Fatal intracranial bleedings in a viper bite: A case report / 中华创伤杂志(英文版)

Viper bite envenomation represents a significant occupational hazard among agricultural workers in India. The viper bite envenomation is usually suspected when a patient presents with predominant local symptoms at the bitten site, including pain, swelling, and necrosis. Further, systemic findings such as diffuse intravascular coagulation, hypotension, and shock may alert physicians of viper bite envenomation rather than a neurotoxic snake bite. However, cerebral complications are rare in viper bites but may potentially fatal. Central nervous system involvement in a viper bite is either due to neurotoxins or hemorrhagins present in the venom, which may induce cerebral thrombosis, ischemia, infarction, and hemorrhage. Here we present a case of a previously healthy adult male who succumbed to extensive subarachnoid, intracerebral, and intraventricular hemorrhages involving bilateral cerebral hemispheres following viper snake bite envenomation. This report highlights the importance of anticipating cerebral complications in viper bite envenomation, a rare occurrence. It also emphasizes the need for early antisnake venom administration to prevent and control systemic envenomation and its complications.

Anti-Snake Venom Properties of Medicinal Plants: A Comprehensive Systematic Review of Literature

Abstract Snakebite is one of the major health issues posing considerable morbidity and mortality. According to an estimate of World Health Organization (WHO) (World health organization, 2021) approximately 5 million people are bitten by several species of snakes resulting in up to 2.5 million envenomation cases annually. The mainstay of treatment for envenomation is intravenous administration of anti-snake venom. Although antivenom neutralizes the systemic effects but it does not relieve the symptoms such as venom-induced hemorrhage, necrosis and nephrotoxicity. Moreover, the use of antivenoms is associated with hypersensitivity reactions including urticaria, anaphylaxis, or serum sickness due to their heterologous property. Furthermore, stringent storage conditions and narrow specificity of antivenoms limit their use in both developed as well as developing countries. In this context, researchers have been searching for natural products and plant extracts to explore their antivenom activity along with anti-myotoxic, anti-hemorrhagic and anti-inflammatory properties. Plant remedies may prove to be an effective alternate for antivenom sera with less adverse events and better tolerability. To the best of our knowledge, this is the first comprehensive review of medicinal plants possessing anti-snake venom activities against certain species of snakes. The current review highlights the investigated plants with their phytochemical analysis to integrate the available information for future research and development of antivenom sera.

A comparative study in the outcome between the two fixed doses of polyvalent anti snake venom, 10 vials versus 20 vials, with mechanical ventilation in children with severe neurotoxic snake envenomation

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.

Epidemiological and clinical profile of paediatric snake bite patients at a tertiary care centre of Himachal Pradesh, India

Background: Pediatric snake bite cases are frequently encountered at health care centers of Himachal Pradesh. It is a medical emergency which require early hospitalisation and immediate medical intervention. This study determines the epidemiological and envenomation details along with clinical profile and management of pediatric snake bite patients in Himachal Pradesh, India.Methods: This prospective clinico-epidemiologic study included 30 paediatric snake bite cases reported at Department of Paediatrics, IGMC, Shimla. Demography, envenomation details, first aid and treatment, antivenom administration and outcome were recorded for all patients.Results: Of the total 30 cases, 56.6% were males and 43.3% were females. All patients were resident of rural areas and most of them belonged to middle socioeconomic status. Most (56.7%) snake bites occurred between 6pm to 12am and peak time was during rainy season. More cases of hemotoxic envenomation were observed as compared to neuroparalytic envenomation. Most common hematologic abnormalities were hematuria (4.8%) and epistaxis (4.8%). Respiratory paralysis, ptosis and opthalmoplegia were the most common presentation in patients with neuroparalytic envenomation. Clinical profile of patients showed thrombocytopenia (26.7%), prolonged PT/INR (76.6%) and 36.7% had prolonged activated partial thromboplastin time. All symptomatic patients were given ASV as primary treatment out of which 79.2% patients required more than 10 vials of ASV. Most common complication observed in neuroparalytic envenomation was respiratory failure (33.3%) and in hemotoxic envenomation was coagulation failure (66.7%). Only 3.3% case fatality was observed in this study.Conclusions: Snake bite in children is a medical emergency in hilly state of Himachal Pradesh where people still follow traditional first aid methods and treatment protocol. A widespread awareness programme is needed to propagate the newly advised first aid methods to prevent mortality by early hospitalization and administration of ASV.

