You are on page 1of 129
HAND BOOK ON TREATMENT GUIDELINES FOR SNAKE BITE AND SCORPION STING Tamil Nadu Health Systems
HAND BOOK ON TREATMENT GUIDELINES
FOR
SNAKE BITE AND SCORPION STING
Tamil Nadu Health Systems Project
Health and Family Welfare Department
Government of Tamil Nadu, Chennai.
Tamil Nadu Health Systems Project
Health and Family Welfare Department
Government of Tamil Nadu, Chennai.
2008
HANDBOOK ON TREATMENT GUIDELINES FOR SNAKE BITE AND SCORPION STING Tamil Nadu Health Systems Project

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

Dr. S. VIJAYA KUMAR I.A.S.,

Special Secretary to Government Health & Family Welfare Dept.,

&

Project Director

Health & Family Welfare Dept., & Project Director Tamil Nadu Health Systems Project 7th Floor, DMS

Tamil Nadu Health Systems Project 7th Floor, DMS Building, Chennai - 600 006. Tel. Off : (91-44) 2434 5997 Fax : (91-44) 2434 5997 Email : mail@tnhsp.net

INTRODUCTION

The Tamil Nadu Health Systems Project formed a snake bite task force in 2006 to try and understand the staggering gures 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 ofcers 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 redene 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

Chennai.

iii

and appropriate quality of care for snake bite and scorpion sting victims. November 2008 Chennai. iii

Dr. S. VIJAYA KUMAR

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 scientic 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 leaets 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 [mail@tnhsp.net] which will be helpful for modifying / revising future editions.

vi

ABBREVIATIONS

Anti Snake Venom

AS

AT

Antithrombin

BP

Blood Pressure

Computerised Tomography

Disseminated Intravascular Coagulation

Fresh Frozen Plasma

CT

DIC

FFP

Hg

Mercury

HR

Heart Rate

HCL

Hydrochloride

Intra Compartment Pressure

ICP

IM

Intramuscular

IV

Intravenous

LAB

Laboratory

Primary Health Centre

Pressure Immobilisation Method

Pulse Rate

Respiratory Rate

Standard Deviation

PHC

PIM

PR

RR

SD

WBCT –

WHO

Whole Blood Clotting Test

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: Inuencing 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 Identication 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:

8. SECTION II:

9. SECTION III:

10. SECTION IV:

SNAKEBITE

SCORPION STING

MISCELLANEOUS

ANNEXURES

SECTION - I

SNAKE BITE

Titles

Page

1.1 General

1

Introduction

Magnitude of the problem

Epidemiology of snake bite

Ecological aspects

1.2 Classification of snakes

4

Snakes of Medical Importance in Tamilnadu - Distinguishing features

1.3 Clinical aspects of snake bite

7

Pathophysiology

Symptoms and signs

Criteria for diagnosis

Complications and outcome

Investigations

1.4 Treatment

14

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

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

29

Hypotension

Persistent or severe bleeding

Renal failure

Surgical issues

Use of Heparin and Botropase

1.6 Snake Bite in special situations

32

Victims requiring life saving surgery

Victims arriving late

Snake bites again!

Pregnancy and lactating women

Others

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 magico- religious 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-scientic ideas on snakes and snakebites, and display traditional treatment. Hence, there is a need for the health department to disseminate the scientic 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 gures 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.

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

Number

Local

Neuro

Hemo.

 

Supportive

Number

snake

treated

signs

Toxicity

Toxicity

Mechnical

Hemo-

 

Expired

ventilation

Dialysis

Fasciotomy.

Cobra

118

80

118

-

90

-

- 2

 

Krait

82

-

51

82

60

3

- 2

 

Russell’s

               

viper

42

42

-

42

6

23

1 1

Hump-

               

nosed

44-

4

-

4

- 1

viper

Saw

               

scaled

16

16

-

16

-

3

- 1

viper

Sea

               

snake

33-

-

-

-

- -

Non

               

poisonous

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 rst 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 magico- religious 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

Treatment Guidelines for Snakebite and Scorpion sting - 2008

be prevented, if some simple rst 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 rst 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 rst 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 rst two. Though the specic 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 elds, which harbour millions of rats attract a lot of snakes. The number of snakes per acre in a rice eld is abnormally high when compared to the natural population in the forest. Humans go into the eld 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 ourish as long as there are rice elds; 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 elds because they like the plentiful small rodents such as the

