ABSTRACT
Background: Every year about 50,000, people die of snake bites in India. Anti-snake venom and mechanical ventilation is mainstay of treatment in cases with severe neurotoxic envenomation. ASV is costly and scarce resource. There is lack of universal consensus towards the optimal dose of ASV in management protocol for children with severe neurotoxic snake envenomation. Objective was to compare the difference in outcome between two fixed doses of ASV, 10vials versus 20 vials, in children with severe neurotoxic snake envenomationMethods: This comparative observational study was carried out for a period of 3 years in Department of Pediatrics of SVS Medical College, Mahabubnagar, Telangana, India. Children with history of snake bite and clinical evidence of neuroparalysis were included. In addition to the mechanical ventilation and other supportive measures, every alternate patient was administered with 10vials (low dose) and 20 vials (high dose) of ASV over 1 hour. Outcome was compared between the two groups.Results: Of the 62 patients, 32 were in each group. The median time to extubation was 41 hours and 39.5 hours and mean duration of the hospital stay was 4.6 days and 4.5 days among the low dose and high dose groups, respectively. There were three deaths, one from low dose group and two from high dose group.Conclusions: There was no significant difference in outcome between the 10 vials vs 20 vials of ASV in addition to mechanical ventilation in treatment of children with severe neurotoxic snake envenomation. So, 10 vials of ASV can be utilized to reduce the cost of treatment.
ABSTRACT
Fulminant myocarditis is an unusual manifestation of cardiotoxicity with severe elapid snake envenoming and is meagrely reported with snake bite due to Indian common krait. We report a 12-year-old boy who was admitted in complete locked-in state and hemodynamic instability after severe neurotoxic snake envenoming by Bungarus caeruleus (Indian common krait). His hospital course was complicated with recurrent episodes of sustained ventricular tachycardia requiring defibrillation; and cardiogenic shock requiring inotropes, vasopressors and intraaortic balloon counterpulsation. Severe heart failure features secondary to fulminant toxic myocarditis persisted even after full neurological recovery requiring prolonged standard medical heart failure therapy. Patient subsequently achieved full clinical recovery and regained normal left ventricular systolic function. We also reviewed the literature on cardiac manifestations, possible mechanisms and treatment of patients with cardiotoxicity due to elapid snake bites. The importance of anticipating severe cardiovascular complications is highlighted to help formulate appropriate therapeutic strategy.
ABSTRACT
Background: Dhule district in Maharashtra (India) has snake bite as a common medical emergency. There are 168 villages in Dhule district and its majority of the population is engaged in farming and snakebite is a major occupational hazard particularly during the harvesting season. The available data on the epidemiology of snake bite from the here is sparse. Poisonous and nonpoisonous snake bites accounts approximately 30 admissions per month which increase to 35-40 admissions in rainy season in Civil Hospital. Methods: Fifty patients with severe neuroparalytic snake envenomation, resulting in acute type II respiratory failure, admitted to medical ICU for mechanical ventilation during one year period, were studied. Ventilatory requirements, amount of antisnake venom (ASV) infused, period of neurological recovery and hospital survival were evaluated. Results: 60% of patients affected were in the age group of 21-40 years. Maximum numbers of bites were during April to September (84%). All patients had severe manifestations such as ptosis, ophthalmoplegia, neck muscle weakness, limb and respiratory muscle weakness. 200 ml ASV was administered to all, along with atropine and neostigmine. Mechanical ventilation was required for a median duration of 26.60 hours. All victims in the study group survived with complete neurological recovery except one mortality for a patient who had suffered irreversible hypoxic cerebral injury prior to arrival in hospital and needed ventilatory support for 9.58 days. Conclusions: Timely institution of ventilatory support and fixed dose of 200 ml of ASV along with anticholinesterase treatment was sufficient to reverse neuroparalysis in severe elapid bites.