Snake bite, a neglected menace: a prospective observational study in a tertiary care pediatric intensive care unit

Background: Snake bite is a neglected and underestimated public health problem in tropical and subtropical region. Snake envenomation is a well-known cause of morbidity and mortality in India. In 2009, WHO declared snake bite a neglected disease. Ophitoxaemia is an exotic term characterising the clinical spectrum of snake bite. Objective of this study was to know the outcome in paediatric snake bite cases in a tertiary care PICU (Paediatric Intensive Care Unit) with special reference to envenomation time and also to evaluate and analyse few atypical presentations of snake envenomation by proper history taking, physical examination and help start early intervention to prevent morbidity and mortality.Methods: A prospective observational study was done in Paediatric Intensive care unit of the hospital from June 2017 to June 2019.Results: Around 56.8% of 109 cases were non-poisonous snake-bites. Out of 47 cases admitted to PICU, 68.08% developed cellulitis at the site of bite with Staphylococcus aureus being the commonest organism isolated (56.25%). Anaerobes (bacteroides and clostridium) were also isolated in few cases. Edema at site of bite (hematotoxic) and ptosis(neurotoxic) were most common initial presentation. 36.17% of patients received ASV (Anti- Snake Venom) and first aid within 6 hours of snake bite. The morbidity and mortality were significantly less (p<0.05) as compared to those who didn't receive ASV. 12.76% of cases with normal CRT (Clot Retraction Time) presented with features of coagulopathy. DIC (58.33% of hematotoxic bites) and respiratory paralysis 68 (75% of neurotoxic bites) were the commonest complications. Renal replacement therapy was required in 6.38%, transfusion in 10.63% cases and case-fatality-rate was 12.7%. There were a few atypical presentations of snake bite mimicking Gullain-Barre syndrome, acute onset encephalitis with absent brainstem and pupillary reflexes, intracerebral hemorrhage and cortical blindness.Conclusions: Most snake bites are non-poisonous. Early first aid and ASV administration has better outcome. Fibrinogen levels are more reliable than CRT to diagnose coagulopathy. Acute presentations i.e, altered sensorium, paralysis, blindness and stroke like features should always be evaluated for snake envenomation in suspected cases to prevent morbidity and mortality.

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.

Clinico-Epidemiological Profile and Outcome of Snake Bite Cases Admitted in a Tertiary Care Centre in South India

Snake bite is an important life-threatening emergency but often neglected public health problem in India. India being a subtropical country, has been a land of poisonous snakes, especially in Southern India poisonous snakes like Russell’s Viper, Cobra, Krait and Saw Scaled Viper are commonly encountered. In India around 50,000 people are dying every year from snake bites. In spite of these, the true scale of mortality and morbidity from snakebite remains uncertain. We wanted to study the pattern of envenomation and dry bite among the snake bite cases admitted in Government Vellore Medical College Hospital for the period Jan 2018- Jan 2019, describe the clinicoepidemiological profile and outcome of snake bite cases. We also wanted to evaluate the predictive factors of mortality among snakebite cases admitted in a tertiary care centre in Vellore, South India.METHODSA retrospective descriptive analysis of data extracted from medical records of 522 snakebite cases admitted in the Medical wards and IMCU at Government Vellore Medical College and Hospital, Vellore, Tamil Nadu, during the period extending from January 2018 to January 2019 was done, to describe Clinico –epidemiological profile and management of snake bite cases. We described age/gender distribution, seasonal trends of snake bite cases. We computed proportion of envenomation, dry bite and case fatality rate. Among envenomation we analysed the trends in antisnake venom (ASV) usage and its clinical outcome. Statistical analysis was done using Epi Info – Version 7.2 software.RESULTSOf the total 522 snake bite cases admitted in the hospital during the period from Jan 2018 to Jan. 2019, it was found that the median age of the snake bite victim was 40 years (range 13-76). Snakebite cases were higher among male (56%), agriculture worker (47%), rural population (92%) and during monsoon July-October (65%). Sixty percent of the bites occurred in ankle and foot. Species of snake was identified in 23 (4%) cases. The proportion of dry bite and envenomation were 46% and 54% respectively. Of the envenomation cases 20% were haemotoxic, 24% were neurotoxic and 10% were local envenomation. The median duration of hospital stay among envenomation cases was 4 (range 1-20 ) days and interval between bite and ASV administration was 4 (range 1-48) hours. Sixty cases (13%) were allergic to ASV. Case fatality was 2.5 %( 13/522).CONCLUSIONSEffective management of snakebites would include early admission to a hospital, appropriate ASV administration and early identification of the warning signs. Delay in hospitalization is associated with poor prognosis and increased mortality rate due to consumptive coagulopathy, renal failure and respiratory failure.

