A study of profile, management and outcome of patients admitted for snake bite with envenomation in general medicine department, Government Chengalpattu Medical College and Hospital.
In any part of the world, snake produces unimaginable fear and anxiety. This fear has been present from ancient civilisation. Right from the past, snakes are the cause for one of the first poisoning heard. The death caused then might have been first alarm of sensing death at vision of a snake. 
At the beginning of twenty first century, annual mortality from snakebites continues to be as high, around 30 to 60 thousands in the world. Snakebite morbidity and mortality is a major health problem in rural areas.
Mortality rates of around 5.5 per 100,000 residents, Indian rural coastal population tell about the magnitude of the problem. According to Frayer in his study of Thanatophidia of India, it was estimated that about 1 in 1 lakh population died due to snake bite.  But in spite of this, snake bite has been overlooked through ages. Snake bite is also responsible for about 2.85% - 5.3% of the mortality of total hospital admission in India. India is reported to have the highest snakebite incidence and mortality in the world.  World Health Organisation (WHO) estimates the total number of bites to be 84,000 per year with 11,000 deaths. A national survey in India suggests that snake bite deaths estimated are more than 30 fold higher than documented. Most of the death are mainly due to the snake bite victims not reaching the hospital in time.
Studies signify that primary care treating doctors hesitate to treat snakebite patients immediately mainly due to lack of experience and confidence. At the secondary and tertiary level hospitals, several treatment protocols and schedules were being followed for Anti-Snake Venom (ASV) administration, mainly based on foreign textbooks.
Mortality rate is further increased by inappropriate administration of first dose of ASV, particularly in Krait and Russell's viper snakebite.  There is also delay in providing a simple method of endotracheal intubations and artificial ventilator or Ambu bag ventilation in neurotoxic envenoming.
In response to our Health and Family Welfare Department, Government of India, after careful analysis of trials has prepared a National Snakebite Management Protocol for snake bite to provide doctors and lay people a best evidence-based treatment approach to deal with this problem in our country.  Around 235 species of snakes are found in India, most of which are non-venomous. Most of the bites will cause panic reaction, but do not cause envenomation, However, there are few snake species that are venomous and of these four (Big four) namely Russell's viper (Daboia russelii), common cobra (Naja naja), saw-scaled viper (Echis carinatus) and common krait (Bungarus caeruleus) are highly venomous and believed to be responsible for most of the poisonous bites in India. 
In our Government Chengalpattu Medical College and Hospital situated in Kanchipuram district, snake bite cases comprises a major proportion among hospital admissions. We are well equipped and trained in managing this most common problem. In spite of good care and timely management some cases end up in complications or death; main reasons are patients presenting lately for treatment due to lack of awareness, patients undergone native treatment and then getting admitted to hospital with complications or comorbid illness of the patients. In 2012 total number of snake bite cases were 424, out of which 167 cases were poisonous bites with signs of envenomation.
MATERIAL AND METHODS
This study was carried out from June 2013 to May 2014 (One Year Study). The study was conducted prospectively. The study comprised of 181 cases of snakebite patients (>13 years) with signs of envenomation admitted to the Department of General Medicine, Government Chengalpattu Medical College and Hospital, Chengalpattu.
RESULTS AND DISCUSSION
Among 181 cases, most of the victims (26.8%) belongs to fourth decade of life. Many similar studies conducted in the past show similar distribution, one such study in JIPMER7 show that majority of victims belong to 15-60 yrs. of age. Another study by Sawai et al show that most of the cases belong to 10 to 30 years. There is a rapid decline in the incidence of cases after 5th decade of life.
In our study, male-to-female ratio of incidence of bite is 1.8:1. Comparing this with studies done earlier like study conducted by Banerjee RN,  a higher preponderance of males than females was observed. Similar to studies done at JIPMER7 and in Safdarjung Hospital,  our present study clearly showed that the incidence of bite is more among agricultural workers, i.e. 46.41% in our present study. We also observed that 10 victims (5.52%) are school or college students.
In our present study we noticed majority of patients (60.77%) did not identify the snake. Among the identified cases, most common was cobra (16.57%) followed by krait (12.71%).
To evaluate the outcome of patients in relation to comorbid illness, we obtained a detailed history of comorbid illness among snake bite victims. Nearly 9.39% of cases were hypertensives and 8.29% were diabetic. One patient was antenatal mother (5 months gestation). In our present study, maximum incidence of snake bite (29.28%) was between 4:00 PM to 8:00 PM. Least number of bites were distributed in morning hours, i.e. 4 to 8:00 AM (9.94%) and 8 to 11:59 AM (9.94%).
Among 181 cases, 50.83% of victims reported to have bitten in lower limb and most common site was feet. Other sites in decreasing order were upper limb (33.15%), abdomen (7.73%) and face (4.42%). These findings clearly suggests that the site of bite is determined mainly by inadvertent contact of the snake during activities. All these findings are more or less similar to that of study conducted by Viramani SK,  Dutt OP and Bhat RN. About 131 (72%) cases are outdoor (farm, work place, school ground, forest), and 50 (28%) cases are indoor bite (Home, other buildings).
