A Study on the Clinical Profile and Complications of Snake Bite among Patients at a Tertiary Care Centre in Western Odisha

Abstract

Background: 

India is a country known to the West as a country of snake charmers and snakes. Generation after generation, some families in our country continue to play and live with snakes (snake charmers), but we fail to protect the community from snake bites. Protection from this environmental and occupational hazard requires at least some education of the public with regard to how to protect them from snake bites, as well as what to do after the bite has occurred.

Methods: 

The clinical profile of 88 patients who were admitted to the hospital with snake bites and gave informed consent were studied. Patients were treated with anti-snake venom (ASV) whenever required, the initial dose and total dose of ASV administered were also calculated.

Results: 

Most patients were male (54.5%). The majority of the cases (39.8%) were farmers, followed by housewives (15.9%), daily-wage laborers (13.6%), students (11.4%), and shopkeepers (4.5%). The most common clinical manifestation was an extension of edema beyond the site of bite (29.5%) followed by neurological features (26.1%), pain abdomen (20.5%), vomiting (14.8%), and regional lymphadenitis (12.5%). Out of the 88 cases, 11 cases died and the remaining 77 cases recovered. Mortality was significantly higher among patients with complications such as wound infection (P < 0.0010.000), sepsis (P = 0.000), compartment syndrome (P = 0.028), and haematuria (P = 0.004).

Conclusion: 

Snakebite is an occupational hazard, as more than half of the patients were farmers and labourers. The risk factors such as the time between bite and treatment, snake bite -related complications, and adequate doses of ASV determine the treatment outcome.

INTRODUCTION

Snakebite is predominantly a rural problem. It has important implications for the nutrition and economy of the countries where it commonly occurs since it is largely an occupational disease of food producers such as farmers, plantation workers, fishermen, and also among wild life park rangers, and military personnel. It is recommended that snake bite should be formally recognized by the international labor office as an important occupational disease in South-East-Asia Region.^[1]

Widely distributed species of major medical importance, such as Russels’ vipers show geographical intra species variations in their venom composition. The venomous snakes found in India belong to three families Elapidae, Viperidae, and hydrophinae (Sea Snakes). The most common Indian elapids are Naja naja (Indian Cobra) and Bungarus caeruleus (Indian Krait), Daboia russalii (Russells’ Viper), and Echiscarinatus (Saw scaled viper).^[2]

Snakebite is an acute life-threatening time limiting medical emergency. It is a preventable public health hazard often faced by the rural population in tropical and subtropical countries with heavy rainfall and humid climates. It is estimated that 2500 to 6000 cases of snake bite occur in Odisha (every year), and among them, 400 to 900 die (around 1000 snakebite deaths per annum in Odisha).^[3–6] The present study was undertaken in western Odisha with the following objectives:

1. To evaluate the clinical profile and complications of hospitalized patients with snake bite.
2. To study the morbidity and mortality in patients with snake bite envenomation.

SUBJECTS AND METHODS

The study was carried out in the Department of Medicine of a tertiary care hospital. Patients above the age of 14 years with a history of a snake bite attending the outpatient department and emergency during the period Nov 2016-Oct 2018 are included in this study. A total of 88 patients were studied according to the following inclusion and exclusion criteria (Ethics commitee approval obtained on 15-9-2016).

Study Design-Hospital based cross-sectional study

Inclusion Criteria-All cases of snake bite enrolled in the study after obtaining informed consent.

Exclusion Criteria- Patients not willing to participate in the study (not giving consent) and snake bite patients of <14 years of age

Data collection method

At first, the airway, breathing, and circulation of the patient were stabilized. Vital signs like cardiac rhythm and oxygen saturation were monitored. Informed consent was obtained from the patient for the study and data were collected in a pre-designed and pretested questionnaire. History taking, thorough physical examination, and identification of the offending snake if possible were done. Measurement and recording of the circumference of bitten extremity, local site examination performed. 2ML 20 min whole blood clot retraction test was performed, repeated as with the management. ASV is administered according to severity. Observation of amount of ASV needed in the individual case. Observation of each case for a possible complication like AKI, compartment syndrome, wound site infection, shock, sepsis, respiratory distress, neuroparalytic morbidity, bleeding diathesis.

Prior permission and ethical clearance for the study were obtained from the Research & Ethics Committee of the institution.

Data thus collected were entered and analyzed by using appropriate statistical measures in SPSS version 21.

