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A Study of Clinical Profile and Outcome of Snake Bite at Tertiary Care Centre in South Rajasthan

1 Professor, 2,5 Post-Graduate Resident, 3 Sr. Professor, 4 Sr. Resident Department of Medicine RNT Medical College Udaipur *Corresponding Author Dr Raviraj Singh Ahada Post-Graduate Resident, Department of Medicine RNT Medical College Udaipur, India Abstract Introduction: Snakebite is a major public health problem throughout the world, more so in tropical and subtropical countries. In India, there are 216 species of snakes, of which only four are venomous snakes (Cobra, Krait, Russell’s Viper and Saw Scaled Viper). Poorly informed rural populations often apply inappropriate first-aid measures and vital time is lost before the victim is transported to a treatment center, where cost of treatment can constitute an additional hurdle. Materials & Methods: This descriptive observational study was carried out from January 2017 to December 2017, at Department of Medicine in Maharana Bhupal Government Hospital, R.N.T. Medical College, Udaipur, a tertiary care hospital serving population of Southern Rajasthan. Result: A total of 100 patients with a history of snake bite and signs of envenomation were included in this study. 38(38%) had viper bites, 33(33%) were unidentified and 29(29%) had krait bites. Maximum incidence were in farmers (73%) and in rural areas (82%). Commonest vasculotoxic manifestation was local bleeding (71.42%). Commonest neurotoxic manifestation was ptosis (100%)The mean dose of ASV vials required for vasculotoxic snakebites was more (32.62vials) and for neuroparalytic snakebite was less (10.00 vials). One patient died because of respiratory paralysis, due to delayed presentation in hospital. Conclusion: Snake bites are common in rural areas affecting mainly agricultural workers, in rainy season and the most common site is lower limbs. Most poisonous snake bites are due to hematotoxic bites in this region. From this study, it is inferred that delay in presentation following snake bite has an overall negative effect on the outcome and there is no substitute for early and effective treatment with ASV. Population awareness programs regarding prevention, first-aid and the importance of the early transfers to be emphasized.


Introduction
Snakebite is a major public health problem throughout the world, more so in tropical and subtropical countries. In a predominantly agricultural country like India with its rich florafauna, the encounter between man and snake is a frequent occurrence. With rapid urbanization and deforestation, the incidence of snake bite is high and forms a significant group of hospital admissions. There are no accurate records available to determine the exact epidemiological or even mortality in snakebite cases as the true incidence of snakebites is difficult to assess and often is underreported. There are approximately between 1.2 million and 5.5 million snakebites worldwide each year, with 20,000-94,000 deaths . 1 In India more than 20,00,000 snake bites are reported annually, of which 35,000 to 50,000 people die 2. In India, there are 216 species of snakes, of which only four are venomous snakes (Cobra, Krait, Russell's Viper and Saw Scaled Viper). Viper bites are more common than other poisonous snakebites in human beings. Of the different varieties of vipers, the Russell's viper (Vipera russelli) commonly inhabits the Southern Asian countries ,Indian cobra (Naja naja) and Common Indian krait (Bungarus caeruleus) are two important species of elapid snakes found in India and are responsible for most of the cases of neurotoxic snake bite. The most common poisonous snake is common krait 3 . The overall mortality rates for victims of venomous snakebites are low in regions with rapid access to medical care and appropriate antivenoms. Snake-bite is one of the most lifethreatening bio-weapon system in the nature which may cause local to systemic complication the form of neurotoxicity or haematotoxicity.

Materials & Methods
This descriptive observational study was carried out from January 2017 to December 2017, at Department of Medicine in Maharana Bhupal Government Hospital, R.N.T. Medical College, Udaipur, a tertiary care hospital serving population of Southern Rajasthan.

