Meenakshi Shah¹, Archana Asher^2*, Kedar Mehta³

^{1 Associate Professor, Department of Medicine} {³Assistant Professor, Department of Community Medicine} GMERS Medical College and General Hospital, Gotri – Vadodara, Gujarat, INDIA.

²Assistant Professor, Department of Medicine, GMERS Medical College and Hospital, Vadnagar, Gujarat, INDIA.

Email: archanaasher258@yahoo.co.in

Table 1: Demographic profile of snake bite patients (N = 114)

Table 2 shows the epidemiological profile of snake bite patients. More than half of the cases (64.9%) were seen in the months of July, August and September. More cases (56.1%) were reported during day time (from 7 am to 7 pm). 57 % of the incidents took place outdoors. A majority of patients (39.5 %) were working in fields when they were bitten by a snake. Almost all (99.1%) snake bites were unprovoked.

Table 2: Epidemiological profile of snake bite patients (N = 114)

As shown in table 3, 13.2 % of the patients were referred from community health centres, 1.8% patients were referred from private hospitals and a majority of patients (85 %) came directly to our hospital. Before reaching our hospital, only 10.5 % patients received ASV, 12.3 % patients received tetanus toxoid and only 4.4% patients had applied tourniquet. 7.9% of the patients had taken some sort of traditional or folk remedy before arriving at our hospital.

Table 3: Pre hospital care received by snake bite patients (N = 114)

As shown in table 4, maximum patients (52.6%) were bitten over lower limbs. 3.5% patients were hypertensive. Most common presenting signs and symptoms were local pain (78.9%), presence of fang marks (76.3%), local swelling (74.6%), respiratory paralysis (14.9%), nausea/ vomiting (11.4%), and ptosis (10.5%). Neurological manifestations were present in 14.9% patients. Local and systemic bleeding was present in 9.6% patients.

Table 4: Clinical profile of snake bite patients (N = 114)

As described in table 5, almost half of the patients (53.5%) reached our hospital within 4 hours of snake bite. About one third of the patients (31.6%) were critical and required intensive care. ASV was given to 87.7% of patients. 10.5% of patients required transfusion of blood products like red cell concentrate or fresh frozen plasma, 14.9% of patients required mechanical ventilation, 12.3% of patients had hypotension requiring inotropic support, 0.9% of patients had acute kidney injury requiring haemodialysis and 6.1% of patients required surgical wound debridement. Almost half of the patients (52.6%) required hospitalization for 4 or more days. A majority (91.2%) of patients were discharged.

Table 5: Hospital care in snake bite patients (N = 114)

Laboratory parameters of patients at the time of presentation to the hospital were as detailed in Table 6. Whole blood clotting time (WBCT) > 20 minutes was seen in 9.6% patients. Prothrombin time / international normalized ratio (PT/INR) was deranged (raised) in 9.6% of patients.

Table 6: Laboratory parameters of snake bite patients on presentation (N = 114)

We observed that factors significantly associated with death in snake bite patients were need for mechanical ventilation, need for inotropic support, total leucocyte count on presentation > 11000 /cumm, serum creatinine on presentation > 1.4 mg/dl, serum bilirubin on presentation >1 mg/dl and the presence of neurotoxicity. Presence of vasculotoxicity and requirement of blood product transfusion was not significantly associated with mortality.

Table 7: Factors associated with outcome of snakebite patients (N=114)