RESULTS

Snake bite cases who were admitted to the hospital majority were from the Sambalpur district (38.6%) followed by Bolangir (8%), Sonepur (8%), and Nuapada (6.8%). The majority of the patients (39.8%) were farmers; they were followed by housewives (15.9%), laborers (13.6%), students (11.4%), and shopkeepers (4.5%). Most snake bites (72.7%) happened between 6 PM and 6 AM. The majority of bites (52.3%) were seen in the lower limbs followed by the upper limbs (28.4%) and the trunk (9.1%). In the present study, neurotoxic snake bite was 43.2%, followed by vasculotoxic (29.5%), and the rest 27.3% were non-poisonous and dry bites. Regarding the various manifestations of snake bite at the time of hospitalization, the most common was an extension of edema beyond the site of bite (29.5%) followed by neurological features (26.1%), pain abdomen (20.5%), vomiting (14.8%) and regional lymphadenitis (12.5%). A twenty-minute whole-blood clotting test was positive only in 34 (38.6%) patients. [Table 1] Increased TLC found among 23.9% cases and raised aPTT & PTINR found among 13.6% cases. Sixty-four cases received antisnake venom (ASV). As a starting dose, 65.9% of cases received 1 to 10 vials of ASV, and 6.8% received ≥10 vials. Regarding the total dose, 30.7% cases received 1-10 vials, 36.4% received 11-20 vials, and 5.7% received ≥20 vials of ASV [Table 2]. Among the different types of neuroparalytic symptoms, bilateral ptosis was present in 35.2%, followed by ophthalmoplegia in 22.7%, and bulbar palsy in 19.3% cases. Intubation was required in 28.4% and surgical intervention was needed in 6.8% of cases; dialysis was required in 6.8% of cases. Twenty-five patients need ventilator support, among them 10 (11.4%) needed ventilatory support for 1 to 5 days, 14 (15.9%) for 6 to 10 days, and only one patient was on the ventilator for more than 10 days. 11 cases died out of 88 cases [Table 3]. Mortality was significantly higher among cases with complications such as wound infection (P < 0.001), sepsis (P < 0.001), compartment syndrome (P = 0.028), and hematuria (P = 0.004) [Table 4]. Mortality was significantly higher in cases that had increased Total leucocyte count (TLC) and reduced platelet count. Raised Activated partial thromboplastin time (aPTT) and Prothrombin time/international normalized ratio (PT/INR) were not found to be statistically significant with mortality [Table 5].

Table 1: Different blood profile parameters of cases

Table 2: ASV vials given (starting dose & total dose)

Table 3: Final outcome of the snake bite cases (n = 88)

Table 4: Outcome (mortality) of study subjects by the nature of complications developed following bite

Table 5: Comparison of different blood profile parameters in management of snakebite with mortality

DISCUSSION

In the present study, 54.5% were male. The male predominance of snake bite cases may be due to their outdoor activities and involvement in farming and other agricultural activities. Similar findings were observed by Harshavardhana et al. (72%).^[7] Most patients (31.8%) were in the age group of 31-40 years, followed by 23.9% in the age group of 21-30 years. In a study by Bhelkar et al.,^[8] most (28.84%) of the cases were in the age group of 21-30 years of age. Contrastingly, in the study by Harshavardhana et al.,^[7] the maximum incidence of snake bite was found to be in patients >40 years (58%). Unskilled workers constituted 54.9% of patients with snake bites in the study by Bhelkar SM et al.^[8]

Three-fourths of patients had been bitten between dusk and dawn and these findings were echoed in - a study was done by Rahman et al. (36%).^[9] Bhelkar et al.^[8] had 58.33% of their patients bitten during daytime. Gangadharam et al. had their maximum number of cases between 4.00 PM and 8.00 PM.^[10]

In this study, the majority of bites (52.3%) were seen in the lower limb. A similar finding was observed by Bhelkar et al. (61.54%),^[8] Biradar et al. (66.1%)^[11], and Gangadharam et al. (68.71%).^[10]

Regarding the various manifestations of snake bite at the time of hospitalization, the most common was an extension of edema beyond the site of the bite (29.5%) followed by neurological features (26.1%). Gupta et al.^[12] found edema and swelling over bite marks (65.62%), while Gangadharam et al.^[10] found local pain at the bite site (74.60%) was the most common finding at the time of hospitalization. In this study, 23.9% of cases had leukocytosis, 13.6% had deranged aPTT and PT, with only 3.4% had thrombocytopenia [Table 1]. FNP Monteiro et al.^[13] found 51.6% had leukocytosis and 41.9% had thrombocytopenia, 32.3% had increased PT, and 29% had increased aPTT.

Eleven (12.5%) cases died in our study [Table 3]. In a study by Gangadharam et al.,^[10] seven patients died. All patients with neuroparalytic bite died because of a delay in receiving respiratory assistance. Among four deaths due to vasculotoxicity, three died of acute renal failure, and one patient died of DIC and intracerebral hemorrhage. Lahori et al.^[14] showed the mortality rate to be 2%, and three deaths were due to central nervous system (CNS) involvement.

A study by Biradar S et al.^[11] showed that minimum four vials and maximum of 48 vials of ASV were given to the patients. Among them, 33.3% of patients received 1 to 10 vials of ASV, 22.2% of patients received 11 to 20 vials and 13.9% of patients received more than 20 vials. The most common complication developed was wound site infection (27.3%), followed by compartment syndrome (20.5%), sepsis (13.6%), and hematuria (6.8%) [Table 4]. In a study by Nisar A et al.,^[15] 3% patients developed acute renal failure and needed hemodialysis but recovered completely, 6% patients went into shock because of DIC and needed multiple transfusions, and 3% needed surgical intervention because of compartment syndrome.

Limitations

Small study (only 88 snake bite cases).

CONCLUSION

Snakebite is an occupational hazard among farmers and laborers, but it can be preventable by taking adequate safety measures like doing fewer outdoor activities after the evening. Awareness should be created among the general public that they should not become panic after a snake bite but immediately go to the hospital for treatment. The risk factors such as time between bite and treatment, snake bite-related complications at the time of hospitalization, and an adequate dose of ASV determine the treatment outcome. Health professionals should also explain the consequences that may occur after a snake bite to the patient relatives.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.