Problems of isolated private hospitals in a rural setting.

In the era of the Consumer Protection Act, doctors running small private hospitals in rural settings face unique ethical challenges, especially in acute medical emergencies. I would like to share a few such cases

Profile of snakebite envenoming in rural Maharashtra, India.

One hundred and eighty two cases of snakebite were admitted during twelve months at five hospitals situated in five different districts of rural Maharashtra. Out of these 55 (30.2%), 38 (20.8%), 48 (26.3%), 41 (22.5%) cases were bitten by Echis carinatus (Eh), Russell's viper (Rv), krait (Kr) and Cobra (Cr) respectively. Clinical confirmation of snakebite with envenoming was by identification of the dead snake brought by victims and by clinical signs and symptoms such as absent or minimum local signs, pain in abdomen preceding to neuroparalysis in the victim slept on floor bed, suggestive of krait bite. Rapid development swelling at the site of fangs marks with ecchymosis with rapid development of neuro-paralysis, respiratory depression suggestive of cobra bite. Severe local edema with fangs marks, active bleeding from fangs marks with rapid development of systemic bleeding with positive 20minute whole blood clotting test (20WBCT) suggestive of Russells's viper bite. Slow development mild local oedema with fangs marks, delayed development of local ecchymosis and systemic bleeding (20WBCT) in a case of Eh bite. Irrespective of similar clinical effects of particular type of snake, the total dose of anti-snake venom (ASV) administered is differs. In these five centers physicians are practicing and treating the snake bite cases for more than five year and know how to suspect and diagnose clinically the envenoming by poisonous snake. Early detection of clinical signs and symptoms and rapid administration of adequate initial dose of ASV on arrival, endotracheal intubation and timely intervention with either manual ventilation by amboo bag or mechanical ventilation in nuroparalysis and early detection of renal failure and its rapid treatment helped to reduce the morbidity and mortality in a rural setting.

Utility of scorpion antivenin vs prazosin in the management of severe Mesobuthus tamulus (Indian red scorpion) envenoming at rural setting.

BACKGROUND : Scorpion antivenom (SAV) is specific antidote to scorpion venom..SAV did not prevent the cardiovascular morbidity and mortality (autonomic storm), hence its utility in the management for severe scorpion envenomingmay be limited. Since 1983 the advent of prazosin revolutionized the management of severe scorpion sting. Since 2002 SAV against Indian red scorpion (IRS) for the treatment of scorpion sting cases is available at primary health centers. We compared the effects of SAV Vs Prazosin (PRA) in the management of severe scorpion stung cases at rural setting in a non-randomised open label manner. METHODS : From January 2002 to December 2004, 53 patients accidentally stung by scorpion were admitted in hospital at Mahad. Of these 25 patients received intravenous SAV at primary health centers and were referred to Mahad for further management. 28 patients directly reported to Mahad were treated with oral prazosin (PRA). Time interval between sting and hospitalization, the total dose of SAV and PRA administered was noted. Clinical manifestations were noted in a standard protocol. Details of SAV patients were noted from referred letters or in case of a doubt, details were obtained by direct communication with the medical officer who first saw and examined the case. All 53 cases were evaluated clinically for improvement, deterioration or fatal outcome. RESULTS : SAV Vs PRA ( 25 Vs 28) cases reported to hospital within 11/2 -3 (1.4) Vs 1/2-4 (1.3) hours after stung. On arrival 21 (84%) Vs 26 (92%) had hypertension, 2 (8%) Vs 1 (3.5%) had hypotension, 2 (8%)Vs 1 (3.5%) had normal blood pressure. Heart rate 58-102 (82) Vs 48-120 (80.2) respectively. 9 cases received 20 ml, 1 case 30 ml and remaining 15 cases were given 10 ML of SAV on arrival to PHC, while 28 cases received oral prazosin. 20 (80%) Vs 2 (7.5%) had acute pulmonary edema, 5 (20%) Vs 8 (30%) had persistent raised blood pressure. 4 (16%) Vs 0% died. Recovery time was 11-4 (2.26) Vs 1-2 (1.25) days respectively. CONCLUSION : We found that SAV is no more effective to alleviate or reverse the cardiovascular effects of scorpion venom actions in severe case as against prazosin prevents and cures the cardiovascular manifestations in a severe scorpion envenomation. Therefore role of SAV in severe scorpoin venomation needs to be relooked and prazosin needs to be a standard of care in such cases to overcome the autonomic storm.