Treatment Guidelines for Snakebite and Scorpion sting

eld 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 classied into poisonous (venomous) and non-poisonous (non venomous) snakes. Poisonous snakes are classied 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 re ected 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 misidentication 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 signi cance 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 denition of snakes of medical importance (Table No.2). This model is more accurate and useful than denitions 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

Name of the snakes

I

Commonly cause death or serious disability

Russells viper / Cobra / Saw scaled viper

II

Uncommonly cause bites but are recorded to cause serious effects (death or local necrosis)

Krait / Hump-nosed pit viper / King cobra / Mountain pitviper

III

Commonly cause bites but serious effects are very uncommon.

Water snakes, Green snake

Treatment Guidelines for Snakebite and Scorpion sting - 2008

Treatment Guidelines for Snakebite and Scorpion sting - 2008 Picture No.1 Tamil Nadu Snakes of Medical

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 signi cant species from non signicant 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 denitive (the identication 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 identication that enable the medical professional to rapidly identify whether they are dealing with a venomous species, and what that species might be.

Treatment Guidelines for Snakebite and Scorpion sting

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 identication features that are worth noting. The rst is a series of chain-like or black edged almond shaped marks along the snakes back and anks. 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 identication features of this species is the posture it adopts when

it is agitated. It moves its body into a gure 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 ve 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 denitive as other

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 identiers 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 signicant 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

Treatment Guidelines for Snakebite and Scorpion sting

enzymes promote formation of weak brin 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 non- venomous 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 late- onset envenomation are listed below.

General symptoms and signs of Viperine envenomation

Local effects

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 orices.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 difculty 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.

Treatment Guidelines for Snakebite and Scorpion sting

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

Cobras

Kraits

Russells

Saw Scaled

Hump Nosed

Viper

Viper

Viper

Local Pain / Tissue Damage

YES

NO

YES

YES

YES

Ptosis / Neurological Signs

YES

YES

YES!

NO

NO

Haemostatic

NO

NO!

YES

YES

YES

abnormalities

Treatment Guidelines for Snakebite and Scorpion sting - 2008

Renal Complications

NO*

NO*

YES

NO*

YES

Response to

YES

NO?

NO?

NOT

NOT

Neostigmine

applicable

applicable

Response to ASV

YES

YES

YES

YES

NO

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

Sea snakes:

Sea snake bites are reported rarely among shermen 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 insignicat 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 nally 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 ngers); 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)

Treatment Guidelines for Snakebite and Scorpion sting

Treatment Guidelines for Snakebite and Scorpion sting Picture No.2 Typical signs of local envenomation namely edema,

Picture No.2

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

local envenomation namely edema, blister and joint swelling Picture No.3 Cellulitis with compartmental syndrome

Picture No.3

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 inuence 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 signicantly 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

Treatment Guidelines for Snakebite and Scorpion sting - 2008

Table No. 5: 20 Minutes Whole Blood Clotting Test (20WBCT)

Advantages

Requirements

Procedure

The most reliable test of coagulation.

Dry glass test tube (clean and new)

Wash hands with soap and water.

Wear the gloves

2ml disposable

Collect 2ml blood from the peripheral vein of the unaffected

Can be carried out, at the bedside.

syringe

Cotton

limb

Antiseptic solution

Remove the needle and pour the

Does not require specialised training.

Clean gloves (one pair)

blood along the walls of the test tube

(The test tube must not have been washed with detergent, as this will inhibit the contact element of the clotting mechanism)

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

Treatment Guidelines for Snakebite and Scorpion sting

1.4 Treatment First aid for snake bite

The rst 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 benet 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 ow 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.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

(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 ow 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 bene cial

Cryotherapy involving the application of ice to the bite was proposed in the 1950’s. It was subsequently shown that this method had no benet 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 benecial effects

Electrical Therapy:

Electric shock therapy for snakebite received a signicant amount of press coverage in the 1980’s. The theory behind it stated that applying an electric current to

Treatment Guidelines for Snakebite and Scorpion sting

the wound denatures the venom. Much of the support for this method came from letters to journals and not scientic papers. It has been demonstrated that the electric shock has no benecial effect and hence, it has been abandoned as a method of rst 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 signicant snakes of India. In view of the difculties 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 benet in the rst aid treatment of snakebite. This method should be subjected to further research in India to assess its efcacy. 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 rst aid in difcult 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”

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 [uid for children refer to Annexure II –Table No.29]

Treatment Guidelines for Snakebite and Scorpion sting

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 uids as per need [uid 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 specic one. (Non-speci c ulcers are dened 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.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 identied.

