. Antihistamine should be used with caution in pediatric patients. 0.25-0.3mg Adrenaline 1:1000 given subcutaneously.

If the victim has a known sensitivity to ASV, pre-medication with adrenaline, hydrocortisone and anti-histamine may be advisable, in order to prevent severe reactions.

Repeat Doses of ASV in Neurotoxic Envenomation The ASV regime relating to neurotoxic envenomation has caused considerable confusion. If on reassessment after 1 - 2hrs the initial dose has been unsuccessful in reducing the symptoms / if the symptoms have worsened / if the patient has gone into respiratory failure then a further dose should be administered. This dose should be the same as the initial dose, i.e., if 10 vials were given initially then 10 vials should be repeated for a second dose and then ASV is discontinued. 20 vials is the maximum dose of ASV that should be given to a neurotoxically envenomed patient. Once a patient in respiratory failure, has received 20 vials of ASV and is supported on a ventilator, ASV therapy should be stopped. This recommendation is due to the assumption that all circulating venom would have been neutralised by this point. Therefore further ASV serves no useful purpose. Evidence suggests that ‘reversibility’ of post synaptic neurotoxic envenoming is only possible in the Þrst few hours. After that the body recovers by using its own mechanisms. Large doses of ASV, over long periods, have no beneÞt in reversing envenomation. Confusion has arisen due to some medical text books and journal articles suggesting that ‘massive doses’ of ASV can be administered, and that there need not necessarily be a clear-cut upper limit to ASV. These texts are talking about snakes which inject massive amounts of venom, such as the King Cobra or Australian Elapids. There is no justiÞcation for massive doses of 50+ vials in India, which usually results in the continued use of ASV whilst the victim is on a ventilator. No further doses of ASV are required; unless a proven recurrence of envenomation is established. Additional vials to prevent recurrence are not necessary.

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Picture 4 Case of cobra snake bite in the recovery phase showing bilateral ptosis with overaction of frontalis

Picture 5 Neuroparalysis recovering only showing Ophthalmoplegia

Repeat Doses of ASV in Anti Haemostatic envenomation In the case of anti haemostatic envenomation, the ASV strategy will be based around a six hour time period. When the initial blood test reveals a coagulation abnormality, the initial ASV amount will be given over one hour. No additional ASV will be given until the next Clotting Test is carried out. This is due to the inability of the liver to replace clotting factors within 6 hours. After 6 hours a further coagulation test should be performed and a further dose should be administered in the event of continued coagulation disturbance. This dose should also be given over one hour. Clotting tests and repeat doses of ASV should continue on a 6 hourly pattern until coagulation is restored, unless a species is identiÞed as one against which Polyvalent ASV is not effective. The repeat dose should be 5 -10 vials of ASV i.e., half to one full dose of the original amount. The most logical approach is to administer the same dose again, as was administered initially. Some, argue that since the amount of unbound venom is declining, due to its continued binding to tissue, and due to the wish to conserve scarce supplies of ASV, there may be a case for administering a smaller second dose. In the absence of good trial evidence to determine the objective position, a range of vials in the second dose has been adopted.

Recurrent Envenomation When coagulation has been restored, no further ASV should be administered, unless a proven recurrence of a coagulation abnormality is established. There is no need to give prophylactic ASV to prevent recurrence. Recurrence has been a mainly U.S. phenomenon, due to the short half-life of Crofab ASV. Indian ASV is a F(ab)2 product and has a half-life of over 90 hours, and therefore is not required in a prophylactic dose to prevent re-envenomation. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

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Anti Haemostatic Maximum ASV Dosage Guidance The normal guidelines are to administer ASV every 6 hours until coagulation has been restored. However, what should the clinician do after say, 30 vials have been administered and the coagulation abnormality persists? There are a number of questions that should be considered. Firstly, is the envenoming species one for which polyvalent ASV is effective? For example, it has been established that envenomation by the Hump-nosed pitviper (Hypnale hypnale) does not respond to normal ASV. Coagulopathy can / may continue for up to 3 weeks as in the case of Hypnale. The next point to consider is whether the coagulopathy is resulting from the action of the venom. Published evidence suggests that the maximum venom yield from say a Russells Viper is 147mg, which will reduce the moment the venom enters the system and starts binding to tissues. If 30 vials of ASV have been administered that represents 180mg of neutralising capacity, this should certainly be enough to neutralise free ßowing venom. At this point the clinician should consider whether the continued administration of ASV is serving any purpose, particularly in the absence of proven systemic bleeding. At this stage the use of Fresh Frozen Plasma (FFP), cryoprecipitate (Þbrinogen, factor VIII) fresh whole blood, thrombocytes or coagulation factors can be considered, if available. Plasmapheresis has been used successfully under such circumstances amidst controversies. More clinical trails are warranted in these areas.

Recovery Phase If an adequate dose of antivenom has been administered, the following responses may be seen: a) Spontaneous systemic bleeding such as gum bleeding usually stops within 15 - 30 minutes. b) Blood coagulability is usually restored in 6 hours. (Principal test is 20 WBCT). c) Post synaptic neurotoxic envenoming such as the Cobra may begin to improve as early as 30 minutes after antivenom, but can take several hours. d) Presynaptic neurotoxic envenoming such as the Krait usually takes a considerable time to improve reßecting the need for the body to generate new acetylcholine emitters. e) Active haemolysis and rhabdomyolysis may cease within a few hours and the urine returns to its normal colour during the course of treatment. f) Patients in shock blood pressure may increase after 30 minutes while on treatment.

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ASV risk and wastage DeÞnitive diagnosis and proper utilisation of ASV helps the patient. Otherwise the patients are subjected to risk of receiving excessive / inadequate dosage of ASV. More over the availability of ASV and doctors views and experience may inßuence the utilisation of ASV for a given patient. Thus there is a possibility of Þrst aid wastage of ASV. The details of provided in Table No.10. Table No. 10: ASV – Risk and Wastage (Ian D.Simpson Model) Low wastage High risk ASV - Not available - InsufÞcient administration Low risk Effective dose of ASV to envenomed patients

High wastage ASV – Too little supply and species are different Receive ASV when not required Too much ASV when not required Unnecessary ASV

1.5 Clinical issues in Snakebite Hypotension Hypotension can have a number of causes, particularly loss of circulating volume due to haemorrhage and vasodilation due to the action of the venom or direct effects on the heart. Test for hypovolaemia by examining the blood pressure lying down and sitting up, to establish postural hypotension. Usually crystalloids are used for volume expansion. However, there is no conclusive trial evidence to support a preference for colloids or crystalloids. In cases where increased generalised capillary permeability has been established, a vasoconstrictor such as dopamine can be used, dose being is 5 - 10 /kg/minute in normal saline or glucose solutions as IV drip. The ßow rate may be adjusted to maintain blood pressure adequately. Rarely Russell’s Viper bites are known to cause acute pituitary and / or adrenal insufÞciency. This condition may also contribute to shock. Hence, this entity has to be remembered while dealing with hypotension in snakebite as these cases require long term follow up.

Persistent or Severe bleeding In the majority of cases the timely use of ASV will stop systemic bleeding. However in some cases the bleeding may continue to a point when further appropriate treatment should be considered. The major point to note is that clotting must be re-established before additional measures are taken. Adding clotting factors, fresh frozen plasma Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

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(FFP), cryoprecipitate or whole blood in the presence of un-neutralised venom will increase the amount of degradation products with the accompanying risk to the renal function. Plasmapheresis has been used successfully in such situation.

Renal Failure and ASV Renal failure is a common complication of Russell’s viper and Hump-nosed pit viper bites. The contributory factors are intravascular haemolysis, DIC, direct nephrotoxicity, and hypotension and rhabdomyolysis. Renal damage can develop very early in cases of Russells Viper bite and even when the patient arrives at hospital soon after the bite, the damage may already have been done. Studies have shown that even when ASV is administered within 1-2 hours after the bite, it is incapable of preventing ARF. Declining renal parameters require referral to a higher centre with access to dialysis. Peritoneal dialysis could be performed in secondary care centres.

Surgical issues The surgical issues observed in snake bite cases are • Ulcer following snakebite • Necrosis of the skin and underlying tissues • Gangrene of the toes and Þngers • Debridement of necrotic tissues • Compartment syndrome and others Practitioner while dealing a case of snake bite with one or other surgical issues has been informed to remember the following and keep the patient and the care givers accordingly. ! Fasciotomy does not remove or reduce any envenomation. ! Visual impression is an unrealistic guide to estimate the ICP. Tissue injury after compartment syndrome may be disproportionate to the clinical status. ! Fasciotomy is not required for every case. The details and approach to some of the surgical issues are provided in Table no. 11.

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Table No. 11: Surgical issues: Assessment and action required •

• • •

• • • • • •

Assess for internal and external surgical issues related to envenomation carefully and observe for the same while the victim is at hospital and / or during follow up care. Wound status Use of topical agents / traditional medicine Compartment syndrome - Less common - Consider compartment syndrome of the limb if any of the following 6 Ps. or a combination of them appear. Pain on passive stretching Pain out of proportion Pulselessness Pallor Paresthesia Paralysis The limb can be raised in the initial stages to see if swelling is reduced. However, this is controversial as there is no trial evidence to support its effectiveness.

•

• •

• • •

Care of the wound - Apply appropriate topical agents and dressing - Maintain proper wound environment - Do surgical debridement, if needed refer to surgeon Prepare and proceed to skin grafting later (if required) Measure intra compartmental pressure (ICP) in suspected cases by Intra compartmental monitoring machine (Stryker pressure monitor) or by use of a saline monitor (normal <20mm Hg) Monitor ICP every 30 to 120 minutes if required Proceed with fasciotomy if the ICP exceeds 30 to 40mm of Hg. Restore coagulation time before commencing the procedures.

Use of Heparin and Botropase in Viper Bites Heparin has been proposed as a means of reducing Þbrin deposits in DIC. However, heparin is contraindicated in Viper bites. Venom induced thrombin is resistant to Heparin, the effects of heparin on antithrombin III (ATIII) are negated due to the elimination of ATIII by the time Heparin is administered and hence, heparin can cause bleeding by its own action. Clinical trial did not show any beneÞcial effect.


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Botropase is a coagulant compound derived from the venom of one of two South American pit vipers. It should not be used as a coagulant in viper bites as it simply prolongs the coagulation abnormality by causing consumption coagulopathy in the same way as the Indian viper venom currently affecting the victim. To conclude, heparin and botropase have to be avoided.

1.6 Snake Bite in special situations ASV Dosage in Victims Requiring Life Saving Surgery In very rare case of snake bite life saving surgery is required in order to save the victim. An example would be a patient who presents with signs of an intracranial bleed. Before surgery can take place, coagulation must be restored in the victim in order to avoid catastrophic bleeding. In such cases a higher initial dose of ASV is justiÞed (upto 25 vials) solely on the basis of guaranteeing restoration of coagulation after 6 hours.

Victims Who Arrive Late A frequent problem is victims who arrive late after the bite, often after several days, usually with acute renal failure. Should the clinician administer ASV? The key determining factor is, are there any signs of current venom activity? Venom can only be neutralised, if it is unattached! Perform a 20 WBCT and determine if any coagulopathy is present. If coagulopathy is present, administer ASV. If no coagulopathy is evident, assess the case for evidences for one or other complications and consequences secondary to complication of snake bite. Such cases require appropriate supportive measures. In the case of neurotoxic envenoming where the victim is having symptoms such as ptosis, respiratory failure etc, it is probably wise to administer one dose of 8-10 vials of ASV to ensure that no unbound venom is present. However, at this stage it is likely that all the venom is bound and patient requires respiratory support.

Snake bites Again! If a patient has been bitten by a poisonous snake and received ASV earlier and comes back with features of repeat snake bite, he / she may be considered as a fresh case and treated accordingly (Whatever the interval between the snakebite). However, care should be taken while administering ASV, since he / she has been sensitised.

Pregnancy and Lactating woman There is very little deÞnitive data published on the effects of snakebite during pregnancy. Though spontaneous abortion of the foetus has been reported, this is not 32



the outcome in the majority of cases. It is not clear if venom can pass the placental barrier. Pregnant women are treated in exactly the same way as other victims. The same dosage of ASV is given. The victim should be re-assessed for the impact on the fetus. One should be alert and rule out retro placental clot. The effects of venom and antivenom on the mother and fetus need further exploration. ASV may be administered to lactating woman if bitten by a poisonous snake and be treated like any other persons. Breast feeding is not contraindicated.

Others: Even if the patients belong to any of the following category viz., autoimmune disorders, debilitating status, endocrine disorders, Immuno-suppressed status, HIV/ AIDS, cancer, asthma and allergic disorders or any other illness arrive with features of snake envenomation, they also require ASV in the same manner like any other case of poisonous snake bite.

1.7 Management in Primary Health Centre (PHC) and Block PHC A key objective of this guideline is to enable even the doctors working in Primary Care Institutions as well as private practitioners treat snakebite with conÞdence. Evidence suggests that doctors are not willing to make use of ASV and other medications, even when equipped, due to lack of conÞdence and guidelines. The present handbook on guidelines is prepared to suite their needs and outlines how they should proceed within their context and setting. The principles envisaged to treat snake bite at all Health Centres / Hospitals irrespective of the status - Government or Private are given below in Table no: 7. The initial evaluation and systemic manifestations following envenomation, and treatment aspects are provided in Tables 12, 13 and 14 respectively. Table No. 12: Initial evaluation – No Systemic Envenomation ASSESS Vital signs • Pulse • BP • Respiration

CLASSIFY

TREATMENT

Vital signs (Adult)* • Pulse rate: 60-100/min • BP 110 / 70 to 140/95 • Respiratory rate <20/ min

Tab.Paracetamol Inj.Tetanus Toxoid IM Routine antimicrobials are not necessary


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Symptoms and signs • Bite marks • Ptosis • Double vision • DifÞculty in swallowing • Bleeding sites • Reduced urine output • Swelling and local pain • Local necrosis • Descending paralysis • Unconsciousness • Regional lymphadenitis • Any other symptoms and signs noted down

Symptoms and signs • Local pain and/ or swelling+ • Bite mark present, skin broken • No other symptoms and signs present Laboratory test: 20 Minutes Whole Blood Clotting Test - blood clot formed If above Þndings are there at the time of assessment classify as No systemic envenomation

Monitor Pulse, Respiration & BP every ½ hourly for 3 hours and every 4th hourly for remaining 48 hours.

If normal send the patient home

*Vital signs for children (see age speciÞc chart) are provided in Annexure II. If the patient has any systemic manifestations refer to Table.13 and 14 for hemotoxic and neurotoxic envenomation respectively. The details of local envenomation are provided in Table 4.