Neurotoxicity (35.38) is high among the toxicities observed, next comes the pure haemotoxicity (25.42%), local reactions like cellulitis, oedema comprises 22.65%, bite to needle time is the interval between time of bite and administration of ASV, 42% cases were given ASV within 2-4 hrs. of bite followed by 36% of cases within 4-6 hrs. This helps in the evaluation of severity and administration of ASV in a crucial period.
In patients those who were alive history of tourniquet application was present in 48 (27.91%) cases, 7 cases (4.07%) had history of other methods of native treatment like cutting, suction, etc. About 117 cases did not receive any native treatments. A significant association was found between tourniquet application, other native treatments and study population. Out of 9 patients who were dead, history of native treatment in the form of tourniquet application, wound cutting, suction, etc. were present in all cases.
Out of 181 cases 100 patients (55%) showed no reaction to ASV, while in remaining 81 cases 64 (35%) developed minor reactions in the form of fever, urticarial rashes and rigors, 17 cases (10%) developed severe anaphylactic reactions.
This clearly shows that majority of cases who received ASV developed no or only mild reaction to ASV. Among 9 dead patients, 7 patients (78%) presented late with bite to needle time of >6 hours and 2 (22%) patients presented less than 6 hours from time of bite. Of 181 patients, 57 patients had undergone surgical procedures out of which 45 patients (24.8%) had simple wound debridement, 9 cases (4.97%) had fasciotomy and 3 patients (1.66%) had amputations. Remaining 124 cases (68.51%) got treated without any surgical interventions. On analysing comorbid illness versus death wise distribution of study population, we found that among 15 diabetic patients 93.33% were alive and 6.67% were dead. Among 17 hypertensive patients, only 5.88% died. Similarly on analysing all the comorbid datas, we found that comorbid illness is less significant in determining the mortality.
We had one antenatal woman (5 months of gestation) who received ASV in 4 hours and she was alive, but resulted in intrauterine death due to feticide effect of ASV. On analysing various antenatal snake bite cases in the past, the feticide effect of ASV is confirmed.
On analysis of bite to needle time with surgery we found that out of 25 patients with BTN time < 2 hrs., 40% had surgery and 60% without surgery. At BTN time of 2-4 hrs., 33% with surgery and 67% without surgery. At 4-6 hrs., values were 23% with surgery and 77% without surgery. At >8 hrs., one patient with surgery. This shows that unlike bite to needle time as an important determinant of mortality, it is not an important determinant in case of surgical interventions.
Snakebite although a preventable problem, it remains to be one of the common emergency.
1. In the present study, the adult snakebite cases with envenomation brought to Government Chengalpattu Medical College and Hospital, Chengalpattu, were mostly males (64%) between the age group of 30 to 40 years (26.8%).
2. With rural background, snake bite is more common among agricultural related activities (46.41%).
3. The most common site of bite was lower limb and the maximum cases were recorded between 4:00 PM to 8:00 PM (29.28%) in the rainy season of July to September.
4. Neurotoxicity constitutes (35.38%) among all the toxicities followed by pure haemotoxicity (25.42%) and local reactions like cellulitis oedema (22.65 %).
5. A significant association was noted between prolonged bite to needle time and mortality with 7 out of 9 patients (78%), who presented more than 6 hours after bite were dead.
6. On analysing comorbid illness versus death wise distribution of study population, we found that among 15 diabetic patients 93.33% were alive and 6.67% were dead. Among 17 hypertensive patients, only 5.88% died. Similarly on analysing all the comorbid illness with outcome, we found that comorbid illness is not a strong determinant in determining the mortality.
7. Native treatment especially tourniquet application is a strong determinant of outcome with 100% prevalence in dead and 85.28% in patients who had undergone surgeries and 27.28% in alive patients without surgeries.
HOW TO CITE THIS ARTICLE: Ramachandran NK, Kumaran AS. A study of profile, management and outcome of patients admitted for snake bite with envenomation in general medicine department, Government Chengalpattu Medical College and Hospital. J. Evolution Med. Dent. Sci. 2016;5(78):5771-5774, DOI: 10.14260/jemds/2016/1302
[1.] Jena I, Sarangi A. Snakes of medical importance and Snakebite treatment. FRCP 1993:7-8.
[2.] Nayak KC, Jain AK, Sharadda DP, et al. Profile of cardiac complications of snakebite. Indian Heart Journal 1990; 42(3):185-8.
[3.] Http://www.umass.edu/nree/snake-pit/pages/begin. html
[4.] Jacob J. Snake venom poisoning: the problem, diagnosis and management of snake venom poisoning. Bombay Varghase Publishing House, 1990.
[5.] National snakebite management protocol, India. Directorate general of health and family welfare, ministry of health and family welfare, India, 2008. www://mohfw.nic.in
[6.] WHO/SEARO guidelines for the clinical management of snakebite in the southeast Asian region. SE Asian J Trop Med Pub Health 1999;30(Suppl 1):1-85.
[7.] Lal P, Shrihari D, Rotti SB, et al. Epidemiological profile of snake bite cases admitted in Jipmer hospital. Indian Journal Community Med 2001;26(1):36-8.