*statistically significant

DISCUSSION

In our study we analysed 114 cases of snake bite. We compared our findings with that of other studies done in India. In our study, maximum patients (28.1%) were in the age group of 31 – 40 years. Harshavardhana et al⁶ reported that 58% patients in his study were above the age of 40 years which differs from our study where only 29.8% patients were above the age of 40 years and 70.2% were below the age of 40 years. In our study, 52.6% of patients were males and 47.4% were female. This is similar to the male preponderance reported by Gangadharam et al⁷ (61.5%) and Harshavardhana et al⁶ (72%). In our study, a majority of the patients were married (82.5%) and resided in rural areas (81.6%). Anjum et al⁸ also reported that a majority of patients in their study were married (73.4%) and resided in rural areas (67.5%). In our study, a significant bulk of patients (39.5 %) was involved in farming by occupation. Anjum et al⁸ also reported that a majority (48.5%) of patients in their study was involved in agriculture. We observed that maximum cases were seen in the months of July, August and September (64.9%) and this is similar to the study reported by Anjum et al⁸ where 67.5% cases were reported in these 3 months. In our study, we noted that 57 % of the incidents took place outdoors. Anjum et al⁸ also reported a similar finding (62.7% outdoor snake bites). We observed that more people (56.1%) were bitten during day time (from 7 am to 7 pm) which is similar to that reported by Bhelkar et al⁹ (58.33% bitten during daytime). In our study, 39.5 % patients were working in fields and 22.8% patients were sleeping when they were bitten by a snake. Bhelkar et al⁹ reported 48.08% patients were working in fields and only 10.26% patients were sleeping when they were bitten by a snake. This differs from our study. Almost all (99.1%) snake bites in our study were unprovoked which is more than that reported by Padhiyar et al⁴ where 64.1% snake bites were unprovoked. In our study we noted that, 13.2 % of the patients were referred from community health centres, 1.8% patients were referred from private hospitals and maximum patients (85 %) came directly to our hospital. Padhiyar et al⁴ reported that in their study, 57.8% patients were referred from rural health centres, 17.2% patients were self-referred and remaining patients were referred from primary health centre and private hospitals. The number of patients who came directly to our hospital is higher. Before reaching our hospital, only 10.5 % patients received ASV, 12.3 % patients received tetanus toxoid and only 4.4% patients had applied tourniquet at or above the site of bite. This is again different from that reported by Padhiyar et al⁴ where 62.5% patients had received ASV, 51.6% had received tetanus toxoid and 45.3% had applied a tourniquet. This difference can be attributed to the fact that maximum patients in our study had come directly to our hospital. In our study we noted that 7.9% of the patients had taken some sort of traditional or folk remedy before arriving at our hospital which is lower than that reported by Bhelkar et a⁹ (30.77%). Maximum patients (52.6%) in our study were bitten over lower limbs. Anjum et al⁸ also reported that 69.2% patients had snake bites on lower limb in their study. Most common presenting signs and symptoms were local pain (78.9%), presence of fang marks (76.3%), local swelling (74.6%), respiratory paralysis (14.9%), nausea/ vomiting (11.4%), ptosis (10.5%), bulbar weakness (7%), bleeding from bite site (6.1%) and fever (6.1%). This is similar to findings of other studies.^{8, 9} We observed that neurotoxicity was present in 14.9% patients and vasculotoxicity was present in 9.6% patients. Padhiyar et al⁴ reported that 43.8% bites were vasculotoxic and 34.4% were neurotoxic. This was much higher than that observed in our study. Almost half of the patients (53.5%) reached our hospital within 4 hours of snake bite and only 7% patients reached after 24 hours. This is similar to that reported by Anjum et al⁸, where 48.5% patients reached hospital within 6 hours and only 5.9% patients reached after 24 hours. In our study 31.6% patients were critical and were admitted in intensive care unit and ASV was given to 87.7% of patients. Anjum et al⁸ also reported similar data (30.8% ICU admissions and 81.1% patients received ASV). In our study we observed that 10.5% of patients required transfusion of blood products like red cell concentrate or fresh frozen plasma, 14.9% of patients required mechanical ventilation, 12.3% of patients had hypotension requiring inotropic support, 0.9% of patients had acute kidney injury requiring haemodialysis. In the study reported by Padhiyar et al⁴, blood transfusion was required in 20.3% patients, 18.75% patients required mechanical ventilation, 6.25% received haemodialysis and 6.25% required inotropic support. In our study more patients needed inotropic support while need for blood products, mechanical ventilation and haemodialysis was less as compared to their study. In our study, a majority (91.2%) of patients were cured and discharged, while 8.8% patients expired. Anjum et al⁸ reported similar findings (92.3% cured and 7.7% expired). We observed that whole blood clotting time > 20 minutes was seen in 9.6% patients and raised PT/INR was seen in 9.6% of patients, which is lower than what was reported by Padhiyar et al⁴ (34.3% and 23.4% respectively). We observed that factors significantly associated with death in snake bite patients were need for mechanical ventilation and need for inotropic support. Padhiyar et al⁴ concluded that patients requiring blood product transfusion, inotropes, haemodialysis and mechanical ventilation had a statistically significant correlation with poor outcome. We did not find that requirement of blood product transfusion was significantly associated with mortality. Padhiyar et al⁴ also reported that acute kidney injury was significantly associated with poor outcome and hepatic involvement was not significantly associated with poor outcome. We observed that renal involvement (serum creatinine on presentation > 1.4 mg/dl) and hepatic involvement (serum bilirubin on presentation >1 mg/dl) was significantly associated with mortality. We also observed that total leucocyte count on presentation > 11000 /cumm and the presence of neurotoxicity was associated with mortality and presence of vasculotoxicity was not significantly associated with mortality.

CONCLUSION

Snake bite is a common medical emergency in tropics. It is more common in farmers and in monsoon. Factors like - need for mechanical ventilation, need for inotropic support, total leucocyte count on presentation > 11000 /cumm, serum creatinine on presentation > 1.4 mg/dl, serum bilirubin on presentation >1 mg/dl and the presence of neurotoxicity were associated with poor outcome in our centre.

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