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Table No. 13: Haemotoxic envenomation ASSESS

CLASSIFY

TREATMENT Treat the patient with Anti Vital signs Vital signs (Adult)* Snake Venom (ASV) • Pulse Pulse rate >120 per • Start IV Normal Saline with • BP minute, feeble (a wide bore needle • Respiration response to hypotension) • Begin with one vial of ASV Respiratory rate > 20/min in one point of NS and start Hypotension < 10-15 drops per minute for 90/60 mmHg 15 minutes & watch for Symptoms and signs reactions. Symptoms and signs • Bite marks If signs and symptoms of • Swelling and local pain • Ptosis anaphylactic shock (cold or painful enlargement of • Double vision and clammy skin, rapid nearby lymphnodes • DifÞculty in pulse, dyspnoea, etc.) Bleeding from the swallowing develop, stop the ASV drip • Bleeding sites • Gingival sulci temporarily and treat the • Reduced urine output • Epistaxis shock with: • Swelling and local Petechiae, purpura, Inj.Hydrocortisone 100 mg IV or pain ecchymoses Inj.Dexamethasone 8 mg IV • Local necrosis Hematuria Inj.Pheniramine maleate 2ml IV • Descending paralysis Intracranial bleeding: • Unconsciousness • asymmetrical pupils Inj.Adrenaline 1:1000 (0.5ml)IM Inj.Deriphyline 2ml IV • Lymphadenitis • unconsciousness • Breathing difÞculty • convulsions Oxygen administration Persistent and severe • Any other, note IV Normal saline as life line vomiting or abdominal down • As soon as the patient pain recovers or Low back pain • If the patient is not having No urine output or signs and symptoms decreased urine output of anaphylactic shock Laboratory test: continue the ASV drip with 20 Minutes Whole Blood remaining seven vials / Clotting Test. ampoules • Blood clot not • Continue to monitor the formed vital signs at Þve minutes If above Þndings are interval for Þrst 30 minutes there at the time of and then at 15 minutes examination classify as interval for two hours Haemotoxic • Stabilise the patient and envenomation refer to the higher institution Aspirin should not be used


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Fluid requirements per day should be kept in mind while giving ASV. For children readers are requested to see the ßuid requirement chart provided in Annexure II. [Table No.29] * Vital signs for children (see age speciÞc chart) are provided in Annexure III. [Table no.30 to 33]. Table No. 14: Neurotoxic envenomation ASSESS

CLASSIFY

For local

Symptoms and signs Swelling and local pain Local necrosis • Descending paralysis starting with ptosis, external ophthalmoplegia • Numbness around the lips and For systemic mouth progressing to pooling of envenomation secretions, difÞculty to talk and refer to Tables respiratory failure 12 and 13 • Paradoxical respiration • Paralysis • Abdominal pain envenomation • refer to Table • 4.

Laboratory test: 20 Minutes WBCT - Blood clot formed If above signs & symptoms are present at the time of admission classify as Neurotoxic envenomation

TREATMENT Treat the patient with ASV as mentioned in Table 13 and add the following: Inj.Neostigmine 1.5 mg (Therapeutic Test dose) as IM and Inj.Atropine 0.6 mg (Test dose) as IV After that observe patient for every Þve minutes for 30 minutes for signs of response

1.8 Referral aspects The medical ofÞcer who is treating the cases of snake bite should take meticulous care to look in to the patient’s status and provide Þrst aid as well as supportive measures before referring the case to higher centre / speciaslist. The details are furnished in Table 15 below.

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Table No. 15: Referral aspects for snakebite Who needs? Patient requiring • • Respiratory support • Deteriorating neurologic manifestations • Surgical intervention-Necrosis / Fasciotomy • Spontaneous persistent bleeding • Co-morbid diseases • Acute impending kidney failure

When to refer? Refer the patient after stabilising the case and after giving injection ASV (Refer to Annexure VIII and IX)

Where to refer? Refer to higher institution having • Ventilator • Dialysis facilities • Measures to provide further supportive treatment.

Referral Criteria for Haemotoxic envenomation Once the ASV is Þnished and the adverse reaction dealt with the patient should be automatically referred to a higher centre with facilities for blood analysis to determine any systemic bleeding or renal impairment. The 6 hours rule ensures that a six hours window is now available in which to transport the patient.

Referral Criteria for Neurotoxic envenomation If after one hour from the end of the Þrst dose of ASV, the patient’s symptoms have worsened i.e., paralysis has descended further, a second full dose of ASV is given over one hour. ASV is then completed for this patient. If after 2 hours the patient has not shown worsening symptoms, but has not improved consider this case for referral to a higher centre

Instructions while referring • • • •

Inform the need for referral to the patient and / care giver [family member or the accompanying attendant] Give prior intimation to the receiving center using available communication facilities Arrange for an ambulance Transfer in a vehicle to Secondary Care Hospital or Tertiary Care Hospital where mechanical ventilator and dialysis facilities are available


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• • • • • •

Continue life supporting measures Provide airway support with the help of an accompanying staff Send the referral note with details of treatment given Instruct one staff to accompany the patient during transportation if required. Hand over the referral form with details regarding treatment given Mention the clinical status clearly in the referral form at the time of referral.

1.9 Welfare measures The Government of Tamil Nadu is providing solatium to the family members of the deceased snake bite victims. The amount is disbursed by the respective district collector based on the application made by the family members along with the medical certiÞcate mentioning the cause of death as complications following snakebite in a clear manner (as observed while on treatment). The amount varies from state to state. Treating doctor should inform the family members of the deceased, and guide them regarding the ways and means for getting the welfare measures provided by the government.

1.10 Occupational risk for Snake bite The normal perception is that rural agricultural workers are most at risk and the bites occur Þrst thing in the morning and last thing at night. However, this is of very little practical use to rural workers in preventing snakebite since it ignores the fact that often snakebites cluster around certain bio-mechanical activities, in certain geographic areas, at certain times of the day. • Grass-cutting remains a major situational source of bites. • In rubber, coconut, palmyra and arecanut plantations clearing the base of the tree to place manure causes signiÞcant numbers of bites. • Harvesting high growing crops like millet which require attention focused away from the ground. • Rubber tapping workers are susceptible and it happens often in the early hours 03:00-06:00. • Agricultural workers involved in vegetable harvesting / fruit picking. • Tea and coffee plantation workers face the risk of arboreal and terrestrial vipers when picking or tending bushes. • Clearing weeds exposes workers to the same danger as their grass-cutting colleagues. • Walking at night without a torch, barefooted or wearing sandals accounts for a signiÞcant number of bites.

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•

• • • •

Bathing in ponds, streams and rivers, in the evening. It should not be assumed that because the victim is bitten in water that the species is non-venomous. Cobras and other venomous species are good swimmers and may enter the water to hunt. Walking along the edge of waterways. Plucking ßowers in areas of ßower cultivation Plucking hay / straw from bundle of hay / straw Persons involved in picking up dry Þre wood, loose stones, heaps of paddy, sugar cane or jowar husk.

1.11 Preventive measures and health education • •

• • • • •

Walk at night with sturdy footwear and a torch and use the torch! When walking, walk with a heavy step as snakes can detect vibration and will move away! Carry a stick when grass cutting or picking fruit or vegetables or clearing the base of trees. Use the stick to move the grass or leaves Þrst. Give the snake chance to move away. If collecting grass that has previously been cut and placed in a pile, disturb the grass with the stick before picking the grass up. Keep checking the ground ahead when cutting crops like millet, which are often harvested at head height and concentration is Þxed away from the ground. Pay close attention to the leaves and sticks on the ground when wood collecting. Keep animal feed and rubbish away from your house. They attract rats and snakes will follow. Try to avoid sleeping on the ground. Keep plants away from your doors and windows as plants help snakes to climb up and into windows.

1.12 Resource materials 1. Agarwal P.N., Agarwal A.N., Gupta. D., Behera. D., Prabhakar. S., Jindal. S.K. Management of Respiratory Failure in Severe Neuroparalytic Snake Envenomation. Neurol India 2001: 49: 25 – 28. 2. Agarwal R. Singh AP, Agarwal AN. Pulmonary oedema complicating snake bite due to Bungarus caeruleus. Singapore Med J 2007 Aug;48(8):e227-30. 3. Ahmed SM, Ahmed M, Nadeem A, Mahajan J, Choudhary A, Pal J. Emergency treatment of a snake bite: Pearls from literature. J Emerg Trauma Shock 2008;1:97-105.


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4

Alvares R. (Goanet) Myths and Snake bites. http://lists/whatwg.org/goanetgoanet.org/2004-september/017828.html accessed on 28.01.08. 5. Amarel CFS, Campllina D, Dias MB, Bleno CM, Razende NA. Tourniquet ineffectiveness to reduce the severity of envenoming after crotalus durissus snakebite in Belo Horizonte, Minas Gerasis, Brazil. Toxicon 1998, 36(5): 805808. 6. Athappan G, Balaji MV, Navaneethan U, Thirumalikolundusubramanian P Acute renal failure in snake envenomation: a large prospective study. Saudi J Kidney Dis Transpl. 2008 May; 19(3):404-10 7. Babu N, Rajendiran C, simpson ID, Ravi .G, Thirumalaikolundusubramanian P. Snake bites in South India: Community concepts and indigenous methodscause and concern (PP-099). Abstract book of 6th annual conference of Asia PaciÞc Association of Medical Toxicology held at Bangkok, Thailand, December 12-14, 2007 P.204 8. Bambery P.snakebites and arthopod envenomation. In: Shah SN, etal. [Edrs] API text book of Medicine 8th edition. The Association of Physicians of India, Mumbai 400 011. 2008; Volume 2: section 24, chapter 11 : 1517-20. 9. Banerjee RN, Sahni AL, Chacko KA. Neostygmine in the treatment of Elepidae bites. Journal of Association of Physicians of India 1972; 20: 503-509. 10. Bawaskar HS, Bawaskar BH. ProÞle of snake bites envenoming in western Maharashtra, India. Trans Roy Soc Trop Med Hyg 2002; 96: 79-84. 11. Bawaskar HS. Snake bite and scorpion stings.In; Khubchandani R, Gajendrsgadkar A, Bavdekar SB, Shah NK. [Edrs] Frequently asked questions Ask IAP: a series. Basics and Beyond. IAP Action Plan 2006; 109-118. 12. Bawaskar HS, Bawaskar BH, Punde DP, Inamdar MK, Dongare RR, Phoite RR ProÞle of snakebite envenomation in rural Maharashtra. Journal of Association of Physician of India 2008:56: 88 – 95 13. Bhat R.N., Viperine Snake Bite Poisoning in Jammu. JIMA 1974:63:383 – 392. 14. Chugh K.S. Snake Bite induced Acute Renal Failure. Kidney International 1989:35:891 – 90 15. Daga S, Biswas K, Roy K. Editorial: Medical record keeping- are we prepared? J Indian Med Assoc 2008; 10: 145. 16. Dutta T.K., Mukta V. Snake Bite. JIMA 2006:104, 251 – 254. Guidelines for the Clinical Management of Snake Bites in the South East Asian Region. World Health Organization, Regional OfÞce for South East Asia, New Delhi 2005;PP67 + viii.

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17. Ghosh S. Management of snake bite – an update. In: Bichille SK, Hasa NK, Mehta SS. (Edrs). Medicine update. The association of physicians of india 2008; 18(chapter 90): 691-696. 18. Government Order (D) No.46, Health and Family Welfare Department, State Government of Tamilnadu, Chennai, dated 19.01.2006. 19. Government Order (2D) No.125, Health and Family Welfare (EAP 1/1) Department, State Government of Tamilnadu, Chennai, dated 02.11.2007. 20. Government Order (MS) No.10, Health and Family Welfare (MCA 1) Department, State Government of Tamilnadu, Chennai, dated 09.01.08 21. Health and Family Welfare (P1) Department, State Government of Tamilnadu, Chennai, Letter No. 637/P1/06-2 dated 27.01.06 22. Ho M, Warrell MJ, Warell DA, Bidwell D, Voler A. A critical appraisal of the enzyme linked immunosorbent assays in the study of snake bite. Toxicon 1986; 24:211-221. 23. Howarth DM, Southee AS, Whytw IM, Lymphatic ßow rates and Þrst aid in simulated peripheral snake or spider envenomation. Medical Journal of Australia 1994; 161: 695-700 24. Jeganathan N.Siddha Medicine for poisons. In: Subramanian SV, Madhavan VR. Heritage of tamils: Siddha Medicine. International Institute of Tamil studies, T.T.T.I, Taramani, Chennai 600 113. March 1983; chapter 31; 504 – 522. 25. Kalantri S, Singh A, Joshi R, Malamba S, Ho C, Ezoua J, Morgan M. Clinical Predictors of in-hospital mortality in patients with snakebite: a retrospective study from a rural hospital in central India Tropical medicine and International health. 2005; 11(1): 22-30 26. Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, etal. (2008) The global burden of snakebite; A literature analysis and modeling based on regional estimates of envenoming and deaths, PLoS Med 5(11): e218 doi:10.1371/journal.pmed.0050218 27. Kularetra SAM, Reaction of snake venom antisera: study of pattern, severity and management at General Hospital, Anuradhapurra, Sri Lanka J Med 2000: 9: 8-13. 28. Management of Snakebite. Training module for staff nurse and auxillary nurse midwife. Basic emergency services for poisoning, State Health Mission Health and Family Welfare Government of Tamil Nadu, Chennai. 2007, 33-42, i-vii 29. Medical management of severe anaphylactoid and anaphylactic reactions. www.australianprescriber.com/magazine/24/5/artid/546/ accessed on 08.02.08


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30. Nayak KC, Jain AK, Sharda DP, Mishra SN. ProÞle of cardiac complications of snake bite. Indian Heart J. 1990 May-Jun;42(3):185-8 31. Norris RL, Ngo J, Nolan K, Hooker G, Physicians and lay people are unable to apply Pressure Immobilisation properly in a simulated snakebite scenario Wilderness and Environmental Medicine 2005;16:16-21 32. Norris RL, Bite marks and the diagnosis of venomous snakebite. Journal of Wilderness Medicine 1995; (6): 159-161 33. Pahlajani DB, Iya V, Tahiliani R, Shah VK, Khokhani RC. Sinus node dysfunction following cobra bite:case reports. Indian Heart J. 1987:39:48-9 34. Pillay VV. (Edrs). Modern Medical Toxicology. Third Edition. Jaypee Brothers. medical publication(P) Ltd., New Delhi 110 002. 2005; PP 499 + xviii 35. Rajendiran C, Simpson ID. Indian National Snake bites Protocol-2007 (OP-040). Abstract book of 6th annual conference of Asia PaciÞc Association of Medical Toxicology held at Bangkok, Thailand, December 12-14, 2007 P.104 36. Sarangi A, Jena I, Sahoo H, Das JP. A proÞle of snake bite poisoning with special reference to haematological, rental, neurological and electrocardiographic abnormalities. J 37. Singh S, Dass A, Jain S, Varma S, Bannerjee AK, Sharma BK. Fatal non-bacterial thrombotic endocarditis following viperine bite. Intern Med. 1998 Mar;37(3):342-4. 38. Senthilkumaran S. Cardiac complications among snake bite victims. Personal communication 39. Simpson ID. The paediatric management of snake bite . The National Protocol. Indian Pediatrics 2007,44:173-176 40. Simpson ID, Norris RL. Snakes of Medical importance in India: In the concept of the “ Big 4” still relevant and useful? Wilderness and Environmental Medicine 2007; 18(1) : 2-9 41. Simpson ID. Snake bite management in India, the Þrst few hours: a guide for primary care physicians. Journal Indian Medical Association 2007;105: 324, 326, 328, 330, 332, 334 & 335. 42. Simpson ID. Indian National Snake bite Protocol. www.indianwildlifeclub. com/blog/topic.asp?id_top=10 accessed on 28.01.08 43. Sharma S, Chappins F, Jha N, Bovier PA, Loutan I, Koriala S. Impacts of snake bites determinants of fatal outcomes in Southern Nepal. Amer J Trop Med Hyg 2004; 71(2):234-38