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, lling 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.

Treatment Guidelines for Snakebite and Scorpion sting

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 half- life of over 90 hours. Though it is puried, 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 difcult for the physician to determine which type of Monovalent ASV to employ in treating the patient. In addition there are difculties to prepare, supply and maintain adequate stock of species specic 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 speci c 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 denite signs of envenomation. Anti-Snake Venom carries risks of anaphylactic reactions and should not therefore be used unnecessarily. Unbound, free owing venom, can only be neutralised when it is in the bloodstream or tissue uid. 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.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 conrmation, but 20 WBCT is paramount.

Evidence of neurotoxicity: ptosis, external ophthalmoplegia, muscle paralysis, inability to lift the head etc.,

arrhythmia,

Cardiovascular

abnormalities:

hypotension,

shock,

cardiac

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 justied.

Dosage

In the absence of denitive 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 suf cient neutralising power to neutralise the average amount of venom injected and during the next 12 hours to neutralise any remaining free owing 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

Treatment Guidelines for Snakebite and Scorpion sting

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 denite 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.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 denitely.

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 rst 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)

Dry cough

Urticaria, even a single spot

Bronchospasm / rhonchi

Nausea

Stridor (rarely)

Vomiting

Angio-oedema of lips and mucous membrane

Abdominal colic / pain

Diarrhoea

Fever

Tachycardia (PR >120/min) (for children refer age specic chart)

Shaking chills (rigors)

Sweating

Fall in blood pressure

Cold and clammy skin

Low volume pulse

Central cyanosis

Febrile convulsions (in children)

Anaphylaxis (Type I )

Treatment Guidelines for Snakebite and Scorpion sting

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

*Children (upto 25 kg)

Inject adrenaline 1:1000 intramuscularly:

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

Weighing < 50 kg give 0.25 ml

Weighing 50 -100 kg give 0.50 ml

Weighing >100 kg give 0.75 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.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 H 1 receptor blockers Inj. Chlorpheniramine maleate 10 - 20mg as IV / intramuscularly or Promethazine 0.5 - 1mg/kg and H 2 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 uids 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 H 1 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 denitive trial evidence.

Treatment Guidelines for Snakebite and Scorpion sting

Two prophylactic regimens normally recommended are given below:

100mg of Hydrocortisone and H 1 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 rst few hours. After that the body recovers by using its own mechanisms. Large doses of ASV, over long periods, have no benet 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 justication 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.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

Treatment Guidelines for Snakebite and Scorpion sting - 2008 Picture 4 Case of cobra snake bite

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

phase showing bilateral ptosis with overaction of frontalis Picture 5 Neuroparalysis recovering only showing

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 identied 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.

Treatment Guidelines for Snakebite and Scorpion sting

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 owing 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

( brinogen, 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 reecting 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.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

ASV risk and wastage

De nitive 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 inuence the utilisation of ASV for a given patient. Thus there is a possibility of rst 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 wastage

High risk

ASV - Not available - Insuf cient administration

ASV – Too little supply and species are different

Low risk

Effective dose of ASV to envenomed patients

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 - 10μ /kg/minute in normal saline or glucose solutions as IV drip. The ow rate may be adjusted to maintain blood pressure adequately. Rarely Russell’s Viper bites are known to cause acute pituitary and / or adrenal insuf ciency. 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

Treatment Guidelines for Snakebite and Scorpion sting

(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 ngers

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.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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.

Care of the wound - Apply appropriate topical agents and dressing - Maintain proper wound environment - Do surgical debridement, if needed refer to surgeon

Wound status

Use of topical agents / traditional medicine

Prepare and proceed to skin grafting later (if required)

Compartment syndrome

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)

- 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

Monitor ICP every 30 to 120 minutes if required

Pain out of proportion

Pulselessness

Proceed with fasciotomy if the ICP exceeds 30 to 40mm of Hg.

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.

Restore coagulation time before commencing the procedures.

Use of Heparin and Botropase in Viper Bites

Heparin has been proposed as a means of reducing brin 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 benecial effect.