[8.] Banerjee RN. Poisonous snakes in India, their venom, symptomatology and treatment of envenomation. In: Ahuja MMS. edr. Progress in clinical medicine in India. 1st edn. New Delhi: Arnold Heinman Publishers 1978: 86-179.
[9.] Viramani SK, Dutt OP. A profile of snakebite poisoning in Jammu region. J Indian Medical Association 1987;85(5): 132-4.
Nanda Kumar Ramachandran (1), Arjunan Senthil Kumaran (2)
(1) Assistant Professor, Department of Medicine, SRM Medical College and Hospital, Potheri.
(2) Assistant Professor, Department of Medicine, Chengalpattu Medical College and Hospital.
Financial or Other, Competing Interest: None. Submission 21-08-2016, Peer Review 14-09-2016, Acceptance 20-09-2016, Published 27-09-2016. Corresponding Author: Dr. Nanda Kumar Ramachandran, Assistant Professor, Department of Medicine, SRM Medical College and Hospital, Potheri. E-mail: firstname.lastname@example.org DOI: 10.14260/jemds/2016/1302
Table 1: Identified Snake vs. Unidentified Snake Wise Distribution of Study Population Type of Snake Female Male Total Identified No. % No. % No. % Snake Name Cobra 10 15.38 20 17.24 30 16.57 Krait 11 16.92 12 10.34 23 12.71 Russell Viper 3 4.62 15 12.93 18 9.94 Unidentified 41 63.08 69 59.48 110 60.77 Total 65 100.00 116 100 181 100.00 Table 2: Occupation Wise Distribution of Study Population Occupation Male Female Number Percent Number Percent Agriculture 72 62.07 12 18.46 Industry 1 0.86 4 6.15 State Govt. 7 6.03 1 1.54 Central Govt. 0 0.00 1 1.54 Business 3 2.59 4 6.15 Small Trade 5 4.31 3 4.62 Private 3 2.59 4 6.15 Not Working/Home Maker 13 11.21 35 53.85 Forest Worker 2 1.72 0 0.00 Student 9 7.76 1 1.54 Snake Handler 1 0.86 0 0.00 Total 116 100 65 100 Occupation Total Number Percent Agriculture 84 46.41 Industry 5 2.76 State Govt. 8 4.42 Central Govt. 1 0.55 Business 7 3.87 Small Trade 8 4.42 Private 7 3.87 Not Working/Home Maker 48 26.52 Forest Worker 2 1.10 Student 10 5.52 Snake Handler 1 0.55 Total 181 100 Table 3: Comorbids Distribution of Study Population Comorbids Male Female No. Percentage No. Percentage DM 8 6.90 7 10.77 HT 11 9.48 6 9.23 CAHD 2 1.72 3 4.62 CVA 2 1.72 0 0.00 BA/COPD 6 5.17 1 1.54 Malignancy 0 0.00 1 1.54 Residual Polio 1 0.86 0 0.00 NIL 80 68.97 46 70.77 CKD 0 0.00 0 0.00 Pregnant 0 0.00 1 1.54 DM+HT 4 3.45 0 0.00 DM+HT+CAHD 2 1.72 0 0.00 Total 116 94.82758621 65 98.46153846 Comorbids Total No. Percentage DM 15 8.29 HT 17 9.39 CAHD 5 2.76 CVA 2 1.10 BA/COPD 7 3.87 Malignancy 1 0.55 Residual Polio 1 0.55 NIL 126 69.61 CKD 0 0.00 Pregnant 1 0.55 DM+HT 4 2.21 DM+HT+CAHD 2 1.10 Total 181 96.13259669 Fig. 2: Bite to Needle Time vs Mortality Wise Distribution of Study Population BITE TO NEEDLE TIME vs MORTALITY WISE DISTRIBUTION OF STUDY POPULATION Series 1 <2 HRS 0 2.00-4 HRS 1 4.00-6.00 HRS 1 6.00-8.00 HRS 3 8.00-12.00 HRS 3 >12.00 HRS 1 Note: Table made from bar graph. Fig. 3: Distribution of Population Based on Toxicity male female total neurotic 42 22 64 haemotoxic 33 13 46 Neurotoxic+haemotoxic 9 6 15 Local toxicity 26 15 41 Neuro+local toxicity 5 2 7 Hemo+local toxicity 1 2 3 Neuro+hemo+local 4 1 5 Note: Table made from bar graph. Fig. 4: Distribution of Study Population Based on Time of Bite vs. Sight of Bite Distribution FACE UPPER LOWER CHEST ABDOMEN BACK LIMB LIMB 4.00-7:59 AM 6 6 2 0 8.00-11:59 AM 3 10 7 3 12.01-3:59 PM 14 7 17 6 4.00-7:59 PM 6 20 1 1 8.00-11.59 PM 5 15 0 10 12.00-4.00 AM 11 5 0 1 Note: Table made from bar graph.
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|Title Annotation:||Original Research Article|
|Author:||Ramachandran, Nanda Kumar; Kumaran, Arjunan Senthil|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Sep 29, 2016|
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