Inclusion Criteria
A total of 100 patients with a history of snake bite and signs of envenomation were included in this study after an informed consent for participation in the study.
Evidence of bite by a poisonous snake included: i. Fang marks, ii. Swelling, ecchymosis, blister formation and/or bleeding from local site, iii. Disturbances in coagulation mechanism with or without systemic bleeding, and iv.
Identification of snake wherever possible. v. Neurotoxicity was defined as documented ptosis, external ophthalmoplegia, weakness of neck or bulbar muscles, use of neostigmine or ventilatory support (endotracheal intubation, Ambu bag or a mechanical ventilator).

Exclusion Criteria
Patients with pre existing renal disease, liver dysfunction and bleeding disorder were excluded from the study. After obtaining consent, data was collected on pre-designed 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, time of bite, site of bite and place of bite, type of snake if identified by patient or bystanders by showing photographs or by identification of the dead snake brought by the victim, etc., was obtained. Time interval to reach the health facility after snake bite and first aid received if any was asked to them. Patients reached to hospital within 6 hours of snake bite were kept in immediate treatment group while those who reached after 6 hours were kept in delayed treatment group. Subsequent information like complications and outcome was collected on the day of discharge or death of the patient from the case paper of the patient and entered in a computer database for analysis. Following statistical methods were applied in the present study-Contingency table analysis and Independent samples 't' test.

Result
In the present study, 100 patients of snake bite were studied. Maximum incidence of snake bite was found in farmers (73%) than in any other occupation, which shows snake bite is a major public health problem among farmers in rural areas. Males (59%) were bitten more than females (41%). This suggests a risk of outdoor activities. Maximum incidence of snake bite was found in rural areas (82%) than urban areas (18%). Bites were commonly seen on the lower extremities (50%), as in most cases, snakes were inadvertently trodden upon. Majority of snake bites occurred during night time (65%) than day time (35%), due to poor visibility in darkness. Higher incidence of snake bites was found in monsoon (60%) i.e. June to September. Many victims (33%) could not identify the snake. Among the identified, 38%were due to viper. 41% of patients reached the hospital after 6 hours of snake bite. Most of them had received native treatment from traditional healers. A total of 68% patients came with tourniquet application. 32% of patients did not receive any sort of first aid. Complications like ARF requiring dialysis, spreading cellulitis requiring debridement/ fasciotomy amongst vasculotoxic snake bite and need of ventilator support among neuroparalytic snake bite was more common in delayed group. (Table 2) Commonest vasculotoxic manifestation was local bleeding(71.42%).
Commonest neurotoxic manifestation was ptosis (100%) followed by opthalmoplegia (85.1%). 59.57% of patients with neuroparalytic bite required artificial ventilation, the need for mechanical ventilation was more in patients who presented late to the hospital. Two patients developed anaphylactic reaction to ASV and were treated conservatively and recovered completely. Mean hospital stay in the patients who presented early was 3.32 ± 0.78 days while in patients who presented late, mean hospital stay was 5.8 ± 2.14.
The mean dose of ASV required for vasculotoxic snakebites was more (32.62 Vials) and for neuroparalytic snakebite was less (10.00 Vials). One patient died because of respiratory paralysis, due to delayed presentation in hospital. Presentation time Immediate (less than 6 hrs) 59% Delayed(more than 6 hrs) 41% In the present study, mean duration of hospital stay for those who reached early was 3.32 ± 0.78days and 5.80 ± 2.14 days for those who reached the hospital late. Omogbai et al.,(2000) 19 studied 433 patients of snake bite with a mean duration of stay in hospital of 5.7 ± 5.1 days.
In the present study, overall mortality was 1(1%), death was due to respiratory paralysis because of late presentation in the hospital (10 hours after envenomation). In the study done by Patil et al 18 and Punde DP et al 12 , mortality was 1.94% and 4.7% respectively.

Conclusion
From this study, it is inferred that delay in presentation following snake bite developed local and systemic complications and need for surgical intervention, renal failure, mechanical ventilation was more in those who reached the hospital late.
There is no substitute for early and effective treatment with ASV. Population awareness programs regarding prevention, first-aid and the importance of the early transfers to be emphasized.