A Clinico-Epidemiological Profile of Neuroparalytic Snake Bite, Using Low Dose ASV in a Tertiary Care Centre from Western Maharashtra

According to the World Health Organization, snakebites cause more death and disability and are more notorious than some tropical diseases. Snakebite is a leading medical emergency in Asia/Pacific. It is one of the major causes of mortality in India. The objective of this study was to determine the clinico-epidemiological profile of a neuroparalytic snake bite at the Department of Medicine, Krishna Institute of Medical Sciences, Karad, one of the tertiary care centers of Western Maharashtra, in India.METHODSA descriptive study of 80 patients was carried out at the Department of Medicine, KIMS, Karad, a tertiary care center of Western Maharashtra, India. Present study showed outcome, delay in arrival, and epidemiology of patients with low dose of ASV in neuroparalytic snakebites and ventilator support. Descriptive statistics were shown by using MS Excel and SPSS Version 25.RESULTSOut of 80 cases 56.2% were males and 43.8% were females with a mean age of 28.16 years. 63.7% of the snakebite victims were bitten outside and 85% of the snakebites occurred on the lower extremity. On an average, 15.24 vials of ASV were administered. 80% patient were in Intensive Care and they were on ventilator support and 91% patients recovered from these snake bites. 51.25% of the patients reached the hospital within the interval of 3-7 hours.CONCLUSIONSStudy signifies the importance of snakebite threat to the community. Delay in reaching a hospital in time where snakebite patients can be treated, was the most important cause of death. Public health programs should be strengthened. Administration of Low dose ASV and ventilator support can provide sufficient cure if patients reach on time. Lack of awareness, delay in reaching the hospital, and treatment by non-medical persons are important factors that should to be addressed.

Hemorrhagic stroke following viper bites and delayed antivenom administration: three case reports from the Western Brazilian Amazon

Abstract Snakebites were included by the World Health Organization in their list of neglected diseases. In Latin America, most snakebites are caused by species of the Viperidae family, notably by the genus Bothrops. Bothrops atrox accounts for 90% of the cases of envenoming in the Brazilian Amazon. In this report, we present a series of three cases of snakebites that evolved with hemorrhagic stroke due to delays in the access to antivenom in the Brazilian Amazon, being fundamental for diagnosis to validate the clinical suspicion and make decisions that would improve the treatment and prognosis of the patients.

FabAV antivenin use after copperhead snakebite: clinically indicated or knee-jerk reaction?

Abstract Background Crotalidae Polyvalent Immune Fab (Ovine) (FabAV) antivenin is commonly recommended after pit viper snakebites. Because copperhead envenomations are usually self-limited, some physicians are reluctant to use this costly treatment routinely, while others follow a more liberal approach. We hypothesized that, in practice, only patients with evidence of significant (moderate or severe) copperhead envenomation [those with snakebite severity score (SSS) > 3] receive FabAV and examined a large cohort to determine the relationship between clinical findings and FabAV administration. Methods All data from patients evaluated for copperhead snakebite at a rural tertiary referral center from 5/2002 to 10/2013 were compiled. Demographics, transfer status, antivenin use, and clinical findings were collected; SSS was calculated. The relationships among FabAV use, clinical findings, and SSS were analyzed using t-test, chi-square, and Pearson’s coefficient (p < 0.05 was significant). Results During the study period, 318 patients were treated for copperhead snakebite; 44 (13.8 %) received antivenin. Median dose was four vials (range: 1–10; IQR: 4,6). There were no deaths. Most patients receiving FabAV (63.6 %) were admitted. With regard to demographics and symptoms, only the degree of swelling (moderate vs. none/mild; p < 0.01) and bite location (hand/arm vs. leg: p < 0.0001) were associated with FabAV use. A SSS > 3, indicating moderate or severe envenomation, was only very weakly correlated with antivenin use (r = 0.217;p < 0.0001). The majority of patients with SSS > 3 (65.8 %) did not receive antivenin while most patients who did receive antivenin (70.5 %) had SSS ≤ 3 (indicating mild envenomation). Conclusions Considerable variation occurs in antivenin administration after copperhead snakebite. Use of FabAV appears poorly correlated with patients’ symptoms. This practice may expose patients to the risks of antivenin and increasing costs of medical care without improving outcomes. Guidelines used for treating other pit viper strikes, such as rattlesnake or cottonmouth snakebite may be too liberal for copperhead envenomations. Our data suggests that most patients with mild or moderate envenomation appear to do well independent of FabAV use. We suggest, for patients with copperhead snakebite, that consideration be given to withholding FabAV for those without clinical evidence of severe envenomation until prospective randomized data are available.