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44. Srivastava RK. Director General, OfÞce of the Directorate General of Health Services, Nirman Bhawan, New Delhi – 110011. Letter D.O.No.D.32020/3/2008 – EMR, Dated 5th February, 2008. 45. Training module Poison First aid and Treatment Centre (BEmONC, PHC), State Health Mission Health and Family Welfare Government of Tamil Nadu, Chennai. 2008. 46 Thirumalaikolundusubramanian P, Areas for research on Snake Bite / Scorpion Sting, Personal records. 47. Thirumalaikolundusubramanian P, Rajendiran C. Medical audit for snake bite and scorpion sting. Unpublished records 48. Tun Pe, Tin-Nu-Swe, Myint-Lwin, Warrell DA, Than-Win, The efÞcacy of tourniquets as a Þrst aid measure for Russells Viper bites in Burma Trans. R Soc Trop Med Hyg 1987; 81:403-405 49. Tun P, Khin Aung Cho. Amount of venom injected by Russells Viper (Vipera russelli) Toxicon 1986; 24(7): 730-733 50. Veerapandian R. [Edrs]. Guidelines for common surgical interventions in the elderly. Developed under WHO – Government of India collaborative programme 2006-07. August 2007. 51. Visweswaran RK, George J. Snake bite induced acute ranal failure. Indian J Nephrol 1999; 9(4): 156-159. 52. Warrell, D.A. (Edrs). 1999. WHO/SEARO Guidelines for The Clinical Management sof Snakebite in the Southeast Asian Region. SE Asian J. Trop. Med. Pub. Hlth. 30, Suppl 1, 1-85. 53. Warrell, D.A., Davidson, N. McD., Greenwood, B.M., Ormerod, L.D., Pope, H.M., Watkins, B. J., Prentice, C.R.M.. Poisoning by bites of the saw-scaled or carpet viper (Echis carinatus) in Nigeria. Quart. J. Med. 1977;46: 33-62. 54. Wen Fan H, Marcopito LF, Cardoso JLC, Franca FOS, Malaque CMS, Ferrari RA, Theakston RD, Warrell DA, Sequential randomised and double blind trial of Promethazine prophylaxis against early anaphylactic reactions to antivenom for Bothrops snake bites. BMJ. 1999; (318):1451-1453 55. When a cobra strikes. The Hindu (Online edition of India’s National newspaper) June 13,2004. www.thehindu.com accessed on 30th June 2008. 56. Yildirim C, Bayraktaroglu Z, Gunay N, Bozkurt S, Kose A, Yilmaz M. The use of therapeutic plasmapheresis in the treatment of poisoned and snake bite victims: an academic emergency department’s experiences. Journal of Clinical Apheresis 2006;21(4):219-23.


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SECTION - II

SCORPION STING Titles

Page

2.1 General • Introduction • Epidemiology • Eco-biological aspects of scorpion • Distribution of various species of scorpions • Socio cultural aspects

45

2.2 Clinical aspects • Components of venom and mechanisms of action • Pathophysiology • Symptoms and signs. • Criteria for diagnosis • Differential diagnosis • Investigations • Clinical course • Complications

47

2.3 Treatment • First aid measures • Traditional methods • Principles involved in the management • Pharmacological aspects of Prazosin

54

2.4 Scorpion sting in special situations

60

2.5 Management at PHC and Block PHC

60

2.6 Referral aspects

62

2.7 Occupational risk, patient education and prevention

63

2.8 Prognosis

64

2.9 Resource Material

64


2.1 General Introduction Scorpion sting is a life threatening medical emergency. The effect of envenomation is greatest among children below 5 years of age. Adults too can succumb to scorpion sting. Many social and environmental factors contribute to scorpion sting. Hence, it becomes an important public health problem. The epidemiology, presenting features, clinical course, complications, therapeutic response and outcome are variable in different series. However, early recognition and appropriate intervention inßuence the outcome. Hence, scorpion sting deserves special attention and cases should never be taken lightly. Though the research on scorpion venom and knowledge on treatment of scorpion sting have advanced, these newer ideas are yet to reach the health care provider and the community. In this context, it is worthwhile to remember Dr.H.S.Bawaskar, a private practitioner from Maharashtra who for the Þrst time in world has introduced the usefulness of alpha blocker in scorpion sting nearly 25 years ago. This has been accepted globally now in the treatment of scorpion sting.

Epidemiology In general for every case of snakebite, there may be 10 or more numbers of scorpion stings. If that is the case, the number of cases of scorpion sting may run to millions. There is no reliable statistics on the scorpion sting in India. Scorpion sting is underreported. Published reports are institution based, hence include only serious cases of scorpion sting treated in such institutions. As most of the cases of scorpion sting have mild symptoms, the general practitioners or family physicians or a traditional medical practitioners provide treatment and they never appear in health statistics. In Mexico, 1000 deaths due to scorpion sting occur per year whereas in USA four deaths were reported in 11 years. Of the 13,000 stings reported in USA, majority was due to non lethal scorpions. Most deaths occur during the Þrst 24 hours of the scorpion sting and are secondary to respiratory and cardiovascular failure. Children and elderly are at great risk of death due to their decreased physiological reserve. Death due to scorpion sting occurs in 25% of children below 5 years, if not treated, whereas only 1% of scorpion stings are lethal to adults. In India too, deaths due to scorpion sting occurs across the country but do not get due attention. Larger the scorpion population, greater is the number of scorpion sting cases. Scorpion stings are reported more from rural areas and the rural to urban ratio is approximately 3:1. Mostly stings occur between 6 P.M. to mid-night and between 6 A.M. to 12 Noon, which correlate very well with human activity. Scorpion sting occur more in temperate and tropical zones, and more during summer than winter. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

45


The Institute of child health, Madras Medical College, Chennai, has recorded nearly 1900 cases between 1980 and 1999 and the death rate varied from 4 to 7%. Of the 727 cases of scorpion stings treated during the period of 2000-2007 which included 406 males and 321 females [M: F= 4:3]; the death among them were 11 and 8 respectively. The death rate in children due to scorpion sting was 2% which has come down from 4 to 7% earlier. In general, male to female ratio of scorpion sting is approximately 2:1 but females suffer more due to lower body weight. There is no racial predilection but clinical symptoms, course, and outcome vary because of individual’s genetic constitution and other factors [vide infra]. Human stinging occurs accidentally, when scorpions are touched, threatened, cornered or disturbed (stepped upon) while in their hiding places. So, people involved in handling construction materials, carpentry works, clearing bushes or house cleaning as well as children playing nearby these areas are susceptible to scorpion sting.

Eco- biological aspects of scorpion Scorpions are shy creatures and not aggressive by and large. These are nocturnal creatures and hunt for their prey at night. Scorpions hide normally in crevices and burrows during daytime to avoid light. Scorpions are found elsewhere outside the environmental range. eg., accidentally crawl into luggage, boxes, containers, or shoes, pile of bricks, wooden materials, Þrewood, etc. They may also be transported in traveller’s luggage and cargo. There are about 1500 scorpion species of which 50 are dangerous. In India 86 species of scorpion have been identiÞed. Among them, Mesobuthus tamulus and Palamneus swammer-dami are important medically. Except Hemiscorpius species, all lethal scorpions belong to the family called the Buthidae. The lethal members of Buthidae family include the genera of Buthus, Parabuthus, Mesobuthus, Tityus, Leiurus, Andractonus and Centruroides. Among the 30 scorpion species found in USA, only one of them is dangerous to human beings. Scorpions live in temperate and tropical regions especially between the latitudes of 50 north and 50o south of equator. The distinguishing features between lethal and non lethal scorpions are provided in Table 16 given below. o

Table No. 16: Distinguishing features of lethal and non-lethal scorpion

• • • • 46

Structure Sternum Shape Pincers Body Tail

Lethal Scorpion Triangular Weak looking Thin in a empathetic manner. Thick

Non lethal scorpion Pentagonal Strong and Heavy Thick Thin



Scorpions use their pincers to grasp the prey. It arches its tail over its body and stings into its prey. Thus it injects its venom, sometimes more than once. The venom glands are situated in the tail. The striated muscles in the stings regulate the amount of venom injected. When entire venom is used, it takes several days to replenish venom. Scorpion with large venom sacs such as Parabuthus species can even squirt their venom.

Distribution of various species of scorpions Buthus is found in Mediterranean area, Parabuths in Western andSouthern Africa, Mesobuthus in Asia, Tityus in Central and South America, and Caribbean, Leiurus in Northern Africa and Middle East, Andractanus in Northern Africa to Southeast Asia, and Centruroides in South West USA, Mexico and Central America.

Socio cultural aspects For scorpion sting also, patients are taken for magico religious treatment where mantras are chanted, herbal medicines are applied externally and / or given orally. Since the scorpion sting has mild effects in many, most of them improve with local practices. Hence the community has conÞdence on the local / traditional practitioner or priest. If the pain continues or symptoms get aggravated or general condition deteriorates and in children if crying or restlessness continues, the patients are brought to the hospital. Thus local practices contribute to delay in health seeking.

2.2 Clinical Aspects Components of Venom and Mechanisms of action The components of venom are cardiotoxin, hemotoxin, nephrotoxin, neurotoxin, hyaluronidases, phosphodiesterases, phopholipases, glycosaminoglycans, histamine, serotonin, tryptophan and cytokine releasers. Among all, the most potent is the neurotoxin. There are two classes of neurotoxins (long chain & short chain polypeptide) which are heat stable, have a low molecular weight and are responsible for causing cell impairment in nerves, muscles, and the heart by altering sodium and potassium channel permeability. The long chain polypeptide neurotoxin induces continuous, prolonged, repetitive Þring of somatic, sympathetic and parasympathetic neurons which results in autonomic, and neuromuscular over excitation symptoms. It also prevents normal nerve impulse transmissions. Further, it results in release of neurotransmitters viz., epinephrine, nor-epinephrine, acetylcholine, glutamate, and aspartate excessively. The short chain polypeptide neurotoxin blocks the potassium channels.


47


Pathophysiology The venom is produced by columnar cells of the venom glands. Scorpion venom is water soluble, antigenic and positively charged. It is a heterogenous mixture and this can be easily demonstrated by electrophoresis method. Also, the heterogenisity of the venom explains the variable response to venom as observed in different people. Normally injected venom is between 0.1 to 0.6mg. Generally most lethal scorpions have a lethal dose (LD50) below 1.5mg. The potency varies with species causing mild ßu to death with in an hour. Humans are much more sensitive than mice. Once the venom is injected, it is distributed rapidly into the tissues. If the venom is deposited into a vein, the symptoms develop within 4 to 7 minutes after injection, with a peak concentration in 30 minutes. The half life of venom varies from 4.2 to 13.4 hours.

Symptoms and signs Symptoms and signs are inßuenced by factors related to “3 Ss” viz., scorpion, sting and the status of the patient. Table No. 17: Influencing factors for symptoms and signs

• • • •

Scorpion Species Age, size and nutritional status Stinging apparatus (telson)

• • •

• • •

Sting Time of sting Number of stings Quantity of venom injected (low dose – adrenergic, high dose – cholinergic) Depth of the sting penetration Site of sting IV/SC/IM Components of venom

• • • • • •

Status of the patient Age of the patient Health status Comorbid conditions Weight of the victim Physiological response of the individual Sensitivity of the systém to the neurotransmitters and toxins

Usual signs of scorpion sting are as follows • • • • •

48

Mydriasis Nystagmus Hyper salivation Dysphagia Restlessness



Usual mode of death is via •

•

Respiratory failure secondary to Anaphylaxis Broncho constriction Bronchorrhoea Pharyngeal secretion Pulmonary edema Diaphragmatic paralysis Venom induced multi organ failure

In view of the numerous toxins and enzymes released from the scorpion venom, the clinical signs and symptoms of envenomation may vary at local and at systemic level. The local signs are provided in Table 18. Grading of scorpion envenomation is based on neurological and non neurological predominance as shown in Figure 1. The local signs and systemic signs are provided in Table 18, 19 and 20 respectively. Figure 1: Grading of scorpion envenomation

(83%)

(10%)

(5%)

Local signs at the site of sting are further classiÞed into non-lethal local effects as well as neurotoxic and cytotoxic local effects. The details are provided in Table No: 18.


49


Table No. 18: Local effects at the site of sting

• • • •

Nonlethal local effects Pain Erythema Induration Wheal (due to activation of kinins and slow releasing substances of venom)

Neurotoxic local signs at Cytotoxic local signs at the the site of sting site of sting • Local effect of sting • Appearance of a macule • minimal or absent or papule within Þrst • Tissue necrosis (rare) hour • Sharp burning pain • Diameter of the lesion • Erythema vary with quantity of • Local tissue swelling venom injected • Ascending hyperasthesia • Progress of the lesion to (paresthesia persists for a purpuric plaque which several weeks and the will necrose and ulcerate last symptom to resolve)

Nonlethal local effects

Neurotoxic local signs at Cytotoxic local signs at the the site of sting site of sting • Positive “Tap test”• Lymphangitis (if the (Paresthesia worsens venom is transferred with gentle tapping at the through lymphatics) site of sting) • Hypersensitive to touch and temperature

Systemic signs are grouped into neurologic signs and non-neurologic signs, and a brief description of the same is provided in Table 19. Table No. 19: Systemic signs of scorpion sting

•

Central nervous system signs

Non neurologic sytemic signs [refer Table 20] • Cardiovascular signs

•

Autonomic nervous system signs Sympathetic signs Parasympathetic signs Somatic signs Cranial nerve signs

• • • • •

Respiratory signs Gastro intestinal signs Hematological signs Metabolic signs Genitourinary signs

• •

Allergic signs Pregnancy signs

Neurologic signs [refer Figure No.2]

• •

50

Peripheral nervous systém signs



Figure 2: Nervous system signs

Non-neurologic systemic signs: The scorpion venom affects all systems and details of non neurological signs are depicted in Table 20. However, the commonly observed were local, respiratory, cardiovascular and neurologic manifestations.


51


Table No. 20: Non-neurological signs *

*

*

Cardiovascular signs • Hypotension • Hypertension • Tachycardia (bradycardia at times) • Cardiac dysrhythmia • Transient apical pansystolic murmur • Cardiovascular collapse • Cardiogenic shock • Cardiac dysfunction Respiratory Signs • Tachypnoea • Pulmonary edema • Respiratory failure Gastro intestinal Signs • Dysphagia • Excessive salivation • Nausea and vomiting • Gastric hyperdistension • Increases gastric acid out put and gastric ulcer • Acute pancreatitis • Liver glycogenolysis • Toxic hepatitis

* Hematologic Signs • Platelet aggregation • Disseminated intra vascular coagulation (DIVC) * Metabolic Signs • Hyperglycemia • Increased lactic acidosis • Electrolyte imbalance * Genitourinary Signs • Acute renal failure • Rhabdomyolysis • Priapism * Allergic Signs • Urticaria • Angioedema • Bronchospasm • Anaphylaxis * Pregnancy Signs • Toxin induced uterine contraction

Criteria for diagnosis Definite confirmatory signs • Witnessed sting • A dead scorpion • Evidence at the site of sting - single puncture mark • Local pain – positive tap sign • Local and systemic manifestations (Absence of pain or manifestations does not rule out scorpion sting) 52



Probable scorpion sting • • •

Local edema Pin hole bleeding Profuse sweating – Local or generalised

Differential diagnosis • • •

Botulism Tetanus Organophosphorus toxicity

Less common conditions for differential diagnosis • • • • •

Myasthenia gravis Guillain barre syndrome Neuroleptic syndrome Sympathomimetic over dose Envenomation due to snake

Investigations Haematology - Complete Blood Count (CBC) - Leukocytosis - Hemolysis (variable) - Coagulation proÞle - DeÞbrination [if required] Blood Chemistry - Blood sugar - Serum creatinine - Serum creatine kinase - Serum amylase / lipase - Serum aspartate / alanine amino transferase - Arterial blood gas (ABG) analysis [if required]

Imaging studies •

Chest x – ray

Other investigations •

Electro cardiogram & serial ECG (monitor ST, T & others) during follow up.