Clinical Profile of Snake Envenomation with Complications and Outcome in a Tertiary Health Care Centre, Kalburgi.

Bites by snakes represent an important health problem in the tropical world including India. The true incidence of snakebites is difficult to assess and often is under reported. Though the exact number of snake bites is unknown, an estimated 5.4 million people are bitten each year with up to 2.7 million envenoming. Around 81,000 to 1,38,000 people die each year because of snake bites, and around three times as many amputations and other permanent disabilities are caused by snakebites annually. We wanted to determine frequency of various modes of presentation, complications and management of snakebite.METHODSAll patients presenting to emergency department of Basaveshwara Teaching and General Hospital with history of snakebite and features of envenomation were included in the study. All these patients were given Anti-Snake Venom. Symptomatic treatment of complications was done. Semi-structured questionnaire was filled during hospital stay to analyse various characteristics of snakebite and people’s attitude towards this problem.RESULTS75 cases of snakebite admitted to Basaveshwara Teaching & General Hospital, Gulbarga between January 2018 to November 2019 were studied. Males [50 (62.5%)] were affected more than females [25 (31.5%)] in the ratio of 2:1. Most common age group is 20-40 years [45 (60%)]. Snakebite is a common health hazard in rural areas [55 (73.34%)]. Agricultural labourers (68.6%) are the major sufferers with majority of bites occurring outdoor 60 (80%). 71 (94.66%) bites occurred over limbs, out of which 38 (50.66%) were in lower limbs. Most bites occur between 12 Noon to 12 Midnight 60 patients (81.2%). Out of 75 patients, 60 (80%) were poisonous snakebites, 20 (20%) were non-poisonous snakebites. Among 60 (80%) poisonous bites, 32 (53.34%) had neurotoxic manifestations and 28 (46.66%) had hemotoxic manifestations.CONCLUSIONSSnakebite is common in rural setup, in agricultural labourers. Most common victims are males in the age group between 20-40 years. Poisonous bites were more common than non-poisonous snake bites in this study. In neurotoxic envenomation ptosis was the commonest and earliest symptom while in hemotoxic envenomation, most common symptoms were bleeding from bite site and hematuria. The commonest complications were acute renal failure and respiratory paralysis. Shock, infection and gangrene were also noted in some patients. Maximum mortality was observed in patients who were admitted after 24 hours. Early hospitalization and timely ASV administration were the corner stones in the treatment of snakebite.

Clinical profile and prognostic indicators of neurotoxic snake bite in rural India

Background: In rural India, snakebite is an occupational and environmental hazard. WHO listed snakebite as one of the neglected tropical diseases and in rural India it is underreported because of popular traditional methods of treatments and lack of healthcare facilities. This study is an attempt to look into the epidemiological, clinical and prognostic indicators of neurotoxic snake bite in rural India.Methods: This study is a prospective, descriptive study of 25 neurotoxic snake bites admitted in our hospital from January to September 2019. Clinical factors like age, sex, clinical features, management and the outcome of patients are studied.Results: Young males were common victims of snakebite in evening hours during monsoon season. All patients received traditional methods of treatment, and despite this 64% of our patients reported to the hospital within 6 hours after the bite. Overall, the mortality rate in this study was 12%. Poor outcome was also noted in cases who were having respiratory failure and needed artificial ventilation (30%). Mortality was 22.2% in patients where bite to admission time was greater than 6 hours as compared to 6.25% in patients where it was less than 6 hours.Conclusions: Author concluded that a neurotoxic snake bite is a life-threatening emergency. In preventive measures, outdoor activities in dim lights during monsoon season should be restricted. Traditional treatments are still popular and trusted methods of treatment in rural India and these healers can be educated to recognize and refer immediately all neurotoxic bites to nearby medical facilities.