FabAV antivenin use after copperhead snakebite: clinically indicated or knee-jerk reaction?

Crotalidae Polyvalent Immune Fab (Ovine) (FabAV) antivenin is commonly recommended after pit viper snakebites. Because copperhead envenomations are usually self-limited, some physicians are reluctant to use this costly treatment routinely, while others follow a more liberal approach. We hypothesized that, in practice, only patients with evidence of significant (moderate or severe) copperhead envenomation [those with snakebite severity score (SSS) > 3] receive FabAV and examined a large cohort to determine the relationship between clinical findings and FabAV administration. Methods All data from patients evaluated for copperhead snakebite at a rural tertiary referral center from 5/2002 to 10/2013 were compiled. Demographics, transfer status, antivenin use, and clinical findings were collected; SSS was calculated. The relationships among FabAV use, clinical findings, and SSS were analyzed using t-test, chi-square, and Pearsons coefficient (p 0.05 was significant). Results During the study period, 318 patients were treated for copperhead snakebite; 44 (13.8 %) received antivenin. Median dose was four vials (range: 110; IQR: 4,6). There were no deaths. Most patients receiving FabAV (63.6 %) were admitted. With regard to demographics and symptoms, only the degree of swelling (moderate vs. none/mild; p 0.01) and bite location (hand/arm vs. leg: p 0.0001) were associated with FabAV use. A SSS > 3, indicating moderate or severe envenomation, was only very weakly correlated with antivenin use (r = 0.217;p 0.0001). The majority of patients with SSS > 3 (65.8 %) did not receive antivenin while most patients who did receive antivenin (70.5 %) had SSS 3 (indicating mild envenomation). Conclusions Considerable variation occurs in antivenin administration after copperhead snakebite. Use of FabAV appears poorly correlated with patients symptoms. This practice may expose patients to the risks of antivenin and increasing costs of medical care without improving outcomes. Guidelines used for treating other pit viper strikes, such as rattlesnake or cottonmouth snakebite may be too liberal for copperhead envenomations. Our data suggests that most patients with mild or moderate envenomation appear to do well independent of FabAV use. We suggest, for patients with copperhead snakebite, that consideration be given to withholding FabAV for those without clinical evidence of severe envenomation until prospective randomized data are available.

Anti-venom Activity of Mucuna pruriens Leaves Extract Against Cobra Snake (Naja hannah) Venom.

The study was done to investigate the anti-venom activity of Mucuna pruriens leaves extract against cobra snake (Naja hannah) venom. Study Design: The mice were randomly grouped into six groups (A, B, C, D, E, and F) of five rats each. Group A served as the normal control (no induction), and the mice in the group were given normal saline (1ml/kg/body weight).Group B served as the test control (snake venom was induced but no treatment administered), Group C served as the standard control (snake venom was induced and treated with antivenin, a standard drug), Group D, E and F were all induced with the cobra snake venom and treated with ethanolic extracts of the leaves of M. pruriens for 14 days. Methodology: The induction with cobra snake venom was done with 0.075mg/kg b.w of venom and thereafter the treatment with M. pruriens extract for Group D, E and F were done with 40 mg/ kg, 60 mg/ kg and 80 mg/ kg respectively intraperitoneally in the mice. Serum blood of the animals was used to assay for total cholesterol, bilirubin, AST, ALT, GSH and catalase levels after 14days. Result: The injection of crude venom of cobra snake (Naja hannah) caused an increase in cholesterol, AST, ALT, bilirubin, catalase and glutathione in envenomated mice which significantly reduced (p<0.05) compared to all the controls after 14 days of treatment with the extract. Conclusion: The results suggests that 80 mg/ kg of the plant extract is more effective than the standard drug, therefore M. pruriens leaves has a greater anti-venom potential for curing snake bite, than antivenin.

Indian common krait envenomation presenting as fulminant myocarditis and coma: a case report.

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.