53


Special investigations [if required] • Echocardiogram / and repeat for follow up studies • Color-ßow doppler • Pulmonary artery catheterisation studies • Serial spirometry to measure pulmonary functions • Hormone studies • Estimation of different cytokines • Serum venom level

Clinical Course Clinical course of scorpion sting is usually less alarming but in some cases it may progress to maximum severity in about 5 hours to 12 hours and starts subsiding within a day or two. Even if the patient has features of autonomic nervous system manifestations, it may start subsiding by 12 hours after initiating treatment. Tachycardia usually subsides within 24 to 48 hours. Hypertension may last for 4 to 8 hours. Hypotension and bradycardia are encountered usually within 2 hours. Once treatment is started, the signs of recovery begins within 48 or 72 hours. In some cases pulmonary edema may develop within 30 minutes to 3 hours, usually secondary to myocardial dysfunction. Unfortunately some cases of scorpion sting may die within 30 minutes and this may be related to ventricular arrhythmias or non cardiac pulmonary edema due to ARDS [often reported from Brazil]. Central nervous system manifestations with or without convulsions may occur within one to two hours in fatal cases.

Complications Various complication of scorpion sting are: • Respiratory failure • Multi organ failure • Dilated cardio myopathy • Rhabdomyolysis • Persistent paresthesia • Anti venom anaphylaxis and serum sickness • Ankylosis of small joints if sting occurs at a joint • Iatrogenic high dose sedative hypnotic respiratory arrest

2.3 Treatment The Þrst aid currently recommended is based around the mnemonic ‘R.I.G.H.T’. The details provided earlier in Table no.6 is again furnished below for easy reading. 54



Table No. 6: Currently recommended First aid • •

• •

R = Reassure the patient. I = Immobilisation of the limb in the same way as a fractural limb helps to prevent rapid absorption of the venom into the circulation. (Use bandages or cloth to hold the splints, not to block the blood supply or apply pressure. Do not apply any compression in the form of tight ligatures, they don’t work and can be dangerous!). G. H. = Get to Hospital Immediately. (Traditional remedies have NO PROVEN beneÞt in treating scorpion sting). T = Tell the doctor all that happened from the time of scorpion sting along with symptoms that developed till reaching (or arrival) the hospital.

This method will get the victim to the hospital quickly, without recourse to traditional medical approaches which can delay effective treatment.

Traditional methods The traditional methods such as application of counter irritants, herbal materials or paste over the site of sting or tight tourniquet (it may intensify local effects of venom), or hot fomentation should be avoided as they may enhance the effects of venom. Also avoid cutting and suction (oral extraction of venom from the site), or cutting and letting out the blood, or washing the wound with chemicals or alcohol or other methods as they facilitate the absorption of toxin. In view of the consequences noticed, these traditional methods have to be discarded. However, local application of ice bags (one of the traditional methods) to reduce the pain is acceptable for some time if not contraindicated. This method slows down the absorption of venom via vasoconstriction. This is the most effective one during the Þrst 2 hours following the scorpion sting. One should not cause freezing injury, while using ice cubes / bag.

While dealing a case of scorpion sting consider mnemonic ‘RASI’. • • • •

Remember principles Address the problems – clinical and social Seek help from others when required and Inform the patient and / or care givers on the status of illness, clinical course, management, outcome, welfare measures and follow up clearly with empathy.


55


Principles involved in the management of scorpion sting The principles envisaged to treat scorpion sting at all Health Centres / Hospitals irrespective of the status (Government or Private) are given below (the same given under snake bite) under “12 As”. Table No. 7: Principles involved in the management 1. Admit the victim immediately. 2. Ask effectively. 3. Assess quickly. 4. Act swiftly. 5. Administer medication meticulously. 6. Address to the wound properly. 7. Anticipate complications keenly. 8. Avoid errors carefully. 9. Ascertain the status repeatedly. 10. Amicable with patients and care givers and show empathy. 11. Advise on follow up accordingly. 12. Arrange for referral early. 1) Admit all victims of scorpion sting & keep the victims under observation for 24 to 48 hrs. (If scorpion is brought try to identify the colour and size of it). 2) a) Ask for the details of scorpion sting and never be carried away with the sting marks either for diagnosis or for assessment of severity. • Time of sting • Number of stings • Nature of the incident • Depth of the sting • Site of envenomation-close to head & torso [results in quicker venom absorption & onset of symptoms in the former] b] Ask for the time interval between the sting and arrival at the hospital. c] Ask for the details of traditional medicines or household remedies used, as it may sometimes cause confusing symptoms or interfere with other drugs to be administered. d] Ask for clinical symptoms and correlate with the progression of symptoms and signs due to scorpion sting [provided in page vide supra] 3] Assess the following quickly. a] Airway, Breathing and Circulation b] Vitals HR, RR, BP and Pulse oximetry (if required) 56



c] Site of sting and the probable route of envenomation - (Intravenous have immediate effects, while subcutaneous and intramuscular routes take several minutes to hours to cause effect) d] Chest expansion e] Clinically from head to foot as well as back f] For associted co-morbid illness[es] g] For consuming any medication[s] h] Status of envenomation – mild, moderate and severe [in view of neurotoxic, cardiotoxic, hemotoxic, myotoxic or a combination of them] 4] Act swiftly a] To support Airway, Breathing and Circulation b] To start IV line [ßuid for children - refer Annexure II Table No.29] c] To provide supportive measures depending upon the requirements d] To connect ventilator if there is a need 5] Administer medication meticulously a] Tetanus Toxoid injection intramuscularly b] Topical anaestetic agent to the site of sting to decrease paraesthesia. c] Injection lignocaine 1% without adrenaline; 2ml as local inÞltration (after test dose for lignocaine) (0.1 to 0.2mg/kg body weight for children) d] Oral rehydration solution to hydrate the patient if not contraindicted. e] Tab. Paracetamol 10mg/kg body weight to reduce pain f] Tab. Prazosin [plain 1mg]

Pharmacological aspects of Prazosin Prazosin is an alpha blocker. It counteracts scorpion induced adrenergic cardiovascular effects and reduces pulmonary edema through vasodilatory effect, Usually it is started with small dose using plain tablet but not exceeding 5mg/day. For children the dose preferred is 30 microgram / kg body weight. Though pediatric requirement has not been established, it is started with small dose. Prazosin can be given irrespective of blood pressure, provided there is no hypovolemia It should be avoided, if the patient is hypersensitive to prazosin. Always exercise caution if patient has renal insufÞciency and hypertension. Users must remember that it interacts with beta blocker and causes hypotension. Also, verapamil may increase serum levels of prazosin and increase patient’s sensitivity to prazosin and cause postural hypotension. Interestingly, prazosin decreases the anti hypertensive effect of clonidine. Safety in pregnancy has not been established. Also, users are informed to follow standard measures while using prazosin (Refer Table No.21).


57


Table No. 21: Measures to be adopted while using Prazosin • • •

• • • • •

Prazosin should not be given as prophylactic dose when pain is the only symptom. Give Prazosin through nasogastric tube, if baby has vomiting. Keep the patient in lying posture for about 3 hours (even while examining the case) in order to prevent ‘Þrst dose phenomenon’ (hypotension) due to Prazosin. Monitor pulse, BP, and respiration every 30 minutes for 3 hours. Reassess for warmth and return of pain at the site of sting. Continue monitoring of pulse, BP, and respiration every 60 minutes for next 6 hours. Recheck the same every 4 hours till improvement is visible. Repeat Tab. Prazosin in the same dose at the end of 3 hours according to clinical response and later every 6 hours till extremities are warm, dry and peripheral veins are visible easily.

* Alternative to Tab. Prazosin is NiÞdipine, Nitroprusside, Nitroglycerine, Isosorbide di-nitrate, Hydralazine or Angiotensin converting enzyme inhibitors (ACEIs). However, users have to remember the constraints while prescribing such drugs. g] Beta-blockers in small doses along with alpha blockers if needed and if not contraindicated. h] Nitrates if patient has hypertension and myocardial ischemia i] Ionotropics such as digitalis (has little effect), or dobutamine (refer snake bite section for details). Avoid Dopamine as it aggravates the myocardial damage. j] Nor-epinephrine as IV drip to correct hypotension refractory to ßuid therapy. k] Antimicrobials if infection is suspected l] Inj. Atropine (required at times) to counter venom induced parasympathetic effects. m] Inj. Insulin has been shown to prevent multiorgan failure (especially cardiopulmonary) in animal experiments. n] Barbiturate and / or benzodiazepine as continuous infusion for severe / excessive motor activity o] Steroids to decrease shock and edema is of unproven beneÞt. p] Antivenom for scorpion sting is not used commonly in India (as species speciÞc antivenom is not available and usage has not demonstrated any beneÞt) q] Vaccine – not available (tried in experimental animals). r] IV fluids as per need [ßuid for children- refer Annexure II Table No.29].

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s] Other supportive medications such as sodium nitroprusside (0.3 –0.5 mcg/ kg/min with upward titration), or nitroglycerine as per need (usually in pulmonary edema) Though Inj. Morphine is used as a standard therapy for pulmonary edema, it should be avoided in scorpion sting since narcotics worsen dysrhythmias in children 6] Address to the wound properly The details of wound care are provided below. However, one should also remember the other surgical issues described vide Table 11 in the snake bite section. a] Wound following scorpion sting may show sting marks with or without local manifestations. b] Sometimes venom may penetrate deep and hence deeper tissues may be damaged which may not be visible during initial examination (rare). c] At the site of the sting a bleb or vesicle may develop and end in the form of non speciÞc ulcer. (Non-speciÞc ulcers are deÞned as ulcers due to infection of wounds, physical or chemical agents or due to local irritation). d] Consider the following while managing the wound / ulcer (uncommon in scorpion sting). • Minimize unnecessary blood loss. • Initiate adequate cleaning with normal saline or tap water, and edema control. • Remove debris and necrotic tissue, irrigate gently with water / normal saline. • Expose viable tissues, excise eschar after controlling hemotoxic complications. • Use topical antibacterial agents. • Apply dressings after complete debridement. • Maintain proper wound environment and prevent ischemia. • Keep the bacterial count as low as possible. • Facilitate healing of acute wound by applying non adherent dressing to ensure adequate epithelialization and to prevent contamination of the wound. • Keep wounds clean and dry. • Avoid soaking or scrubbing the wound. • Teach & explain the care of wound to the patients and / or care givers. • Educate on good personal hygiene and nutrition. • Control diabetes if identiÞed.


59


7] Anticipate complications keenly. a] b] c] d]

Examine the victims at regular intervals for alterations in symptoms and signs Anticipate dysrhythmias during the Þrst 24 to 48 hours after sting Start tapering prazosin after the clinical improvement begins to manifest Observe for drug related systemic changes and drug toxicity, and treat them accordingly. 8] Avoid errors carefully while assessing the case, investigating the victims, administering medications, following the case at hospital, undertaking any procedures for the patient, referring to other specialists or hospitals, communicating with patients / and care givers, planning for discharge, preparing reports, Þlling up the forms, reviewing the data and conducting the audit. 9] Ascertain the status repeatedly and provide supportive measures, as these cases may develop covert signs during hospital stay while on treatment. 10] Amicably interact with patient and care givers and show empathy to them in view of the socio clinical aspects related to scorpion sting. 11] Advise on follow up accordingly in view of the systemic toxicity. Patients may also be motivated to attend to the nearest Health Centre / Hospital for follow up care. Follow-up checks are required for assessment of long term effects on different organs / systems and for appropriate management wherever required / needed. 12. Arrange for referral early - One should also remember the criteria for referral and provide clear instructions while referring the case. The details on referral aspects are provided in Table 24.

2.4 Scorpion sting in special situations If patients already suffering from one or other illness(es) with or without medications for the underlying illness, suffers from scorpion sting, these patients have to be treated like any other case of scorpion sting. However, treating doctor has to exercise caution while prescribing and using medications, consider drug interaction, contraindications, absorption, and excretion of the drugs used so as to avoid toxicity. Also, one has to carefully monitor the status of underlying illness. Pregnant women and lactating women with scorpion sting have to be treated like any other women. Remember to consider the baby in utero by clinical and technological means.

2.5 Management in Primary Health Centres (PHC) and Block PHC The key objective of this guideline is to enable even the doctors working in Primary Care Institutions as well as private practitioners to treat scorpion sting with conÞdence. Evidences suggest that doctors are not willing to make use of the medications and devices, even when available, due to lack the conÞdence and guidelines. The present handbook provides guidelines to meet their needs, and outlines how they should proceed 60



within their context and setting. The principles envisaged to treat scorpion sting at all Health Centres / Hospitals irrespective of the status (Government or Private) are given in Table no: 7 (vide supra under treatment) The initial evaluation and systemic manifestations following scorpion envenomation (described in Table 18, 19 and 20, and Figure 1 and 2), and treatment aspects are provided in detail vide supra. However, a format for quick assessment is provided in Table 22 and 23 (refer Annexure VIII and X). Table No. 22: Initial evaluation of scorpion sting without Systemic Envenomation ASSESS Vital signs • Pulse • BP • Respiration

CLASSIFY Vital signs (Adult)* • Pulse rate: 60-100/ min • BP 110 / 70 to 140/95 • Respiratory rate <20/ min

SYMPTOMS AND SIGNS • Local pain and/ or Local effects (Table 18) swelling • Sting marks and site • Swelling and local • Sting mark present pain • No other symptoms • Pain, erythema & and signs wheal If the patient has • Induration, macule/ above Þndings at the papule time of assessment, • Progress to purpuric classify as No systemic plaque envenomation • Local necrosis • Lymphangitis • Ascending hyperesthesia • Positive “Tap test” • Conscious level • Any other systemic effects SYMPTOMS AND SIGNS

TREATMENT Tab.Paracetamol Inj.Tetanus Toxoid IM Routine antimicrobials are not necessary Monitor Pulse, Respiration & BP every ½ hourly for 3 hours and every 4 hourly for remaining 48 hours. If normal send the patient home If the patient develops one or other systemic manifestations as described in Table 18, 19 and 20, and Figure 1 and 2, proceed to treat as given in Table 23.

*Vital signs for children (see age speciÞc chart) are provided in Annexure III (Table No.30 to 33). If the patient has any systemic manifestations as described in Table 19 and 20, and Figure 1 & 2, proceed to manage as described in Table 23. The details of local envenomation is provided in Table 18. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

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Table No. 23: Evaluation of scorpion sting with Systemic Envenomation ASSESS Vital signs • Pulse • BP • Respiration

SYMPTOMS AND SIGNS In addition to those described in Table 22, look for those mentioned in Table 19 and 20 as well as Þgure 1 and 2 for one or other systemic manifestations as described in Table 19 and 20, and Figure 1 and 2.