Incidence & management practices of snakebite: A retrospective study at Sub-District Hospital, Dahanu, Maharashtra, India

This study was undertaken to know the incidence and management practices of snakebite envenomation at the First Referral Unit - Sub-District Hospital, Dahanu, Maharashtra, India. Retrospective analysis of snakebite case records (n=145) was carried out for one-year period (January to December 2014). The annual incidence of snakebite was 36 per 100,000 population with case fatality rate of 4.5 per cent. Venomous snakebites were 76 per cent and non-venomous snakebites were 24 per cent. Overall, snakebites were more common in males (52.4%) than females (47.6%). Majority of the snakebites (66%) were in the age group of 18-45 yr. Seasonal variation was observed with highest snakebites in monsoon (58%). Lower extremities were the most common site of bites (63%). Neurotoxic and vasculotoxic envenomation were reported in 19 and 27 per cent snakebite cases, respectively. Anti-snake venom (ASV) was administered at an average dose of 7.5±0.63 vials (range 2-40, median 6). There was no uniform protocol followed for ASV administration as per the National Snakebite Management Protocol of Government of India (2009).

A comparative study between retrospective and prospective assessment of rationality and effectiveness of snake bite management in a tertiary care teaching hospital

Background: Snake bite envenomation remains one of the commonest causes of mortality and morbidity in rural West Bengal. Objective of present study was to compare the rationality, effectiveness and adherence to standard treatment guidelines of Government of West Bengal of snake bite management over the high-risk periods of two years.Methods: This was a comparative study of snake bite management between 2016 and 2018 (over April to September) during peak risk season in a tertiary care teaching hospital in rural Bengal. The data was collected retrospectively from the treatment records in 2016 and from patients admitted with history of snake bite in the Medicine ward, ICU and ITU in 2018.Results: Records from 2016 yielded 177 snake bite patients (144 venomous and 82.5% neurotoxic envenomation) and in 2018, 190 cases (114 venomous and 71.1% neurotoxic). There was delay in presentation (>2 hours) in almost 80% cases in both years and 2.56% had anaphylactic reaction following ASV administration in 2018 against 3.15% in 2016. Ventilator support was necessary for 12% patients in 2018. Overall percentage of mortality reduced from 6.70% to 3.2% in 2018. Adherence to snake bite management STG was seen in 81.8% of the retrospective records vis a vis 80% cases in prospective analysis (p = 0.21).Conclusions: The survival rate in venomous snake bite is found to be high in this institution over last two seasons of snake bite. The practice of snake bite management is found to be adherent with standard protocol in most cases.

A prospective analysis of adherence to standard treatment guidelines in management of snakebite in a tertiary care teaching hospital of rural Bengal, India

Background: Rural Bengal has one of the highest snakebite prevalence in India. This prospective observational study was initiated with the motive to analyse the effects and adherence to implementation of the new national snakebite protocol 2016.Methods: Data were collected from the patients admitted with snake bite on a pre-designed and pre tested case study form and analysed with the help of descriptive statistics.Results: A total of 75 patients arrived in the hospital during the study period out which 53 were male (most in the age group of 31-40 years) and majority of them were farmers (26.6%) or housewives (25%). Maximum of them were bitten in the lower limbs (54.6%) and peak time of bite was between 6 am-12 pm (40%). Most of them reached the hospital late, i.e., beyond 2 hours (70.6%). It was found that there were 26 neurotoxic, 16 hemotoxic and 1 neuro-hemotoxic cases and the rest were non-venomous cases. Fifty-one of them received ASV and 4 died. There was 80% adherence in the indication of ASV administration, 73.3% in the ASV dose, 32% in the monitoring after ASV administration, 94.66% in the monitoring 20 WBCT, 100% in adherence to haemodialysis as indicated.Conclusions: The results showed good adherence in all the parameters. Protocol guided treatment has also resulted in rational use of ASV. So, from this study, it was concluded that protocol guided treatment is effective in snakebite management, but its continuous revision and amendments should be considered in future.

Outcome of poisonous snake bites treated with high dose anti snake venom serum versus low dose –A critical review

Background: In India, about 1 million people are bitten by snakes more in the rural area and they get admitted to hospitals. About 50,000, people die of snake bites every year in India. The patients admitted with poisonous snake bites were treated with polyvalent anti snake venom serum. Aim: To determine the significant difference and outcome between High Dose and Low dose Polyvalent Anti Snake Venom Serum (PVASVS), with regards to age gender and severity of coagulation abnormalities. The cost of ASV has an economic impact and if low dose ASV saves the scarce resource. Materials and Methods: 45 patients bitten by snake admitted and treated which included both males and females were taken up for this study based on Poisson model of sampling. All the patients had cellulitis, renal failure and varying degree of coagulation abnormalities. They were classified into LDG and HDG depending on the number of PVASVS they received which was ≤25 vials or >25 vials respectively. This was decided based on the treatment of ASV analyzed using chi-square contingency statistically for its significance. Results: The age and clotting time as such do not have association to distinguish HDG or LDG. It was revealed that Gender has an effect that female HDG are 26.3% (5 out of 19) as compared to male 73.7% (14 out of 19). In each group, 2 patients died out of 18, LDG (11%) 27 in HDG (7.4%) 62.9% of patients in LDG and 38.8% in HDG required hospital stay more than 10 days. Conclusions: The female gender falls in low dose conserving ASV. The LD ASV demands higher duration of stay (more than 10 days) in the hospital. The age, coagulation abnormality did not establish the significant results in the LDG and HDG.