Treatment Guidelines for Snakebite and Scorpion sting

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 justi ed (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 denitive data published on the effects of snakebite during pregnancy. Though spontaneous abortion of the foetus has been reported, this is not

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 condence. Evidence suggests that doctors are not willing to make use of ASV and other medications, even when equipped, due to lack of condence 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

CLASSIFY

TREATMENT

Vital signs

Vital signs (Adult)*

 

Pulse

Pulse rate: 60-100/min

Tab.Paracetamol

BP

BP 110 / 70 to 140/95

Inj.Tetanus Toxoid IM

Respiration

Respiratory rate <20/ min

Routine antimicrobials are not necessary

Treatment Guidelines for Snakebite and Scorpion sting

Symptoms and signs

Symptoms and signs

Monitor Pulse, Respiration

Bite marks

Local pain and/ or

& BP every ½ hourly for 3 hours and every 4 th hourly

Ptosis

swelling+

Double vision

Bite mark present,

for remaining 48 hours.

Dif culty in swallowing

skin broken

No other symptoms

Bleeding sites

and signs present

Reduced urine output

Laboratory test:

If normal send the patient home

Swelling and local pain

20 Minutes Whole Blood Clotting Test - blood clot

Local necrosis

formed

 

Descending paralysis

If above ndings are there

Unconsciousness

at the time of assessment

Regional lymphadenitis

classify as No systemic envenomation

Any other symptoms and signs noted down

*Vital signs for children (see age specic 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.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

Table No. 13: Haemotoxic envenomation

ASSESS

CLASSIFY

TREATMENT

Vital signs

Vital signs (Adult)*

Treat the patient with Anti Snake Venom (ASV)

Pulse

Pulse rate >120 per

BP

minute, feeble (a

Start IV Normal Saline with wide bore needle

Respiration

response to hypotension) Respiratory rate > 20/min Hypotension < 90/60 mmHg

Symptoms and signs

Begin with one vial of ASV in one point of NS and start 10-15 drops per minute for 15 minutes & watch for reactions.

Bite marks

Symptoms and signs

Ptosis

Swelling and local pain

If signs and symptoms of anaphylactic shock (cold and clammy skin, rapid pulse, dyspnoea, etc.)

Double vision

or painful enlargement of

Dif culty in swallowing

nearby lymphnodes Bleeding from the

Bleeding sites

Gingival sulci

develop, stop the ASV drip

Reduced urine output

Swelling and local pain

Epistaxis

Petechiae, purpura, ecchymoses

temporarily and treat the shock with:

Inj.Hydrocortisone 100 mg IV or Inj.Dexamethasone 8 mg IV Inj.Pheniramine maleate 2ml IV

Local necrosis

Hematuria

Descending paralysis

Intracranial bleeding:

Unconsciousness

asymmetrical pupils

Inj.Adrenaline 1:1000 (0.5ml)IM

Lymphadenitis

unconsciousness

Inj.Deriphyline 2ml IV

Breathing difculty

convulsions

Any other, note down

Persistent and severe vomiting or abdominal pain Low back pain No urine output or decreased urine output Laboratory test:

20 Minutes Whole Blood Clotting Test.

Oxygen administration IV Normal saline as life line

As soon as the patient recovers or

If the patient is not having signs and symptoms of anaphylactic shock continue the ASV drip with remaining seven vials /

Blood clot not formed If above ndings are there at the time of examination classify as Haemotoxic envenomation

ampoules

Continue to monitor the vital signs at ve minutes interval for rst 30 minutes and then at 15 minutes interval for two hours

Stabilise the patient and refer to the higher institution Aspirin should not be used

Treatment Guidelines for Snakebite and Scorpion sting

Fluid requirements per day should be kept in mind while giving ASV. For children readers are requested to see the uid requirement chart provided in Annexure II. [Table No.29]

* Vital signs for children (see age specic chart) are provided in Annexure III. [Table no.30 to 33].

Table No. 14: Neurotoxic envenomation

ASSESS

CLASSIFY

TREATMENT

For local

Symptoms and signs

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

envenomation

Swelling and local pain

refer to Table

4.

Local necrosis

Descending paralysis starting with ptosis, external ophthalmoplegia

For systemic

Numbness around the lips and mouth progressing to pooling of secretions, difculty to talk and respiratory failure

Paradoxical respiration

envenomation refer to Tables 12 and 13

Paralysis

After that observe patient for every ve minutes for 30 minutes for signs of response

Abdominal pain

Laboratory test:

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

 

1.8 Referral aspects

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

Treatment Guidelines for Snakebite and Scorpion sting - 2008

Table No. 15: Referral aspects for snakebite

Who needs?