CLASSIFY

TREATMENT

• Vital signs (Adult)* Pulse rate >120 per • minute, feeble (a response to hypotension) Respiratory rate > 20/min • Hypotension < 90/60 • SYMPTOMS AND • SIGNS Swelling and local pain If systemic Þndings are there at the time of examination, classify as systemic envenomation •

•

Oxygen administration if required Follow various principles described vide supra Start IV Normal Saline with wide bore needle as life line Treat the patient with Tab. Prazosin (Plain) Continue to monitor the vital signs at Þve minutes interval for Þrst 30 minutes and then at 15 minutes interval for two hours. For further details while using Prazosin follow the details provided in Table No.21. Stabilise the patient and refer to the higher institution keeping the patient in lying posture.

Fluid requirements per day should be kept in mind while managing the case. For children readers are requested to see the ßuid requirement chart provided in Annexure II. * Vital signs for children (see age speciÞc chart) provided in Annexure III.

2.6 Referral aspects The medical ofÞcer who is treating the cases of scorpion sting should take meticulous care to look into the patient’s status and provide Þrst aid as well as supportive measures before referring the cases to higher centre / specialist(s). The details are furnished in Table 24 below.

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Table No. 24: Referral aspects for scorpion sting Who needs • Patient requiring • Respiratory support • Cardiac failure/shock • Surgical intervention • Spontaneous persistent bleeding • Co-morbid diseases • Acute impending kidney failure • Multi-system involvement

When to refer Refer the patient after stabilising the case and after giving Tab.Prazosin and other supportive measures (refer to Annexure VIII and X)

Where to refer Refer to higher institution having ventilator and other measures to provide further supportive treatment.

Instructions while referring • • • • • • • • • •

Inform the need for referral to the patient and / care giver [family member or the accompanying attendant] Give prior intimation to the receiving center Arrange for an ambulance Transfer in a vehicle to Secondary Care Hospital or Tertiary Care Hospital where facilities are available for further management Continue life support measures Provide airway support with the help of an accompanying staff Send the referral note with details of treatment given Instruct one staff to accompany the patient during transportation if required Hand over the referral form (Annexure V) with details regarding treatment given Mention the clinical status at the time of referral clearly in the referral form

2.7 Occupational risk, Patient Education and Prevention • • • • • •

Occupational risk for scorpion sting is noticed frequently among those handling building materials, Þre wood, etc., where scorpions hide. Educate the patients and community on how to avoid scorpion and scorpion sting. To check shoes, gloves, clothing and package before use. To keep yards free of debris, which serve as places for scorpions to hide. To prevent entry of scorpion into home (make sure windows and doors Þt tightly). Avoid walking barefoot especially at night.


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• •

Encourage biological methods to control scorpion by introducing chicken, ducks, owls etc., Use chemicals such as (organo-phosphates, pyrethrum and chlorinated hydro carbons) which help to control.

2.8 Prognosis •

•

•

Prognosis is related to species of scorpion, the venom injected (amount and components), physiological response of the individual to the venom, and individual’s response to pharmaco therapy as well as supporting measures. Symptoms generally persist for 24 – 48 hours, if the patient survives without severe toxic effects on cardio respiratory or neurologic systems or multi organ failure. Greater the systemic symptoms and poorer the response to therapy, worse is the prognosis.

2.9 Resource material 1. Amaral CF, Rezende Na,Treatment of scorpion Scorpion envenoming should include both a potent speciÞc antivenom and support of vital functions. Toxicon. 2000:38(8): 1005 – 7. 2. Amitai Y, MinesY, Aker M, Goiten K. Scorpion Sting in children: a review of 51 cases. Clin Pediatr. (Phila). 1985:24(3):136-40 3. Abroug F, Nouira S, Haguiga H, Bouchoucha S. High dose hydrocortisone hemisuccinate in scorpion envenomation. Ann Emerg Med 1997; 30: 23-27. 4. Bawaskar HS, Bawaskar PH. Prazosin for vasodilator treatment of acute pulmonary edema. Ann Trop Med Parasitol 1987; 81: 710-723. 5. Bawaskar HS, Bawaskar PH. Envenoming by scorpions and snakes, their neurotoxins and therapeutics. Trop Doct 2000; 30: 23-25. 6. Bawaskar HS. Scorpion sting. In: Shah SN, etal. [Edrs] API text book of Medicine 8th edition. The Association of Physicians of India, Mumbai 400 011. 2008; Volume 2: section 24, chapter 12 : 1520-23 7. Bawaskar HS. Snake bite and scorpion stings.In; Khubchandani R, Gajendragadkar A, Bavdekar SB, Shah NK. [Edrs] Frequently asked questions Ask IAP: a series.. Basics and Beyond. IAP Action Pl25. Biswal N, Mathai B, Bhatia BD. Scorpion sting envenomation: complications and management. Indian Pediatr. 1993:30 (8): 1055 – 9 8. Brand A, Keren A, Kerem E, Reifen RM, Branski D. Myocardial damage after a scorpion sting: long-term echocardigraphic follow-up. Pediatr. Cardiol 1988:9(1):59-61.an 2006 ; 109-118. 9. Baldessarini RJ. Drugs acting on the central nervous system. In: Goodman and Gilman’s: The Pharmacological Basis of Therapeutics, 9th edn. Eds. Hardman JG, Limbird LE. New York, McGraw Hill, 1996; pp 411- 412. 64



10. Bawaskar HS, Bawaskar PH. Role of atropine in management of cardiovascular manifestations of scorpion envenoming in humans. J Trop Med Hyg 1992; 95: 30-35. 11. Bawaskar HS, Bawaskar PH. Prazosin in the management of cardiovascular manifestations of scorpion sting. Lancet 1986; 1: 510-511. 12. Bawasker HS, Bawaskar PH. Clinical proÞle of severe scorpion envenomation in children at rural setting. Indian Pediatr. 2003:40(11):1072 – 5. 13. Bawasker HS, Bawasker PH. Severe envenomoing by the Indian red scorpion Mesobuthus tamulus: the use of prazosin therapy. QJM. 1996:89(9):701 – 4. 14. Bharani AK, Sepaha GC. Myelopathy after Scorpion sting. Arch Neurol. 1984:41(11):1130 15. Bawaskar HS, Bawaskar PH. Cardiovascular manifestation of severe scorpion sting in India (review of 34 children). Ann Trop Pediatr 1991; 11: 381-387. 16. Carbonario PA, Janniger CK,Schwartz RA. Scorpion sting reactions. Cutis. 1996:57(3):139 17. Chang D, Dattaro JA, Kirkland L. Scorpion sting (article last updated on November 8th,2007). www.emedicine.com accessed on April 12th, 2008. 18. Chippaux JP, Goyffon M. Epidemiology of scorpionism: a global appraisal. Act Trop. 2008 Aug:107(2):71-9. 19. Das S, Nalini P, Ananthakrishnan S, Sethuraman KR, Balachander J, Srinivasan S. Cardiac involvement and scorpion envenomation in children. J Trop Pediatr. 1995:41(6):338 – 40. 20. Devi CS, Reddy CN, Devi SL, Subrahmanyam YR, Bhatt HV, Suvarnakumari G. DeÞbrination syndrome due to scorpion venom poisoning. Br Med J.1970(5692): 345 – 7. 21. Ghalim N, El-Hafny B, Sebti F, Heikel J, Lazer N, Moustanir R. Scorpion envenomation and serotherapy in Morocco. Am J Trop Med Hyg. 2000:62(2): 277 – 83. 22. Goyfon M, Vachon M, Broglio N. Epidemiological and clinical characteristic of the scorpion envenomation in Tunisia. Toxicon. 1982; 20(1):337 – 44 23. Gueron M, Ilia R, Sofer S. The cardovascular systems after scorpion envenomation. J Toxicol Clin Toxicol. 1992:30(2):245 -5. 24. Gueron M. Margulis G, Illa R, Sofer S. The Management of scorpion envenomation. Toxicon. 1993 ; 31 (9) : 1071-83. 25. Ismail M. The Scorpion envenoming syndrome. Toxicon, 1995;33 (7):825 – 58. 26. Jahon S, Al Saigul AM, Hamed AR. Scorpion stings in Qassim, Saudi Arabia -a 5 year surveillance report. Toxicon. 2007:50 302-5. 27. Kric-Dautovic S, Begovic B, Acute renal in insufÞency & toxic hapititis following scorpion sting. Med arh 2007;61:123-4. 28. Krinsky WL. Arthropods and leeches. In: Cecil’s Textbook of Medicine, 19th edn. Ed. Wyngaarden JB. Philadelphia, W.B. Saunders Co, 1992; p 2025. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

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29. Karnad DR. Hemodynamic pattern in patients with scorpion envenomation. Heart 1998; 79: 485-489. 30. Mahadevan S. Scorpion sting. Indian Pediatr. 2000; 27: 504-514. 31. Mahadevan S, Choudhury P, Puri RK, Srinivasan S. Scorpion envenomation and the role of lytic cocktail in its management. Indian J Pediatr. 1981; 48: 757-761. 32. Management of Scorpion sting. Unit IV Training module for staff nurse and auxillary nurse midwife. Basic emergency services for poisoning, State Health Mission Health and Family Welfare Government of Tamil Nadu, Chennai. 2007 33. Magalhaes MM, Pereira ME, Amaral CF, Rezende NA, Campolina D, Bucaretchi F. Serum levels of cytokines in patients envenomed by Tityus Serrulatus scorpion sting. Toxicon 1993:37(8):1155 – 64. 34. Molhotra KK, Mirdehghan CM, Tandon HD. Acute renal failure following scorpion sting. Am J Trop Med Hyg 1987:27(3):623 – 6. 35. Muller GJ. Scorpionism in South Africa. A report of 42 serious scorpion envenomations. Afr Med J, 1993:83(6):405-11. 36. Murthy KR, Hase NK. Scorpion envenoming and the role of insulin. Toxicon. 1994:32(9):1041-4. 37. Naqvi R, Naqvi A, Akhtar F, Rizvi A. Acute renal failure developing after a scorpion sting. Br J Urol. 1998:82(2):295. 38. Rajarajeswari G, Sivaprakasam S, Viswanthan J. Morbidity and mortality pattern in scorpion sting. (A review of 68 cases). J Indian Med Assoc.1979:73(7-8):123 – 6. 39. Ranu Alpay N, Satar S, Sebe A, Demir M, Topal M. Unusual presentations of scorpion envenomation. Hum Exp Toxicol. 2008 Jan;27(1):123-6. 40. Reddy CR, Suvarnakumari G, Devi CS, Reddy CN. Pathology of scorpion venom poisoning. J Trop Med Hyg. 1927:75(5):98-100. 41. Sundaram T, Oilthselvan M, Sethuraman KR, Naryanan KA. Scorpion envenomation as a risk factor for development of dilated cardiomyopathy. J Assoc physicians India 1999:47(11):1047 -50. 42. Santhanakrishnan BR, Sundaravalli N, Raju VB. ArtiÞcial hybernation with lytic cocktail in management of peripheral failure due to scorpion sting. Indian Pediatr. 1972; 9: 23-25. 43. Santhanakrishnan BR. Scorpion sting (Letter to the editor) Indian Pediatrics 2000;37: 1154-1157 44. Santhanakrishnan BR, Gajalakshmi BS. Pathogenesis of cardiovascular complications in children following scorpion envenoming. Ann Trop Pediatr. 1986; 6: 117-121. 45. Santhanakrishnan BR, Ranganathan G, Ananthasubramaniam P, Raju VB. Cardio-vascular manifestations of scorpion sting in children. Indian Pediatr. 1977; 15: 353-356.

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SECTION - III

MISCELLANEOUS Titles

Page

3.1

Quality of Care

69

3.2

Responsibilities of health care providers / professionals

69

3.3

Maintenance of records and reports

70

3.4

Utilisation of Information, Education and Communication (IEC) materials

70

What patients and care givers should know about snake bite / scorpion sting?

70

What health care providers / professionals should know on snake bite and scorpion sting?

73

3.7

Medical pitfalls

74

3.8

Medical audit for snake bite and scorpion sting

74

3.9

Areas for research on snake bite / scorpion sting

79

3.5 3.6

3.10 Key points for snake bite and scorpion sting

84

3.11 Conclusions

85


3.1

Quality of Care

The Medical OfÞcer of a Health Centre / Hospital should be competent enough to manage cases of snake bite and scorpion sting. For all practical purposes competency is deÞned as the point at which the doctor or a health care provider – knows the principles / steps involved in the treatment of cases, has acquired skills [cognitive, psychomotor and affective] to manage the cases conÞdently with available resources and materials, and refers the deserving cases to higher centre or specialist[s] in time when required. Quality of care has to be assessed by objective means for the purpose of approving health centre / hospital for health care services, accreditation, third party payment, upgrading the status, research, etc., Some of yardsticks to measure the services are provided below: 1. 2. 3. 4. 5.

Case fatality rate for snake bite / scorpion sting, Ratio of time interval for treatment, Referral rate, and Availability of drugs and devices Utilization of Anti-snake venom

3.2

Responsibilities of health care providers / professionals

The responsibilities of health care provider with reference to quality of care have been narrated under “10 Rs” provided in Table 25 below. Table No. 25: Responsibilities of health care providers / professionals 1. 2. 3. 4. 5. 6. 7.

Recognise the case and distinguish it from other conditions. Remember the principles of management. Resuscitate if required. Reassure patients in an empathetic manner. Reassess to estimate the clinical status and complications. Refer to higher centre or specialist[s] in time if required. Review the health services and effectiveness of health education with health care team. 8. Retrain the health care team to raise their standard and quality of service. 9. Reeducate the community for empowerment in terms of prevention, control and welfare as well as in the treatment and follow up. 10. Revise the strategies for constant availability of drugs and devices all through the year.


69


3.3 Maintenance of records and reports: Medical record (MR) is systematic documentation of sequential events of patients’ medical history and health care. Medical records serve multi-dimentional roles viz., serve as educational material, provide data for research works, act as material for medical audit, safe guard physician / practitioner from legal wrath, help medical insurance / third party, help authorities for the purpose of accreditation or approval, assist patients for follow-up and to know the status of illness, act as a source to assess quality of care and guide health care planners. Medical council act gives clear directions on maintenance of medical records. So, in the context of snakebite and scorpion sting, the medical ofÞcers have to maintain the treatment records of the victims and send the reports periodically to higher authorities for further monitoring and surveillance. The model forms are provided in Annexure IV, V, VI, XIII and XIV. List of drugs and devices required at health centres to provide Þrst aid treatment for snakebite and scorpion sting are provided in Annexure VII.

3.4 Utilisation of Information, Education and Communication (IEC) materials: The medical ofÞcers and public health staff should make use of the information, education and communication (IEC) materials, and disseminate the correct knowledge on snakebite / scorpion sting management and prevention to the community in order to reduce morbidity and mortality. For this purpose, one has to organise programmes with clear direction. The steps involved are: 1] Identify goals 2] Set objectives 3] Analyse the details required 4] Review the health needs 5] Determine key issues 6] Find out the areas that need change 7] Conduct IEC programmes 8] Reassess the status 9] Provide feed back and 10] Continue the programme with necessary modiÞcations.

3.5 What patients and care givers should know about snake bite / scorpion sting? Snake and Scorpion • • 70

Snakes move frequently in agricultural area to catch its prey Krait bite is more fatal than bite from other three of the “Big 4” Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.