Allergic reactions to antivenom in a patient bitten twice by the same snake within a month: A rare case report and literature review / 中华创伤杂志(英文版)

Antivenom is the most effective method currently available for the treatment of poisonous snake bite. Allergic reactions to antivenom have been reported in the past. Here we shared a case of allergic reactions to antivenom in an old male patient who was bitten twice by the same snake (probably same one) at the same biting site within a month whereas the patient did not show any allergic disorder in the first bitten. Envenomations twice in a short period time by the same kind of snake are very rare. Physician should be alert to the occurrence of allergic reactions in treating this type of patients with antivenom. The skin allergy test has a certain value in predicting the allergic response before the second use of antivenom. Desensitization may reduce the incidence of allergic reactions, but this is insufficient. Rather than non-IgE-mediated immediate hypersensitivity, patients receiving the second treatment of antivenom may develop IgE-mediated immediate hypersensitivity. Once happened, the antivenom treatment should be stopped promptly and anti-allergy treatment should be given immediately.

A Clinical Profile of Neurotoxic Snakebite in Pediatric Population of Jammu Region.

Snake bite is a common neglected emergency in children. Due to lack of adequate epidemiological data its incidence is underestimated. This study analyses the clinical profile of neurotoxic snake bites in children. Retrospective analysis of 37 children with features of neurotoxicity with or without history of snake bite was done. 37 cases of neurotoxic envenomation had a median age of 8 years. 30 were males. Majority of bites occurred during night hours and in upper limbs. Among the 17 who were bitten during night 12 were sleeping on floor. The most common systemic presentation was ptosis (94.59%) followed by difficulty in breathing (78.37%), pain abdomen (64.86%) blurring of vision and diplopia (54.04%), decreasing level of consciousness (45.94%) and vomiting (29.72%). 13 patients (35.13%) with clinical features of neurotoxic envenoming but without any history of snake bite were brought with history of early morning sudden onset of abdominal pain. All patients were given Anti Snake Venom (ASV) with medial dose of 600 units. Twenty patients received ventilator support. Ten (27%) patients died all of whom received ASV after a delay of at least 5 hours.

An Unusual Presentation of Vasculotoxic Snake Bite.

In India, viper bites are more common than any other poisonous snake bites. In these patients, the cardinal features are local pain, swelling and mild coagulation abnormalities; but gangrenous changes involving bilateral upper and lower limbs are uncommon. We are reporting a case of a 62-year-old man bitten by a Russell viper on the right thumb. He experienced local pain, swelling and later developed disseminated intravascular coagulopathy, pre-renal azotemia, sepsis, acute respiratory distress syndrome (ARDS) and peripheral gangrenous changes involving bilateral upper and lower limbs. He succumbed to his ailment 5 months after the bite. There have been very few cases of gangrenous changes involving distal part of extremities associated with snake bite.

A study on the clinico-epidemiological profile and the outcome of snake bite cases in the tertiary care hospital.

Background: Snake bite is a common medical emergency and an occupational hazard in India. It is also a major public health issue in rural India where farming is a major source of employment. Very few studies describe epidemiology of snake bite from India. Hence, this study was planned to collect information on various aspects of snake bite in a tertiary care hospital. Methods: A prospective observational study of 167 patients of snake bite and unknown bite carried out from September 1, 2012 to August 31, 2013. Results: Among a total 167 cases, majority were males (54.49%), aged between 20 and 40 years (38.92%). Most of the cases were laborers (61.67%) and farmers (17.36%). Peak incidence was observed during monsoon (64.67%). Bite mark was seen in 46.70% cases, upper extremity being common site (52.09%). Most cases were of vasculotoxic bite (65.26%) and few were of neurotoxic bite (19.76%). Major complications were respiratory failure (4.79%) and acute renal failure (1.8%). Average bite to needle time was 365 min. Bleeding & clotting time was raised in 44.03% & 35.19% cases, respectively. Average dose of anti-snake venom (ASV) required was 17.1 vials. Allergic reactions to ASV observed in 8.38% cases. Mean duration of hospital stay was 4.3 days. Recovery rate was 94.01% with three cases referred to higher center. Mortality rate was 2.39%. Conclusions: Our study highlights various aspect of snake bite cases and tries to fi nd out ways to improve quality of life of patients, decrease mortality and morbidity and decrease economic burden on society.

