Beruflich Dokumente
Kultur Dokumente
FOR
SNAKE BITE AND SCORPION STING
Tamil Nadu Health Systems Project Tamil Nadu Health Systems Project
Health and Family Welfare Department Health and Family Welfare Department
Government of Tamil Nadu, Chennai. Government of Tamil Nadu, Chennai.
2008
HANDBOOK ON TREATMENT
GUIDELINES FOR SNAKE BITE AND
SCORPION STING
2008
Dr. S. VIJAYA KUMAR I.A.S., Tamil Nadu Health Systems Project
7th Floor, DMS Building,
Special Secretary to Government Chennai - 600 006.
Health & Family Welfare Dept., Tel. Off : (91-44) 2434 5997
& Fax : (91-44) 2434 5997
Project Director Email : mail@tnhsp.net
INTRODUCTION
The Tamil Nadu Health Systems Project formed a snake bite task force in 2006
to try and understand the staggering figures that were surfacing on snake bite and
scorpion sting cases in Tamil Nadu. During the effort, it was apparent that despite
morbidity and mortality, an evidence based handbook on treatment guidelines was not
available to medical officers as a ready reckoner in dealing with affected persons.
A committee was then formed to prepare guidelines to treat snake bite and
scorpion sting with the assistance of the Health & Family Welfare department and in
particular the Poison Control, Training and Research Treatment Centre in Government
General Hospital, Chennai. The Committee has prepared this Handbook after several
rounds of discussion and has also subjected this document to a peer review.
This handbook will help to redefine patient care for those who suffer from
snake bite and scorpion sting and will be useful for health care providers, patients and
policy makers. Information provided in the following pages range from epidemiological
issues, clinical features, treatment modalities, management of complications, referral
aspects medical audit, research areas and so on.
With this handbook, we hope to ensure that a major information gap is
adequately plugged so as to ensure rational medical treatment and appropriate quality
of care for snake bite and scorpion sting victims.
iii
EDITORIAL COMMITTEE
Chair Person :
Thiru.Dr.S.Vijaya kumar, I.A.S.,
Project Director and
Special Secretary to Government,
Tamil Nadu Health Systems Project,
Chennai – 6.
Members:
Dr. (Capt.) M.Kamatchi,
Expert Advisor,
TamilNadu Health Systems Project (TNHSP),
Chennai.
Dr. P. Thirumalaikolundusubramanian,
Former Director, Professor and Head, Institute of Internal Medicine,
Madras Medical College and
Emeritus Professor, The Tamil Nadu Dr.M.G.R. Medical University, Chennai.
iv
ACKNOWLEDGEMENT
Tamil Nadu snakebite task force team and staff Tamil Nadu Health Systems
Project (TNHSP), Chennai thank the Ministry of Health and Family Welfare, Health
& Family Welfare Department, State Government of Tamil Nadu, Chennai, India and
Madras Medical College, Chennai for making arrangements to prepare the treatment
guidelines for snakebite and scorpion sting; and also thank the Ministry of Health
& Family Welfare, Government of India, New Delhi, for considering the treatment
guidelines prepared from Tamil Nadu for Snake bite favourably.
The encouragement provided by Thiru .V.K. Subburaj, I.A.S., Principal
Secretary to Government, Health & Family Welfare Department, Government of
Tamil Nadu, Chennai; Ms. Supriya Sahu, I.A.S., former Additional Secretary, Tamil
Nadu Health Systems Project, Chennai; Thiru. P.W.C. Davidar, I.A.S., Former Project
Director & Special Secretary to Government, Tamil Nadu Health Systems Project,
Chennai; and Thiru. Muthiah Kalaivanan, I.A.S., former Project Director, Reproductive
and Child Health (RCH), Chennai, for the preparation of the treatment guidelines for
snakebite and scorpion sting is gratefully acknowledged.
The support provided by former Director of Medical Education, Dr. Vijayalakshmi,
former Director of Medical and Rural Health Services, Dr. N. Kalyanasundaram and
former Director of Public Health and Preventive Medicine, Dr. S.Murugan are duly
acknowledged.
The services rendered by Dr. P. Padmanabhan, Director of Public Health and
Preventive Medicine, Chennai; Dr.V.K. Rajamani, Professor of Medicine, and
Dr. Saradha Suresh, Director and Superintendent, Professor and Head of Pediatrics,
Madras Medical College, Chennai; Dr. S. Shivakumar, Professor and Head of
Medicine, Stanley Medical College, Chennai; Dr. A. Ayyappan, Professor and Head
of Medicine and Dr. M.L. Vasanthakumari, Professor of Pediatrics, