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A STUDY OF CLINICAL PROFILE OF SNAKE BITE AT A TERTIARY CARE CENTRE

Background: Snake bite is an important occupational and rural hazard because India has always been a land of Exotic snakes. In Maharashtra, common poisonous snakes are Cobra, Russell's Viper, Saw Scaled Viper, and Krait. It is a fact that inspite of heavy morbidity and mortality, very little attention is paid by the clinicians to this occupational hazard. Aims: To study the prevalence of poisonous and non-poisonous snake bites in part of Western Maharashtra with reference to age, sex, occupation, part of body bitten, time of bite and seasonal variation, and the types of poisonous snakes common in this locality and their clinical manifestations along with the systemic envenomation from various types of poisonous snakes and their effective management in reducing the mortality rate. Materials and Methods: This was a retrospective study conducted between May 2010 to May 2012 at a tertiary health care center in Maharashtra. Result: A total of 150 patients were studied in our hospital. Out of 150, 76 patients were of poisonous snake bite and 74 patients were of non-poisonous snake bite. Out of these 76 poisonous snake bites, 42 were viperine snake bites, 21 were neuroparalytic snake bites and 13 were locally toxic (LT) snake bites. Conclusion: Snake bite is a common life-threatening emergency in the study area. Delay in hospitalization is associated with poor prognosis and increased mortality rate due to consumptive coagulopathy, renal failure, and respiratory failure. Unusual complications like pulmonary edema, intracerebral hemorrhage, Disseminated intravascular coagulation (DIC) were observed in present study.


INTRODUCTION
Globally, atleast 421,000 envenoming and 20,000 deaths occur each year due to snakebite. These figures may be as high as 18,41,000 envenoming and 94,000 deaths. [1] The concept of the "Big 4" Snakes of medical Importance in India are-the Indian cobra (Naja naja), the common krait (Bungarus caeruleus), the Russell's viper (Daboia russelii) and the sawscaled viper (Echis carinatus). [2] Inadequate hospital-based reporting has resulted in estimates of total annual snakebite mortality ranging widely from about 1,300 to 50,000. [3] The incidence of envenomation is high in this part of the world where snakes are abundant and human activities like field work and outdoor-sleeping increases the risk of man-snake encounters. Awareness against treatment by quacks is a key factor as complications are directly proportional to the duration of venom in the blood prior to neutralization by ASV. Delayed presentation to the hospital is the main reason for increased morbidity and mortality and despite the known reasons, very few measures are taken to prevent and treat that in time. The present study was conducted in order to assess the magnitude and to study the clinical profile of snakebite cases in Maharashtra (India) and to suggest the measures to prevent and treat them with adequate doses of ASV and also the role of atropine and neostigmine in the treatment of neuroparalytic snake bite.

MATERIALS AND METHODS
The present descriptive observational study was carried out in medicine wards of Krishna hospital, Karad, Maharashtra (India). A total of 150 cases of snake bite were admitted in medical ICU during the study period. After obtaining consent, the data was collected on pre-designed, pretested and structured questionnaire by interviewing the study subjects who were hospitalized during the study period. A detailed information regarding demographic and epidemiological parameters such as age, sex, residence, occupation, site of bite and place of bite, type of snake if identified etc. was obtained. Time interval to reach the health facility after snake bite and first aid received if any was asked to them. Thorough clinical examination was carried out in each case. For identification of type of snake bite (Vasculotoxic, Neuroparalytic and Non-poisonous) opinion from treating physician was taken. Patients requiring the need of ASV were determined by the 20 minute whole blood clotting time (WBCT) on admission, which, if positive, was labelled as the candidate requiring ASV. The patients who required ASV were given the Indian lyophilised polyvalent ASV in the dose of 150 units (diluted in 150cc NS and transfused over 1 hour IV) after negative test dose. The dose of 100 units of ASV (diluted in 100cc NS and transfused over 1 hour IV) was repeated after 6 hours irrespective of the coagulation profile. Subsequent information was collected on the day of discharge or death of the patient from the case paper of the patient. Statistical tests applied were chi square test and percentage.

RESULTS
A total of 150 patients were studied in our hospital. Out of 150 patients, 74 patients had non-poisonous snake bites and 76 patients had poisonous snake bites. Maximum incidence of snake bite was found in farmers (81.33%) than in any other occupation. Males (66%) were bitten more than females (34%) among poisonous bites (Table 1).
Maximum incidence of snake bites was found in rural areas (85%). Poisonous snake bites were more prevalent in rural than urban areas. Bites were commonly seen on the lower extremities 88.6%. Maximum bites were in the night (72.66%) amongst which 73.68% were poisonous bites at night and 27% were poisonous bites at day time. Higher incidence of snake bites was found in summer (51.33%) i.e. March to May. In 8 cases, the snakes were seen/ identified. 57.33% patients reported to medical help within 6 hours, amongst which 24.41% were vasculotoxic and 18.60% were neuroparalytic ( Table 2). 67 patients came with tourniquet application, out of which 45 had poisonous bite and 9 of these patients had received ASV. 51 cases did not receive any sort of medical help before admission. 5 cases had received non-medical treatment. Time of onset of systemic manifestation was earlier in neuroparalytic snake bites than vasculotoxic snake bite. Vasculotoxic snake bites (55.26%) were more common than neuroparalytic bites (27.63%).Commonest vasculotoxic manifestation was local bleed (83.33 %) and next on the list was cellulitis (57.14%) (Table3). Haematuria (42.85%) was the commonest manifestation in those patients who developed acute renal failure. Ptosis (100%) was the commonest & earliest manifestation of neuroparalytic snake bite. Out of vasculotoxic snake bites, 20 were of acute renal failure, of which 7 required haemodialysis. 4 DIC patients received blood transfusion. 13 patients' of ARF received diuretics and recovered completely. 13 cases were locally toxic, out of them 4 patients developed cellulitis. 19 patients with neuroparalytic bite required artificial ventilation. 7 patients died because they came late to seek medical treatment and by that time complications were beyond control and were associated with systemic infection. 2 patients developed anaphylactic reaction to ASV and were treated conservatively and recovered completely. In the present study, 7 patients died of poisonous snake bites out of which 3 (3.94%) were neuroparalytic bite patients & 4 were vasculotoxic bite patients. Among neuroparalytic bites, mortality rate (14.28%) was higher than in vasculotoxic bite (9.52%). All 3 patients died because of delay in receiving respiratory assistance. Among 4 deaths of vasculotoxic bites, 3 patients died of acute renal failure and one patient died of DIC and intracerebral haemorrhage.

DISCUSSION
The number of poisonous snake bites in our study was 76 and the number of non-poisonous cases was 74. Amongst the poisonous snake bites, the number of Viperine bites was 42, Neuroparalytic bites was 21 and locally toxic cases was 13. In the present study maximum no. of patients bitten were between    [5] showed the incidence in farmers to be 75%, 78%, 72% and 53% respectively. In the present study, rural prevalence of snake bite was 117 out of 150 cases. Among them 69 were poisonous snake bites. Incidence of bites in present study is as follows.

CONCLUSIONS
Snake bite still remains a major occupational hazard. Current medical practice lacks the standard guidelines for the use of ASV and, at places, it is used in higher dose without knowing the adverse effects of the same. There is need for proper training and coordination between PHC staff, doctors, nurses, health inspectors and hospital staff to treat the snake bite victims and maintain the record properly.