Novel role of antiplatelet agents (aspirin plus clopidogrel) in an incoagulable blood of a victim of russell's viper snakebite

Snake antivenom is a specific antidote to the venom action, neutralizing the circulating venom. However, it fails to neutralize the venom fixed to target organs such as platelets, renal tubules, etc. Russell's viper venom initiates rapid coagulation in a victim by activating blood platelets, factors V, X, and anticoagulant cofactors. Activation of thrombin, resulting in formation of micro-thrombi, fibrinolysis, and a vicious cascade, sets in. Inhibition of activated platelets by aspirin (cyclooxygenase inhibitor) and clopidogrel (ADP receptor inhibitor) helps to break this vicious circle induced by Russell's venom and may initiate the natural physiological clotting mechanism. They can be utilized as an adjuvant treatment.(AU)

Prazosin therapy and scorpion envenomation.

BACKGROUND: 25-30% fatality due to acute pulmonary oedema in victims of Indian red scorpion (Mesobuthus tamulus) sting have been reported from Western Maharashtra, India. The advent of prazosin in recent years has revolutionized the management of severe scorpion sting cases. Majority of cases developed acute pulmonary oedema in 4-8 hours in a hospital setting irrespective of control of their arterial blood pressure with six hourly oral prazosin regimen, these cases recovered with extra dose of prazosin. We developed a standardised protocol for acute phase of treatment of these cases with the aim of preventing the development of pulmonary oedema. METHOD: We compared scorpion sting cases managed by non-protocol conventional (NPC) treatment and those by standardised protocol (SP) that included three hourly dose of oral prazosin. SP group included severe scorpion sting cases admitted to general hospital at Mahad in the year 1998 (Jan.-Dec.). While those admitted in the year 1997 (Jan.-Dec.) before the SP was implicated were the NPC group. FINDING: Characteristics on arrival of severe scorpion sting patients SP (n-17) and NPC (n-15) groups were similar that more case 6 (35%) from SP group had several hypertension on arrival. On arrival two cases from SP group and one from NPC group had pulmonary oedema. 16 (94.11%) patients from SP group recovered uneventfully, compared with 8 (53.33%) in NPC group (p-0.05). 0% Vs 5 (38.46%) developed acute pulmonary oedema (p < 0.0001) from SP and NPC group respectively, three (one had on arrival two patients during hospitalization) from NPC group had massive pulmonary oedema recovered with i.v. nitroprusside drip (SNP). While from SP group one had massive pulmonary oedema on arrival recovered with i.v. SNP, other one had pulmonary oedema recovered with oral prazosin. Cool extremities (vasoconstriction) persisted 11.5 (5-20) VS 18 (12-26) hours in SP and NPC group respectively. INTERPRETATION: Compared with NPC management; development of acute pulmonary oedema prevented by standardised protocol regimen at rural setting.

Premonitory diagnostic signs and symptoms (scores) of thyroid hypofunction: a clinical observation.

We analyzed signs and symptoms of 79 cases of clinically suspected thyroid hypofunctions. There is positive correlation between clinical manifestations and thyroid stimulating hormone (TSH). In 33 (41.7%) TSH was ranged between 20-75 microunit (mu u) suggestive of hypothyroidism, 36 (45.5) were euthyroid. Clinical signs and symptoms are scored according to their frequency correlated with serum TSH are 4,3,2,1, and 0.5.

Indian red scorpion envenoming.

The clinical course and treatment outcome of scorpion envenoming in 293 children was studied in a hospital at Mahad in Raigad district of Maharastra. 111 (38%) children who reported 1-10 hours (mean 3.5 hours) after sting had hypertension, 87 (29.6%) with tachycardia reported within 1-24 hours (mean 6.7 hours) of being envenomed and 72 (24.5%) children developed acute pulmonary edema after 6-24 hours (mean 8 hours) of sting. Six victims were brought dead, while 17 (6%) died later owing to multiorgan failure with loss of consciousness and convulsions (who reported after 24 hours of sting). Early administration of prazosin (125-250 ug orally) improved the clinical symptoms. Morbidity and mortality due to scorpion envenoming depends upon time lapse between sting and administration of post synaptic alpha-1 blocker, prazosin hydrochloride.

Scorpion sting.

Acute life threatening systemic involvement (cardiovascular and central nervous system) occur due to scorpion poisoning, often reported from rural part of world comprises the majority of developing countries. The most serious symptoms are hypertension, impaired left ventricular systolic function, hypotension and pulmonary oedema. Scorpion antivenin neutralizes circulatory and tissue venin. It has no action on effective effectors (Receptors). Prazosin possesses pharmacological properties that render it most suitable in antagonizing the toxicological effects of scorpion venom.