• • • •

Scorpions are shy creatures, which hide in crevices and burrows, and sting if cornered, disturbed or threatened Destruction of snake / scorpion will not have any effect on mortality Venom variation has been identiÞed among the subsets of snakes / scorpions Venomous snakes / scorpions do not inject venom sometimes or inject only small quantity of venom

Bite and Sting • • • • •

All venomous bites / stings do not end in death or complications. Farmers encounter snakebite more than people in forests Children encounter scorpion sting more than adults Snake / scorpion never runs out of venom Bites / stings due to venomous snake / scorpion may be insigniÞcant at times

Antivenom • • • •

Separate ASV is not available for individual venomous snakebites in India. Antivenom made for Indian Russell’s Viper, may not be effective for Russell’s Viper bite of Srilanka Anti venom is effective but not without side / adverse effects Adverse effects have to be observed and tackled immediately

Clinical course, complications and outcome: Preventive measures and health education: •

•

• • • •

Symptoms, signs, clinical course, complications, therapeutic response and outcome may vary from patient to patient bitten by the same species of the snakebite / scorpion sting. Consider whether poisoning due to snake bite / scorpion sting is of different species, if the clinical course and complications are different or the patient is not responding to treatment. At any point of time, clinical course, complications and outcome cannot be categorically predicted in a given case despite available drugs and devices. Early arrival and treatment may help to improve outcome. Recovery is a natural process and treatment is an adjuvant to assist the process of recovery. Complications can be minimized and avoided to some extent but can neither be predicted nor avoided totally.


71


• •

Co-morbid status / preexisting illness[es] and medication[s] of any sort may inßuence the response to venom as well as treatment and outcome. Each case is different from another in one or other aspects.

Follow up •

Follow-up checks are required for assessment of long term effects on different organs / systems and appropriate management has to be instituted wherever required / needed.

Limitation •

•

Laboratory investigations are of little value in the diagnosis of severity of envenomation or the sub-type of snake due to biological variations, but assist for intervention Currently available treatment modalities and supportive care attempt to reduce morbidity, alter the clinical course, enhance natural process of recovery and minimize mortality.

Welfare measures •

•

More deaths occur following snake bite / scorpion sting outside the hospitals, and at times deaths occur inside the hospital despite treatment, because of the patients’ biological characteristics Many state governments in India provide solatium to the family members of the deceased snake bite victims.

Prevention •

•

At present no effective vaccine is available against snake bite and scorpion sting. Hence, the community must be motivated to understand and adopt preventive measures always. Also, the people should be made aware of the Þrst aid measures and adopt early health seeking behavior before complications set in.

Information and resource Patients and care givers may be informed about the 1. Diagnosis 2. Number of cases referred 3. Number of cases expired at health centre 72



4. Number of cases brought dead 5. The available websites (Annexure XV) and on line resources on snake bites / scorpion sting are given so that they can learn more about these aspects, if they like to do. • Community should be informed on the national consensus on the management of snake bite / scorpion sting through local media uniformly in their respective languages, so that they will not be carried away by any other means and different systems of medicine, etc.,

3.6 What health care provider / professionals should know on snake bite and scorpion sting? •

• •

•

•

•

•

Once community awareness on Þrst aid measures and treatment modality of snake bite and scorpion sting increases, more number of such cases are likely to attend the Health Centre / Hospital till the preventive measures are adopted to reduce the problem. The time interval between bite / sting and application of scientiÞc treatment modalities should come down As snake bite and scorpion sting patients are likely to get appropriate treatment early in the nearest Health Centre / Hospital, morbidity and mortality are likely to come down Health Centre / Hospital may require more materials to handle such cases. So the health care provider has to initiate efforts to maintain adequate stock and replenish their requirements well in advance If the treatment is initiated for snake bite at Health Centre / Hospital as per evidence based (standard treatment guidelines), the total anti snake venom required per patient will come down and also the referral rate to higher centre too. Since the patients are getting treatment at peripheral Health Centre / Hospital, the patients may come to the hospital early without wasting time in other traditional methods Increased awareness of the welfare measures provided by the State Government of Tamil Nadu to the family members of the deceased victim, may result in bringing the cases who died due to the bite / sting outside hospital for death certiÞcate. Under such circumstances the Medical OfÞcer has to inform the family members of the deceased victim, to shift the body to a centre where postmortem could be carried out to ascertain the cause of death if they do not have postmortem facilities in the respective Health Centre / Hospital.


73


3.7 Medical pitfalls (“14 Fs”) Treating doctor should take adequate care to avoid medical pitfalls as these issues are likely to come up during medical audit. Some of the issues are mentioned here. • Failure to provide Þrst aid measures immediately when the victims of snake bite / scorpion sting is brought to a health centre / hospital • Failure to admit the patient and document the Þndings properly • Failure to ask and assess the case in detail, and do the needful with the available measures • Failure to monitor the case who are severely envenomed • Failure to stablise the airway and vital signs before speciÞc intervention • Failure to treat the patient adequately, because of under-estimation of the clinical status • Failure to observe anticipated complications while under medical care • Failure to warn the patient and / or the care givers of the potential complications that could happen due to the envenomation and / or during treatment • Failure to obtain informed consent for interventional procedures • Failure to arrange for follow up care • Failure to refer to higher centre or to specialist[s] when such services are likely to beneÞt the snake bite / scorpion sting victim. • Failure to provide adequate records / reports while discharging or demand • Failure to initiate treatment with ASV without adequate agents for managing anaphylaxis or anaphylactoid reaction. • Failure to inform the patient / care giver(s) on the persistence of pain / lesion or paresthesia at the site of bite / sting for days / weeks even after recovery from the primary illness.

3.8 Medical audit for snake bite and scorpion sting Medical audit for snake bite and scorpion sting is an attempt to review each case who was brought alive or dead or died at the health care centre / hospital even after treatment. In general “audit is a quality improvement process that seeks to improve patient care and outcome through systematic review of case against explicit criteria and the implementation of change” [www.nice.org]. The objectives, goals and vision of medical audit are given below:

Objectives • • 74

To determine the probable reasons that might have contributed to death To Þnd out the lapses and failures in the management Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.


• •

To initiate the root cause analysis (RCA) To compare the case fatality on monthly basis at different levels

Goals • • • •

To introduce remedial measures at all levels. To counsel and guide the affected victim and their family. To create awareness among the community. To implement preventive strategies so as to reduce mortality and morbidity.

Vision •

To provide appropriate care and support for snake bite and scorpion sting cases at all Health Centre / Hospital at all times.

Principles of audit: • • • • • • • •

Not to blame each other, but to improve Avoid reduplication of cases Refrain from false statement / data Find out the reasons for lapses / deÞciencies Provide feed back to members at all levels Get suggestions from end users Find out ways for improvement and to implement them Place the data and resolutions / remedial measures on the web site

Outcome of audit (“5 Es”): • • • • •

Elicit the lacunae / limitations / variations at inter-regional and inter institutional levels Enumerate the needs for requirements Eliminate the constraints Educate the providers of health care and beneÞciaries Encourage health care providers to perform better


75


Table No. 26: Levels of analysis Level

I. Local

Place

Health centre / Hospital

Reviewer Chief of the Health centre / hospital / unit

Materials for analysis Details of snake bite and scorpion sting treated /died / brought dead to the respective health centre / hospital and health services

Details collected from all hospitals [Government / OfÞce of the private], and death due to II. Health Health Unit of Chief of the snake bite and scorpion sting Unit respective health health unit collected from Panchayat / districts Municipality, etc., and health services Details collected from the health units under them and death due to snake bite and scorpion sting collected from III. Revenue OfÞce of the Joint Joint Director of Panchayat / Municipality / district Director of Health Health Services Corporation etc., and as well level Services as details of welfare measures provided for such victims family from the respective Collectorate. Data from all revenue OfÞce of Director Director of districts along with various IV. State of Public Health Public Health Directorates coming under level and Preventive and Preventive Health and Family Welfare Medicine Medicine Department of Tamil Nadu, Chennai

Role of reviewer • • • • 76

Adhere to reviewing of achievement of objectives, goals and vision Remember principles and outcome of audit Review the data with reference to responsibilities of health care providers/ professionals Consider medical / social problems faced with each case



•

Identify gains / setbacks in terms of man power, skills, service, patient satisfaction, maintenance of records, availability of drugs, drugs status including expiry date, functional aspects of medical equipments, morbidity pattern, referral issues and case fatality rate at different levels [for these use formats given in Annexure IV to VII, XIII and IV].

1) Case fatality rate at different levels: Formula to calculate Case Fatality Rate (CFR) at different levels is given in Table 27. CFR is mentioned in percentage. Table No. 27: Formula to calculate case fatality rate at different levels Total number of death(s) due to snake bite / scorpion sting for the particular month x 100 ------------------------------------------------------Total number of cases (alive & dead) of snake bite / scorpion sting brought to the health centre / hospital for the particular month Total number of death(s) due to snake bite / scorpion sting for the particular month in that Case fatality rate for snake bite / scorpion sting at the level of health health unit area x 100 -------------------------------------------------unit for the particular month = Total number of cases (alive & dead) of snake bite / scorpion sting brought to the health centres / hospitals of that health unit for the particular month Total number of death(s) due to snake bite / Case fatality rate for snake bite / scorpion sting of that revenue district for the scorpion sting at the level of revenue district for the particular particular month x 100 -------------------------------------------------month = Total number of cases (alive & dead) of snake bite / scorpion sting brought to the health centres / hospitals and those applied for welfare to the collectorate for the particular month Case fatality rate for snake bite / scorpion sting at local health centre / hospital for the particular month =


77


Case fatality rate for snake bite / scorpion sting at the level of Tamil Nadu state for the particular month =

Total number of death(s) due to snake bite / scorpion sting for the particular month in different revenue districts x 100 -------------------------------------------------Total number of cases (alive & dead) of snake bite / scorpion sting brought to the health centres / hospitals of different revenue districts and data from collectorates for the particular month

2) Ratio of time interval for treatment: In Tamil Nadu due to the available health infrastructure, the maximum time required to reach the nearest health centre is estimated to be 30 minutes. Hence the ratio of time interval for treatment is the ratio of actual time taken to reach health centre / hospital to the estimated time required [i.e., 30 minutes] and calculated as per the formula given in the box below. The ratio should always be below one and infact it should be as low as possible. If the ratio is one or more than one, it indicates delay in reaching the health centre / hospital. Then elicit the probable reasons for each and try to rectify them. This has to be reviewed at different levels. (details may be collected from Annexure IV) The time interval between actual time of snake bite / scorpion sting and the time of arrival for scientiÞc Ratio of time interval treatment in minutes ---------------------------------------------------------------------for treatment = Estimated time required to reach the health centre / hospital (30 minutes) *Estimated time required to reach the health centre / hospital (30 minutes) is an arbitrary one and the ratio of time interval for treatment is calculated to understand the awareness and utilization of health care. However, the ratio should not be used as a lone factor to assess or predict the clinical aspects, course and outcome, as these are inßuenced by multiple factors. 3) Referral rate: Once the treatment is started early, it is expected that referral will come down. This has to be analysed in relation to the reasons for referral (Annexure XIV) and efforts to be taken to minimize the referral without compromising patient care service. Moreover, referral rate has to be analysed at all levels like CFR and measured in percentage.

78



Referral rate =

Number of snake bite / scorpion sting referred x 100 ---------------------------------------------------------------------Total number of cases (alive & dead) of snake bite / scorpion sting brought to the health centre / hospital for the particular month

4) Availability of drugs and devices: Availability of drugs and devices have to be analysed (Annexure VII) carefully and corrective efforts should be undertaken well in advance so that non-availability should not be made as a reason for inadequate treatment / referral. 5) Utilization of anti-snake venom: Utilization of anti-snake venom has to be monitored in each and every health centre / hospital which are providing treatment for snake bite victims. The details given in the following box may be collected from each health centre / hospital of the respective health and revenue district as well as at medical college hospitals and discussed in the monthly medical audit meeting. The minutes of such meeting along with problems encountered, suggestions for improvement, new clinical observations, changing trends, recommendations and action taken for previous meeting should be send to their respective directorates, which will then be consolidated at the ofÞce of the Directorate of Public Health for further updating the modalities of treatment and community participation. Sl.No 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Subjects for discussion Bite to needle time Delay in administration of ASV Reactions to ASV Reasons for repeated doses of ASV on case by case basis Non-responders to ASV Reasons for referral despite giving ASV Status of availability of ASV DeÞciencies in the utilization of ASV Root cause analysis for each Review of action taken on previous meeting Changing trends and limitation(s) Any other. specify

3.9 Areas for research on Snake Bite / Scorpion sting Areas for research on Snake Bite / Scorpion sting that could be undertaken at health care institutions / organizations either alone or in collaboration with Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

79


sister specialties / and institutions are provided below. Interdisciplinary research will bring out enormous information and help to improve the existing system. Though titles are provided more on snake bite, similar areas may be considered for scorpion sting also.

I. Arts and humanities 1. 2. 3.

Myths related to snake bite. Socio cultural aspects of snakes and snake bite. Bibliometric studies on snakes, snake venom, anti snake venom and snake bites from India. 4. Economical aspects of snake bite and regional variation. 5. Counseling and guidance to snake bite victims and their family. 6. Judicial aspects and activism related to snakes and snake bites in India 7. Snakes and snake bite in literature. 8. Snake and snake bite in cinema. 9. Snakes and snake bite in mythology. 10. Proverbs related to snakes and snake bite. 11. Interpretation of snakes and snake bite when appeared in dreams. 12. Ethical issues in snake bite. 13. Crime issue related to snake, snake venom and snakebite. 14. Snakes, snake venom and snakebite in lay press and other media. 15. Discussion on snakes, snake venom, anti snake venom and snake bite related issues in Indian Parliament and Assembly in pre and post independent period. 16. Effects of global warming and climate change on the ecosystem of snakes, behaviour of snakes, constituents of snake venom and snake bite. 17. Snakes in sculptures: what do they convey? 18. Religious aspects related to snakes, snake bite and recovery. 19. Astrological aspects of snakes, snake bite and recovery. 20. Social status and issues related to snake charmers / handlers. 21. Snakes and snake bite issues in philately. 22. Spatiotemporal variation in snakes and snake bites. 23. Demands, production and supply of anti snake venom. 24. Utilisation of anti snake venom in government and private sector.

II. Basic Sciences 1. Preparation of monovalent anti snake venom. 2. Bedside diagnostic kits to assess snake venom levels. 3. Nature and distribution of snakes in different areas in Tamil Nadu and India a geographical study. 4. Use of snake venom in diagnostic and therapeutic purposes. 5. Heterogenecity of snake venom in relation to species and sub types. 80



6. Antioxidant status during snake bites. 7. Metabolic changes during envenomation. 8. Cytokine status during envenomation. 9. Biomarkers to assess envenomation, organ involvement and outcome. 10. Lipid proÞle during and after envenomation. 11. Trace element proÞle during envenomation and after recovery. 12. Mechanisms of thrombus formation and its consequences during snake envenomation and management issues. 13. DNA fragmentation during and after envenomation. 14. Oxidative stress during envenomation. 15. Status of Þbrinogen and Þbrinogen degradation products in snake bite and its applicability. 16. Inßuencing factors for changes in coagualation proÞle. 17. Anatomical site of bite and human behaviour. 18. Genetic basis for organ involvement in snake bites. 19. Microbial ßora of snake oral cavity. 20. Microbial study of snake bite wound. 21. Serological studies while under envenomation. 22. Newer methods in the production of antisnake venom. 23. Postmortem studies in snake bite. 24. Histopathological changes in myocardium and other organs in snake bite victims. 25. Complement proÞle during and after envenomation. 26. Immuno analytical studies following snake envenomation. 27. Immunisation against snake venom: experimental studies. 28. Kinetic studies on snake venom in clinical situations and experimental status 29. Humoral response following snake bite. 30. Early indicators of renal involvement in snake bite. 31. Preparation of anti snake venom for poisonous snake other than “Big 4”. 32. Isolation, identiÞcation and application of components of snake venom. 33. Application of nanotechnology in the diagnosis and management of snake bite.