Comparación entre dos métodos de producción para la elaboración de antivenenos ofídicos / Snake antivenin: Comparison between two production methods

Las mordeduras producidas por serpientes venenosas son un serio problema médico en varias regiones del mundo y sobre las cuales los sistemas de salud actúan en diferentes grados en lo referente a tratamiento y prevención. Sin embargo, el tratamiento de las mordeduras de serpientes venenosas en animales domésticos puede resultar difícil por diversos motivos, siendo uno de estos la baja oferta o ausencia de antivenenos para uso veterinario. Las presiones comerciales en la industria farmacéutica han llevado a una reducción en la producción de antivenenos en varias partes del mundo, su disponibilidad es, a veces, bastante limitada y en algunos casos, son imposibles de conseguir. En este trabajo, inmunizamos caballos con veneno de serpientes Sudamericanas para obtener el plasma hiperinmune que fue procesado para obtener IgG entera o fragmentos F(ab´)2 usando dos métodos convencionales (fraccionamiento por ácido caprílico o doble precipitación salina y digestión con pepsina). Los antivenenos así obtenidos fueron probados en sus características bioquímicas e inmunoquímicas, así como en su potencia neutralizante. El SDS-PAGE de los antivenenos mostró bandas en el orden de los 150 y 100 kDa en los antivenenos conteniendo IgG entera o fragmentos F(ab´)2, respectivamente. La presencia de albúmina o contaminantes de alto o bajo peso molecular no fue detectada en ninguna de las preparaciones. No se observaron diferencias importantes en la potencia neutralizante de los antivenenos, aunque el costo de producción fue mucho más bajo en la obtención de IgG completa. A partir de esto, se sugiere que los bajos costos de producción en la obtención de antivenenos de IgG entera para uso veterinario, hacen a esta tecnología adecuada y rentable cuando la producción de F(ab´)2 no es posible.

Bites by venomous snakes are a serious medical problem in several regions of the world, on which the different health systems act with different modalities. Nevertheless, the treatment of venomous snakebites in domestic animals can turn difficult due several problems among which, the conspicuous, is the low availability or lack of antivenoms for veterinary use. As commercial pressures on the pharmaceutical industry have led to a reduction in the production of antivenins in several parts of the world, their availability is sometimes rather limited and sometimes these products are impossible to obtain. In this work, we immunized horses with venom of South American vipers to obtain hyperimmune plasma. The plasma was processed to separate whole IgG of F(ab´)2 fragments using two conventional methods (caprylic acid fractionation or double saline precipitation and pepsin digestion). The obtained antivenins were tested for their biochemical and immunochemical characteristics and neutralizing potency. The SDS-PAGE of the antivenins showed, in the processed antivenin, bands in the order of 150 and 100 kDa in the whole IgG or F(ab´)2 fragments, respectively. The presence of albumin or contaminants of high or low molecular weight was not detected in any of the preparations. No important differences were observed in the neutralizing potency of the antivenins, although production cost was very low with the method used to obtain pure IgG. The low production cost makes the production of antivenins for veterinary use profitable when the production of F(ab´)2 fragments is not possible.

Emergencia hipertensiva en emponzoñamiento escorpiónico pediátrico: reporte de un caso / Hipertensive emergency in pediatric scorpion envenomation: case report

Se reporta el caso clínico de una niña de 2 años, quien posterior a picadura por escorpión en el brazo izquierdo, presentó náuseas, vómitos, sialorrea e hipertensión arterial, a pesar de la administración precoz de suero antiescorpiónico y captopril. Al día siguiente, debido a la emergencia hipertensiva, desarrolló varias crisis convulsivas tónicas generalizadas, refractarias a diazepam y controladas con difenilhidantoína en infusión por 24 horas; la emergencia hipertensiva se prolongó por 10 días y se trató con captopril, nifedipina y carvedilol por vía oral. Este cuadro clínico se acompañó con miocarditis, pancreatitis y una reacción adversa medicamentosa a la antivenina escorpiónica. Otros fármacos administrados fueron corticoesteroides, midazolam y fentanilo. La evolución fue satisfactoria y la niña fue egresada en buenas condiciones generales dos semanas después del ingreso. Este caso se muestra con características infrecuentes como la concomitancia de los patrones miocárdico y cardiovascular, la severidad del patrón vascular, la duración de la emergencia hipertensiva, la falta de efectividad de captopril y del suero antiescorpiónico y la reacción adversa a la antivenina.