 

When to refer?

Where to refer?

Patient requiring

Refer the patient

Refer to higher institution having

Respiratory support

after stabilising the

Deteriorating neurologic manifestations

case and after giving injection ASV (Refer to Annexure VIII and

Ventilator

Dialysis facilities

Measures to provide

Surgical intervention-Necrosis / Fasciotomy

IX)

further supportive treatment.

Spontaneous persistent bleeding

 

Co-morbid diseases

Acute impending kidney failure

Referral Criteria for Haemotoxic envenomation

Once the ASV is nished 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 rst 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

Treatment Guidelines for Snakebite and Scorpion sting

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 certicate 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 rst 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 signicant 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 signi cant number of bites.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 owers in areas of ower cultivation

Plucking hay / straw from bundle of hay / straw

Persons involved in picking up dry re 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 rst. 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 xed 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.

Treatment Guidelines for Snakebite and Scorpion sting

4

Alvares R. (Goanet) Myths and Snake bites. http://lists/whatwg.org/goanet- goanet.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): 805-

808.

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 methods- cause and concern (PP-099). Abstract book of 6 th annual conference of Asia Paci c 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 8 th 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. Prole 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 Pro le 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 Ofce for South East Asia, New Delhi 2005;PP67 + viii.

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 ow rates and rst 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

Treatment Guidelines for Snakebite and Scorpion sting

30. Nayak KC, Jain AK, Sharda DP, Mishra SN. Prole 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 6 th annual conference of Asia Pacic Association of Medical Toxicology held at Bangkok, Thailand, December 12-14, 2007 P.104

36. Sarangi A, Jena I, Sahoo H, Das JP. A pro le 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 rst 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

Treatment Guidelines for Snakebite and Scorpion sting - 2008

44.

Srivastava RK. Director General, Of ce of the Directorate General of Health Services, Nirman Bhawan, New Delhi – 110011. Letter D.O.No.D.32020/3/2008 – EMR, Dated 5 th 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 efcacy of tourniquets as a rst 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.

SECTION - II

SCORPION STING

Titles

Page

2.1 General

45

Introduction

Epidemiology

Eco-biological aspects of scorpion

Distribution of various species of scorpions

Socio cultural aspects

2.2 Clinical aspects

47

Components of venom and mechanisms of action

Pathophysiology

Symptoms and signs.

Criteria for diagnosis

Differential diagnosis

Investigations

Clinical course

Complications

2.3 Treatment

54

First aid measures

Traditional methods

Principles involved in the management

Pharmacological aspects of Prazosin

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

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 inuence 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 rst 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 under- reported. 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 rst 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.

Treatment Guidelines for Snakebite and Scorpion sting

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, rewood, 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 identied. 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 o north and 50 o south of equator. The distinguishing features between lethal and non lethal scorpions are provided in Table 16 given below.

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

Structure

Lethal Scorpion

Non lethal scorpion

Sternum Shape

Triangular

Pentagonal

Pincers

Weak looking

Strong and Heavy

Body

Thin in a empathetic manner.

Thick

Tail

Thick

Thin

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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 condence 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 ring 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.

Treatment Guidelines for Snakebite and Scorpion sting

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 u 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 inuenced 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

Sting

Status of the patient

Species

Time of sting

Age of the patient

Age, size and

Number of stings

Health status

nutritional status

Quantity of venom

Comorbid conditions

Stinging apparatus (telson)

injected (low dose – adrenergic, high dose – cholinergic)

Weight of the victim

Physiological response of the individual

 

Depth of the sting penetration

Sensitivity of the systém to the

Site of sting IV/SC/IM

neurotransmitters and

Components of venom

toxins

Usual signs of scorpion sting are as follows

Mydriasis

Nystagmus

Hyper salivation

Dysphagia

Restlessness

Treatment Guidelines for Snakebite and Scorpion sting - 2008

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%)
(83%)
(10%)
(5%)

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

Treatment Guidelines for Snakebite and Scorpion sting

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

Nonlethal local

Neurotoxic local signs at the site of sting

Cytotoxic local signs at the site of sting

effects

Pain

Local effect of sting