III. Clinical aspects. 1. 2. 3. 4. 5. 6. 7.

Epidemiology of snake bites. Clinical aspects, management issues and outcome of sea snake bite. Community survey on snake bites and outcome. Circadian rhythms of snake bites. Long term follow up of snake bite victims. Challenges in the management of snake bite. Clinical course and outcome of venomous and non-venomous snake bite other than the “Big 4”.


81


8. Clinical course of ASV in patients with allergic disorder(s). 9. Adverse reactions to ASV. 10. Long term effects of ASV. 11. Newer modalities to treat snake bites. 12. Use of antioxidants in the treatment of snake bite. 13. Blood group pattern and blood / component requirements in the management of snake bite. 14. Prophylactic schedule before ASV and its relevance. 15. Clinical and laboratory status of snake charmers / handlers. 16. Pattern of renal involvement in snake bites. 17. Cardiac involvement in snake bite. 18. ECG and Echo cardiographic assessment during envenomation. 19. EEG changes in snake bites before and after treatment. 20. Taste and smell in snake bite victims. 21. Neurological manifestations in snake bites. 22. Snake bite and pregnancy. 23. Snake bite in patients with coagulation disorders. 24. Hematological proÞle in snake bites. 25. Pulmonary manifestations in snake bite. 26. Effects of Inj.ASV in the unborn. 27. Ophthalmological aspects of snake bite. 28. ENT involvement in snake envenomation an analysis. 29. Endocrine complications following snake bite. 30. Involvement of Pancreas during snake bite. 31. Surgical aspects of snake bite. 32. Compartment syndrome in snake bite. 33. Pattern, clinical course and management of ulcers following snake bite. 34. Snake bite as an occupational hazard. 35. Addiction to snake venom: an emerging issue. 36. Clinical course and outcome of snake bite in tertiary care hospital after implementation of treatment guidelines for snake bite. 37. Medical errors in the management of snake bite victims. 38. Failure of ASV: what, when, why and how? 39. Clinical and therapeutic aspects in patients who had second snake bite. 40. Effectiveness of ‘Pressure pad or Monash Technique’ in snakebite. 41. Role of insulin in preventing multi organ failure. 42. Plasmapheresis in the management of snake bite. 43. Obstetric and Gynecological aspects of snake bite.

IV. Community aspects: 1. 2. 82

Analysis of pre hospital treatment. Case fatality rate in snake bite: Causes and concern. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.


3. 4. 5. 6. 7. 8.

Natural disasters: will those contribute to snakebite. Global warming and behaviour of snakes. Awarenesss programmes for community on snakes, snakebite: an analysis. Comparison of bites and stings with non-communicable diseases. KABP of personal protective measures against snake bite among victims of snake bite and their family members. Multisectoral approach to snake bite.

V. Managerial issues: 1.

Analysis of welfare programmes: awareness and utilisation members of deceased snake bite victims. 2. Utilization of facilities for snake bites at primary care level: problems and solution. 3. Inßuencing factors for utilisation of ASV. 4. Production and utilization of ASV in India. 5. Managerial issues in the treatment of snake bite. 6. Analysis of referral status of snake bite. 7. Outcome of snake bite in ralation to transport modalities adopted. 8. Utilisation and issues related to ambulance services for snake bite victims. 9. Medical audit of snake bite records. 10. Public private partnership in the management of snake bite. 11. Utilisation of NGOs in snake bite management. 12. Welfare policies for snakebite victims and their families in different union territories / states of India. 13. Inter-regional variations on outcome of snake bite. 14. Designing and developing a software for documentation and analysis.

VI. Indigenous medical system related: 1. 2. 3. 4. 5.

Traditional treatment for snake bite: an analysis. KABP of alternative medical practitioners on snakes and snake bite. Snakes and snake bite in complementary and alternative medical system. KABP of Traditional Medical practitioners on snakes, snake venom and snake bite management. Educational modules and training aspects on snakes and snake bite to traditional medical practitioners.

VII. Educational aspects: 1. 2.

KABP of modern medical practitioners and nurses on snakes and snake bite. Analysis of current medical education and training programme on snakes, snake venom and snakebite management.


83


3. Inconsistencies and controversies on the diagnosis and management of snakes, snake venom and snake bite management in the text books used by medical and nursing students. 4. Educational and training programmes on snake bite for practitioners of alternative medicines. 5. Academic audit on teaching and training aspects of snakes, snake venom and snakebite management. 6. Assessement of skills of trainee students of health sciences on snake bite management by OSPE and OSCE methods. 7. Assessement of skills on snake bite management among medical practitioners and nurses. 8. Curriculum on snakes, snake venom and snake bite management in science education at schools and teacher training programme. 9. Analysis of snakes and snake bite management in Þrst aid training programme.

3.10 Key points for snakebite and scorpion sting: * Clinical • Assess every case thoroughly. • Treat them conÞdently and observe vigilantly (at health centre / hospital). • Detect the status and note down the changes, and act accordingly. • Anticipate complications and treat them immediately. • Provide care and support with empathy. • Create conÞdence among patients, public and care givers continuously. • Bring down morbidity and mortality. • Explain the available welfare measures to the family members of the deceased victims clearly. • Arrange for follow up programs regularly. * Community Aspects • Conduct health education programme so as to promote immediate seeking of health care. • Eliminate the barriers that cause delay in health care seeking. * Educational & Research • Organise teaching and training programs for health care workers. • Undertake research activities in a planned manner. * Administrative Issues • Arrange for required amount of drugs and devices in health centres / hospitals regularly. • Maintain records and reports safely. • Monitor the activities at all levels periodically. 84



3.11 Conclusions: The ultimate goal is to provide appropriate Þrst aid and treatment at the nearest health centre / hospital at the earliest. Complicated cases have to be referred to higher centre after Þrst aid and supportive measures. Community should receive health education on preventive and curative aspects of snakebite and scorpion sting. Each health centre / hospital irrespective of the status should maintain a registry for snake bite / scorpion sting and initiate research activities in a trans-disciplinary manner. All these joint efforts will bring down the morbidity and mortality. In addition health care institutions should undertake research activities on various aspects of snake bite / scorpion sting, and share the knowledge and experience with others in order to advance further in health care delivery.


85

SECTION - IV

ANNEXURES Titles

Page

I

Snake bite cases reported in secondary care hospitals

87

II.

Fluid requirement chart for children

88

III.

Vital signs reference table for pediatric age group

88

IV.

Pre hospital treatment for snake bite and issues related to ASV

91

V.

Reporting / referral form for snake bite / scorpion sting

93

VI.

Snake bite and scorpion sting monthly reporting format

94

VII.

List of drugs and devices

95

VIII.

Algorithmic approach to bite / sting

96

IX.

Algorithmic approach to snake bite

97

X.

Algorithmic approach to scorpion sting

98

XI.

Frequently asked questions / self assessment queries

99

XII.

Snakebite and scorpion sting in Tamil literature

100

XIII.

Form to assess the quality of services

104

XIV.

Form to analyse and audit the statistics on snake bite / scorpion sting

105

Useful Websites

106

XV.


Annexure : I Table No. 28: Snake bite cases & deaths reported and ASV vials used in secondary care hospitals in Tamil Nadu (District wise) April 2005- March 2006 Sl. No.

District

April 2006- March 2007

1 2 3

Coimbatore Cuddalore Dharmapuri

1107 1380 679

2 1 1

ASV Vials Used 12236 11779 2261

4 5 6 7 8 9 10 11 12 13

Dindigul Erode Kancheepuram Kanyakumari Karur Krishnagiri Madurai Nagapattinam Namakkal Perambalur

807 1277 670 3 228 432 982 445 804 576

12 10 0 0 3 0 0 0 1 0

3041 11129 890 3 1405 1170 1801 2565 4565 3209

972 1607 714 11 286 453 677 420 1147 475

13 6 5 0 2 6 0 0 1 1

3741 7237 1598 5 2242 1271 2861 2229 5959 5746

14 Pudukkottai

683

3

581

2

1865

15 16 17 18 19 20 21 22 23

428 1175 328 325 69 486 766 160 351

4 5 2 5 0 0 0 2 1

2475 2377 3180 1739 3213 31 2179 1254 866 1819

373 1331 367 514 49 553 604 142 381

3 1 3 5 1 3 2 9 2

2485 4007 2023 3275 0 2391 1305 715 2056

24 Tirunelveli

671

3

2783

540

3

2814

25 Tiruvannamalai

894

5

3776

808

1

5074

Ramanathapuram Salem Sivagangai Thanjavur The nilgiris Theni Thiruvallur Thiruvarur Thoothukudi

Cases

Deaths


Cases

Deaths

1109 2169 1076

0 2 0

ASV Vials Used 16195 6898 3374

87


26 27 28 29

Trichy Vellore Villupuram Virudhunagar Total

193 1098 1109 1195 19321

6 9 9 1 85

837 2650 5791 3457 94481

183 708 1084 1343 20677

0 2 2 0 75

714 2164 2861 3695 96800

ASV vials used in secondary care hospitals (District wise) ASV - Anti snake venom (each vial contains 10ml)

Annexure II: Fluid requirement chart for children Table No. 29: Fluid requirement chart for children Weight Upto 10 kg 11 kg to 20 kg 21 kg & above

Fluid requirement 4 ml / kg / hour 40 ml + 2 ml / kg / hour 60 ml + 2ml / kg / hour

Example: 8 kg child with snake bite is admitted – add the vials to 2 hours of ßuid. 8 kg requirement = 4 ml / kg / hour = 4 ml / 8 kg / 2 hour = 64 ml So mix the vials in 65 ml to 75 ml of IV ßuid and run it for 2 hours as given in the treatment column.

Annexure: III: Vital signs reference table for paediatric age group Respiratory rate Normal spontaneous ventilation is accomplished with minimal work, resulting in quiet breathing with easy inspiration and passive expiration. The normal respiratory rate is inversely related to age. It is rapid in the neonate, then decreases in older infants and children. A respiratory rate consistently greater than 60 breaths per minute in a child of any age is abnormal and is a “red ßag”. Table No. 30: Normal Respiratory Rate by Age Age

Breaths per Minutes

Infants (< 1 year) less than 2months 2months - less than one year

40 to 60 30 - 50

Toddler (1 to 3 years)

24 to 40

88



Preschooler (4 to 5 years)

22 to 34

School age ( 6 to 12 years)

18 to 30

Adolescent (13 to 18 years)

12 to 16

Heart Rate Heart rate should be appropriate for the child’s age, level of activity and clinical condition (Table 2). Note that there is a wide range for normal heart rate and that it varies in a sleeping and awake child. Table No. 31: Normal Heart Rate (Per Minute) by Age Age

Awake Rate

Sleeping Rate

Neonate

100 to 180

80 to 160

Infant

100 to 160

75 to 160

Toddler

80 to 110

60 to 90

Preschool

70 to 110

60 to 90

School age child

65 to 110

60 to 90

Adolescent

60 to 90

50 to 90

References : • •

Hazinski.M. Children are different In:Hazinski M, ed. Manual of Pediatric Critical care. St.Louis, MO: Mosby year book ; 1999. Chapter 1,5-6. Allen HD, Driscoll DJ, Shaddy RE, Feltes TF (Edrs). Moss and Adams’ Heart Disease in Infants Children and Adolescents Including the Fetus and Young Adult. Lippin cott, Williams and Wilkins, Baltimore, MD, USA, 2007.

Blood Pressure Normal blood pressure values for children by age is provided in Table 32. This table summarizes the range from the 33rd to 67th percentile in the Þrst year of life and from the 5th to 95th percentile for systolic and diastolic blood pressure according to age and gender and assuming the 50th percentile for height for children of one year of age and older. Like heart rate, there is a wide range of values within the normal range.


89


Table No. 32: Normal Blood Pressure in Children by Age Systolic BP (mm Hg)

Diastolic BP (mm Hg)

Female

Male

Female

Male

Neonate (1st day)

60 to 74

60 to 74

31 to 45

30 to 44

Neonate (4th day)

67 to 83

68 to 84

37 to 53

35 to 53

Infant (1 month)

73 to 91

74 to 94

36 to 56

37 to 55

Infant (3 months)

78 to 100

81 to 103

44 to 64

45 to 65

Infant (6 months)

82 to 102

87 to 105

46 to 66

48 to 68

Infant (1 year)

68 to 104

67 to 103

22 to 60

20 to 58

Child (2 years)

71 to 105

70 to 106

27 to 65

25 to 63

Child (7 years)

79 to 113

79 to 115

39 to 77

38 to 78

Adolescent (15 years)

93 to 127

95 to 131

47 to 85

45 to 85

Age

Blood Pressure ranges taken from the following source: • “Neonate, Infant (1 to 6 months) 8; Infant (1 year) Child, Adolescent”. • Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents: NHLBI, USA May 2004

Hypotension Hypotension is deÞned by the following thresholds of systolic blood pressure Table No. 33: Hypotension by Systolic Blood Pressure and Age Age

Systolic Blood Pressure (mm Hg)

Term Neonates (0 to 28 days)

< 60

Infants (1 to 12 months)

< 70

Children 1 to 10 years 5th BP percentile Children > 10 years

90

< 70 + (age in years x 2) < 90



Annexure IV: Pre hospital treatment for Snake bite and issues related to ASV (one for each case) 1. 2. 3. 4. 5.

Name: Age: Medical unit: Gender: Male / Female: Hospital:

S.No:

Date: IP NO:

Details about the snakebite: 6. Time of snake bite ________ am / pm 7. Victim walked home - yes / no 8. Shifted home manually - yes / no 9. If yes, state poisonous / non-poisonous 10. Nature of snake specify - Viper (type)...../ Cobra / Krait / Sea snake / others... 11. Nature of snake specify - Viper............./ Cobra / Krait......./ Sea snake group Pre hospital treatment: 12. Household medicines given to the patient – yes / no If yes, specify_____________ 13. Taken to the traditional healer – yes / no. If yes, specify_____________ 14. Taken to the Local Medical Practitioner – yes / no. If yes, Nature of the Þrst aid given15. Other traditional practices followed: tourniquet - yes / no cutting and letting the blood out – yes / no applying traditional substances externally -yes / no any other, specify_________________ Anatomical site of the bite: 16. Upper limb / lower limb 17. Right side / left side / bilateral 18. Other areas in the body ........ specify____________ 19. Multiple sites ....... specify____________


91


ASV related: 20. ASV administered – yes / no 21. If yes, Time of starting ASV___________ am / pm 22. Time interval between snakebite to time at which ASV started (21 - 7)...... 23. Probable reason for delay in bite to needle time a. Travel related b. Beliefs and practices of traditional medicine c. Failure to recognize symptoms d. Sub optimal family support systems e. Financial constraints f. Any other, specify______________ 24. Test dose for ASV given – yes / no 25 If yes, mention the details of reaction(s):................... 26 Mention if any prophylactic medications given - yes / no 27 If yes, mention the details of drugs given .................... 28. Reaction(s) while on ASV – yes / no If yes, describe the nature of reaction to ASV and details of management............... 29. Time taken to complete Þrst dose of ASV............... 30. Time interval between starting and completing Þrst dose of ASV (29 - 21)...... 31. Form of ASV used - Lyophilized / liquid form 32. Name of the manufacturer of ASV________________ Lot No.__________ Batch No._______________ Date of Expiry_____________ 33. Mention if any repeat dose of ASV given -yes / no If yes, reasons for repeat dose ......................................... 34. Total quantity of ASV given (in ml) 35. Any others (specify) …..........