Inhibitory effects of Swietenia macrophylla on myotoxic phospholipases A2

Activity-guided fractionation of an ethanol-soluble extract of the leaves of Swietenia macrophylla King, Meliaceae, led to several fractions. As a result, sample Sm13-16, 23 had the most promising activity against phospholipases A2 (PLA2), Asp49 and Lys49 types. This fraction inhibited PLA2 activity of the Asp49 PLA2, when aggregated substrate was used. On the other hand, this activity was weakly neutralized when monodispersed substrate was used. In addition, Sm13-16, 23 inhibited, in a dose dependent manner, the cytotoxicity, myotoxicity and edema induced by PLA2s, as well as the anticoagulant activity of Asp49 PLA2. Overall, this fraction exhibited a better inhibition of the toxic activities induced by the Lys49 PLA2 than those caused by the Asp49 PLA2. The spectral data of Sm13-16, 23 suggested the presence of aromatic compounds (UV λ max (nm) 655, 266, and 219; IR λ max KBr (cm-1): ~ 3600-3000 (OH), 2923.07 and 1438.90 (C-H), 1656.69 (C = O), 1618.63 and 1607.67 (C-O), 1285.47772.60). We suggest that phenolic compounds could interact and inhibit the toxins by several mechanisms. Further analysis of the compounds present in the active fraction could be a relevant contribution in the treatment of accidents caused by snake envenomation.

Prognostic indicators in patients with snakebite: Analysis of two-year data from a township hospital in central Myanmar.

Background: Rural people seek medical treatment for snakebite at peripheral health care facilities. Hence, identification of the characteristics, which can be used at peripheral levels of health care as reliable predictors of mortality, are required. Methods: Hospital records of 101 patients (70 males and 31 females) with age ranging from 3 to 80 years, admitted to Nahtogyi township hospital in central Myanmar during January 2005 to December 2006 were reviewed retrospectively. Binary logistic regression was used for estimating odds ratio (OR) and 95% Confidence Interval (CI) for various prognostic indicators of mortality. Results: Almost all snakebites were on extremities; more in legs (62%) than hands (37%). Most (52.5%) bites occurred in the morning (4 am to noon). Mean (SD) time for bite-to-hospital and bite-to-injection of anti-snake venom (ASV) was 134.6 (78.6) and 167 (187.8) minutes respectively. Eleven cases (10.9%) had died. Case fatality ratio (CFR) was significantly higher in 39 patients with un-clotted blood as compared to 62 patients with clotted blood (25.6% vs 1.6%, p <0.0005). Significantly higher CFR was observed in 49 patients who received ASV in >2 hours after the bite compared to 52 cases who received ASV within two hours (9.9% vs 0.9%, p <0.0001). Odds ratio of fatality were higher among those who had urine output of <400 ml in the first 24 hours (OR 26.4; 95% CI 2.4 to 288.3), un-clotted blood (OR 4.6; 95% CI 0.3 to 66.7), bite-to-injection time of >2 hours (OR 4; 95% CI 0.1 to 219.8) bite-to-hospital time of >2 hours (OR 3.1; 95%CI 0.1 to 136.3) and bites in the morning (OR 2; 95% CI 0.3 to 16.0). Conclusions: Clinical parameters could be used by healthcare providers to identify snakebite patients for referral, who may have fatal outcome.

'A life threatening scratch on little toe' - at most clinical suspicion the essential key in management of snake bite

Snake bites are one among the under reported clinical emergencies from tropical countries. There are variations in clinical presentation of snake bites and its toxic features differ with the species and type of bite. There are lots of controversies in the treatment guidelines which often makes it difficult to manage. We report the case of a severe hemotoxic snake bite who presented to the outpatient service of our hospital with a trivial foot injury. Even though snakebites are familiar clinical situations for an emergency physician from tropics, we report this case as most are under reported. We also intend to emphasize the excellent outcome of appropriately diagnosed and treated cases of snake bite.