We report the clinical case of a 2 year old girl, who developed nausea, vomiting, increased salivation and arterial hypertension, after ascorpion sting in her left arm, despite the early administration of scorpion antivenom and captopril. Next day, due to a hypertensive emergency, the patient developed generalized tonic seizures, refractory to diazepam, which were controlled with an infusion of dyphenilhydantoine for 24 hours. The hypertensive emergency extended for 10 days and was treated with oral captopril, nifedipine and carvedilol. This clinical picture was accompanied with myocarditis, pancreatitis and an adverse drug reaction to the anti venom. Other drugs administered were corticosteroids, midazolam and fentanyl. The Outcome was satisfactory and the girl was discharged in good general conditions, two weeks after admission. This case appears with uncommon features, such as the occurrence of myocardic and cardiovascular patterns, severity of vascular pattern, the duration of the hypertensive emergency, ineffectiveness of captopril and the scorpion antivenom, and the adverse reaction to antivenin.

Hematological Features of Coagulopathy and the Efficacy of Antivenin Therapy for a Korean Snakebite

PURPOSE: Snake venom induced coagulopathy is a major cause of both morbidity and mortality among affected patients. The effects of venomous factors to coagulation cascade and fibrinolysis were verified by analyzing the hematological data and clinical features of envenomed patients, and the efficacy of blood products transfusion and antivenin against a Korean snakebite clarified. METHODS: A retrospective study was conducted on 57 patients, admitted to the Department of Surgery of Chuncheon Sacred Hospital, between July 2002 and October 2005. According to the guidelines for assessing the severity of North American envenomination, the patients were divided into three groups according to severity, and the clinical course, DIC profile and usages of blood products and antivenin then analyzed. RESULTS: Of the 15 patients in the severe group (26.3%), 9 (60.0%) developed severe coagulation abnormalities, similar to DIC. No substantial bleeding or thrombic event manifested. All the patients with initial hypofibrinogenemia (33.3%) and unmeasured PT/aPTT during the 2nd to 4th hospital days (46.7%) progressed to severe coagulopathy. On average, these patients received transfusions of 18.4 +/- 6.1 pints of FFP and 14.4 +/- 14.9 pints of platelet product. The average amounts of antivenin applied were 1.2 +/- 0.4, 1.7 +/- 0.5 and 2.8 +/- 0.8 vials for the Minimal, Moderate and Severe groups, respectively. There was no death due to a Korean snakebite during this period. CONCLUSION: Korean snake venom is assumed to be a complex mixture of anticoagulant, platelet active and fibrinolytic venom. The discrepancy between abnormal coagulopathy and the clinical course explains venom induced DIC-like syndrome. Hypofibrinogenemia is the most reasonable predictor of DIC-like syndrome. Abrupt prolongation of PT/aPTT during the 2nd to 4th hospital days must weigh against thrombocytopenia. An early antivenin injection, along with the proper use of blood products, could improve the clinical course of envenomed patients.

Clinical Review of Venomous Snake Bite

PURPOSE: The aim of this study was to understand venomous snake bites and to predict the prognosis in the clinical course. METHODS: From April 1995 to October 1999, the case histories of 97 patients with venomous snake bites were reviewed retrospectively. RESULTS: The ages of the patients varied from 17 to 76 (mean age was 49.2 years), and the peak age was in the fourth decade. The sex ratio of males to females was 1.9:1. The accidents occurred mainly in summer (77.3%). According to the grade of envenomation, grade I and II were most common (77.3%). The duration of hospitalization was proportional to the grade of envenomation. The snake bites most commonly occurred in fields (56.7%). The finger was the most common site of the bite (51.5%). 96.9% of the patients arrived at the hospital within 4 hours. 97.9% of the patients were treated with antivenin. The most common local symptoms and signs were edema and pain. The most common general symptoms and signs were blurred vision, dizziness, and hematuria. The most common complication was celluitis. Severe complications such as UGI bleeding and DIC occurred in grade II and III. CONCLUSION: The most important factor for determining the prognosis of venomous snake bites is the grade of envenomation. In grade III or IV envenomation, antivenin should be included as part of intensive systemic treatment.