Medical Officer

92

Name / Signature / Designation / Seal / Date



Annexure V: Reporting / Referral form for Snake bite / Scorpion sting (One for referral, second for reporting & third to be retained) 1. O.P NO................................. / I.P.NO.................................. 2. Date on which snake bite / scorpion sting case attended: 3. Time at which snake bite / scorpion sting case reported to Health Center: 4. Name of the Patient: 5. Address: Father / Mother / Husband / Wife / Son / Daughter of Door No: Street/ Lane / Ward: Village: Nearest Town / Post OfÞce: Pincode: Taluk: District: Phone/Mobile No: 6. Sex: Male / Female 7. Age: 8. Nature of snake bite / scorpion sting (describe what type of snake / scorpion): 9. Describe the condition of the patient on arrival Pulse....../min; Respiration......./ min; BP............mm of Mercury Clinical status of envenomation 10. Describe the nature of Þrst aid and treatment given: 11. Name and designation of the person who gave Þrst aid: 12. If referred, to other hospital: a. Referral time and date b. Details of the hospital to which referred c. Staff accompanied - yes / no, if yes details................ d. Status of the patient at the time of referral e. Others 13. Any other remarks – mention: 14. Follow up action & outcome:

Medical Officer Name / Signature / Designation / Seal / Date


93


Annexure VI: Snake bite / Scorpion sting monthly reporting format (age & gender wise) (Use separate tables for snake bite and scorpion sting would be helpful because we can get rates for each eg. M/F, deaths, referrals etc...) Name of the Health Centre ……………… Address: …..........

Reporting Month..............Year 200... Sl. No.

Details

Below 5 yrs

6-9 yrs

10-14 15-24 25-44 45-64 65 and yrs yrs yrs yrs above

Total

M F M F M F M F M F M F M F I

a. Snake bite /Scorpion sting Total cases treated II Out come of the treatment 1. No. Recovered 2. No. referred 3. No. Expired at health centre III No. of cases brought dead

Medical Officer

94

Name / Signature / Designation / Seal / Date



Annexure VII: List of drugs and devices to be stocked at health centre Name of the Agent / Material

Available as

Numbers

Tab.Prazosin (plain) Inj. Antisnake venom (ASV) Inj. Atropine (0.6mg / amp) Inj. Adrenaline Inj. Chlorpheneramine maleate Inj. Neostigmine Inj. Lignocaine without adrenaline Inj. Hydrocortisone Inj. Dexamethasone Inj. Ranitidine Inj. Diazepam Inj. Dobutamine

1mg 10ml/vial 2ml/amp 1ml/amp 2ml/amp 0.5mg/ml 30ml/vial 100mg 4mg/ml 50mg/2ml 10mg/2ml 10 ml/ampoule

Intravenous fluids a. Normal saline b. Dextrose saline IV Set

20 20 vials 100 ampoules 15 ampoules 15 ampoules 20 ampoules 2 Vials 5 ampoules / vials 5 ampoules / vials 20 ampoules 10 ampoules 5 ampoules 35 bottles

500ml 500ml

15 bottles 20 bottles 20 sets

Intravenous Cannula (Venflon) 18 Size – Green 20 Size – Pink 22 Size – Blue 24 Size – Yellow Nasogastric tube (different size) Airway (different size) Ambu bag (Adult) / (Pediatric) Laryngoscope set (Adult) Endotracheal tube (different size) Glass test tube (5 or 10 ml) Laryngeal Mask Airway Others if any.............. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

5 5 5 5 10 each 5 each One each 1 5 20 2

95


Drugs to be indented based on the requirement Check for the expiry date and change accordingly Other items that should be available in the emergency tray: Sterile Glass syringes, Splint (to support the limb / hand), Compression bandage linen cloth, Laryngeal mask airway, Gloves, Suction Apparatus [Electrically and or manually operated], Thermometer, Torch Light (2 cells) and other item as per need.

Annexure VIII: Algorithmic approach to bite / sting at primary level

u u u

u

u u u

C

2

prazosin

96



Annexure IX: Algorithmic approach to Snake bite

R I G H T symptoms

2

for

&

x

f


97


Annexure X: Algorithmic approach to scorpion sting

Paresthesia

S

persists

x

NGT - Nasogastric Tube; IV - Intravenous; NS – Normal Saline; RL - Ringer Lactate; NG – Nitroglycerine; SNP - Sodium Nitroprusside

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Annexure XI: Frequently asked questions / self assessment queries. 1. 2. 3. 4. 5. 6.

Mention the poisonous snakes / scorpions noticed in Tamil Nadu. Mention the predisposing factors for snake bite / scorpion sting. What are the implications of snake bite / scorpion sting? Mention the various clinical symptoms and signs of snake bite / scorpion sting Describe the local effect of snake bite / scorpion sting. Mention the reasons why the presenting features, clinical course, complications and outcome vary from case to case in snake bite / scorpion sting. 7. What is late onset envenomation in scorpion sting and mention the mechanisms? 8. Mention the various risks involved in tourniquet. 9. What is pressure pad technique and how is it used for snake bite cases? 10. Criteria for the diagnosis of snake bite / scorpion sting at the bed side. 11. What are the laboratory investigation required for snake bite / scorpion sting? 12. Mention the details of 20WBCT - the procedures, the advantages, the requirements and the interpretation. 13. What are the additional investigations and care that should be adopted while treating a case of pregnant women with snake bite / scorpion sting. 14. What are the principles involved in the treatment of snake bite / scorpion sting? 15. What are the prognostic features for a better outcome in snake bite / scorpion sting? 16. What are the long term complications of snake bite / scorpion sting? 17. How do you monitor the cases of snake bite / scorpion sting in resource limited setting? 18. Describe the various complications observed in acute snake bite / scorpion sting. 19. What are the Þrst aid methods to be adopted for snake bite / scorpion sting? 20. Describe the methods to take care of the site of bite / sting. 21. Describe the management of snake bite / scorpion sting in special situation. 22. What are the precautions to be adopted while managing a case of snake bite / scorpion sting in a patient who has one or other co-morbid illness or taking any other medication? 23. Can a patient on ASV therapy for a poisonous snake bite undergo dental procedure? 24. What are the prophylactic medications to be used, to avoid reactions to ASV? 25. Why is prazosin tablet preferred for scorpion sting? 26. What are the alternative for Tab.prazosin in scorpion sting? 27. Why should antihistamines not be given while a patient is getting treated for scorpion sting? 28. Do we have anti snake venom for each and every snake individually? 29. Narrate the pharmacological aspects of ASV. Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

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30. Describe the methods adopted to administer ASV. 31. Is there any concept called prophylactic medication for ASV? 32. What are the immediate reactions that follow after ASV? 33. Mention brießy the treatment a modalities adopted to tackle reactions to ASV. 34. Describe clearly the guidelines to be adopted while planning to repeat ASV. 35. What are the measures to be adopted to tackle a case of snake bite for which no anti-venom is available? 36. What will you do if a patient treated for snake bite with ASV comes back with poisonous snake bite again? 37. What is the role of Heparin / botropase in snake bite? 38. What are the reasons for referring a case of snake bite / scorpion sting to higher centre / specialist? 39. Discuss the measures you would like to adopt to prevent snake bite / scorpion sting? 40. What are the components of competency of a health care provider / doctor? 41. What are the quality care indicators used to assess the management of snake bite / scorpion sting? 42. What facts should patients and care givers know about snake bite / scorpion sting? 43. What should Health Care Providers (HCP) know about snake bite / scorpion sting? 44. What are the medical pitfalls associated with snake bite / scorpion sting? 45. How can HCP help the family members of deceased victim? 46. Why should narcotics not be used in scorpion sting? 47. Describe the late serum sickness reaction and treatment of the same. 48. What are the various unusual complications of snake bite / scorpion sting? 49. What are the various surgical issues related to snake bite / scorpion sting? 50. What are the various uses of venom?

Annexure XII: Snake bite and scorpion sting in Tamil Literature.

100

•

Tamil language is an ancient language. The poems and proverbs of the Tamil language describe the status of living at that time, highlight their knowledge, express talents, reßect cultures, bring out tradition and reveal their beliefs and practices, though the place of origin may not be available clearly. One can also appreciate the changes that had happened over a period of time through literature. Based on the circumstantial evidences the time of origin has been calculated.

•

Communicating to a group of persons in their own language using the poems, proverbs and the procedures adopted in that region, will help to win their Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.


conÞdence. Thereafter changing them and bringing them into the scientiÞc arena is easier. Once a community gets convinced, it is easy to convey health messages and they get adapted to newer methods which will be of immense use for their health and welfare. •

Good amount of information is available in Tamil Literature and Tamil medicine on symptoms, clinical course and outcome of it. Infact the descriptions are better than what is available today. Their knowledge on types of snakes and scorpions are simply astonishing. This can be used to educate the community and make them realize the usefulness of modern medical treatment for better outcome.

•

Proverbs irrespective of the language help to explain or convey messages within and outside a community. Historically collected proverbs of Tamil literature is displayed as early as 5 A.D. one each under one poem of “Pathinen keezh kanakku Nool”. Tamil being an advanced language with high level of grammer, it has given criteria / guidelines for poems and proverbs and these are made available in Tholkappiam (poem 177) and Agananooru (poem No.101: 2 – 2 and 66 : 5-6)

•

Most of the proverbs are thought provoking, contain rich information and are unique to the language. Also, these proverbs help to transfer relevant facts with beauty and brevity between the speaker and the audience or readers. Moreover poems and proverbs act as a bridge between health care professional and the patients or the public to convey health messages convincingly, clearly, and conÞdentially within few minutes.

•

When a speaker uses an apt poem or proverb or both to convey a message to the community, their understanding is greater, ability to accept is better and the capacity to transfer the message in real life is superior. Keeping all these in mind efforts are made to bring / provide Tamil proverbs and certain aspects of Tamil medical practices in relation to snake bite and scorpion sting is given below.

•

The health care professions involved in patient care and community education programme are informed to make use of the information provided. When the professionals use the literary phrases / poems available in their own language, community acceptance the greater. Hence changes will occur which can be measured quantitatively. Health care providers can make use of the proverbs and collect more proverbs and poems related to snakebite and scorpion sting, and forward to us which will be of great use to subsequent editions.


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Tamil proverbs related to Snake bite and Scorpion sting ešthœÎ fšéæš fyªJiuahl gh«ò k‰W« njŸ r«gªj¥g£l gHbkhêfŸ 1. mut¤ij f©lhš Ñç éLkh? (mšyJ) muit¡f©lhš Ñç éLkh? 2. Ïo nf£l ehf« nghy 3. Ïiu Â‹w gh«ò nghy 4. fUlid¡ f©l gh«ò nghy 5. fiwah‹ ò‰W gh«ò¡F cjÎ»wJ 6. fiwah‹ ò‰bwL¡f¡ fUehf« FoòFªjJ nghy 7. fiwah‹ ò‰¿š mut« Fobfh©lJ nghy 8. vè ÏU¡»w Ïl¤Âš gh«ò ÏU¡F« 9. gl« vL¤jhš jh‹ gh«ò 10. gukÁt‹ fG¤ÂèU¡F« gh«ò nghy 11. fhiy R‰¿a gh«ò fo¡fhkš élhJ 12. gh«Ã‹ fhš gh«g¿Í« 13. gh«ÃY«, gh«ò F£o¡F éõK«, ÅçaK« mÂf« 14. gh«Ã‰F gšèš k£L« jh‹ éõ« Mdhš ghéfS¡F clš KGtJ« éõ« 15. gh«Ã‹ F£o gh«ò, mj‹ F£o e£Lth¡fèah? 16. gh«ò v‹whš gilÍ« eL§F« 17. gh«ò Mæu«, gid Mæu«, gh«Ã‹ fhš Mæu« 18. gh«ò¡F gif fUl‹ 19. gh«ò¡F _¥ò Ïšiy 20. gh«ò j‹ gÁia ãid¡F«, njiunah j‹ éÂia ãid¡F« 21. gh«ò Â§»w CU¡F nghdhš eL¡f©l« ek¡F 22. gh«ò ò‰Wf©L, m§F »zW bt£L 23. gh«ò gif, njhš cwth?

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24. ghé¡F gh«ò f© 25. ghé¡F gh«ò bré 26. éÂ Koªjtid éça‹ fo¡F« 27. éça‹ fo¤jhš éÂ KoÍ« 28. Ñç¡F« gh«ò¡F« Ôuh¥gif 29. ÑçÍ« gh«ò« nghy 30. Ú®¥gh«ò fo¤jhY« Ïurg£o MF« 31. bg£o gh«ghf ml§»dh‹ 32. njS¡F kâa« bfhL¤jhš, rhk¤J¡F (bghGJ éoÍ« k£L« ãäl¤J¡F ãäl«) bfh£L« 33. njS¡F éõ« bfhL¡»ny, gh«ò¡F éõ« gšèny 34. bfh£odhš njŸ, bfh£lhé£lhš ÃŸisó¢Áah? 35. njiu Â‹w gh«ò fo¤jhš Ïw¥ò ã¢ra«.

gh£L f©lJ gh«ò fo¤jJ fU¡F Â‹wJ kUªJ bfh‹wJ kU¤Jt‹


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Annexure XIII: Form to assess the quality of services rendered to snake bite / scorpion sting for the month of ……….200…/ for the quarter ending March / June / September / December200........ Name of the Health Centre / Hospital …………………………Code No………. Sl. No 1.

2.

3.

Quality of services

Observations / Problems / Complaints

Remarks

Clinical matters • Admission • Assessment & Administration of appropriate drugs • Observation on adverse reactions to ASV and / other drugs • Lapses in clinical care • Referral of cases • Morbidity status for the reporting month • Mortality • Sharing of experiences with others • Guiding on welfare programme • Others –specify Preventive aspects • Organising awareness programmes • Reduction in the time interval between bite / sting to hospitalisation • Immobilisation of the victim • Avoidance of traditional practices • Any other – specify Administrative issues • Availability of medications • Submission of report to higher authorities • Monitoring and review of a. Patient care b. Preventive aspects • Any other – specify

Name, Designation, Signature, Date and Office seal of Medical Officer 104



Annexure XIV: Form to analyse and audit the statistics on snake bite / scorpion sting for the month of ……….200…../ for the quarter ending March / June / September / December 200… Name of the Health Centre / Hospital ………………….....Code No……

1. 2. 3. 4. 5. 6. 7. 8. 9.

b.

Name, Designation, Signature, Date and Office seal of Medical Officer Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

105


Annexure XV: Useful Websites:

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http://www.globalcrisis.info/poisonandvenomemergency.html

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http://www.whosea.org/bct/snake/5htm

•

http://www.whosea.org/bct/snake/2introB.htm

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http://www.whosea.org/bct/snake/5f.html

•

http://www.fda.gov/Fdac/features/995_snakes.html

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http://www.emedicine.com/MED/topic2143.htm

•

http://www.emedicinehealth.com/snakebite/article_em.htm

•

http://www.lfsru.org/Þrstaid.htm

•

http://www.healthcentral.com/ency/408/000031.html

•

http://www.umm.edu/non_trauma/snake.htm


HANDBOOK ON TREATMENT GUIDELINES FOR SNAKE BITE AND SCORPION STING 2008 - TNHSP PUBLICATION

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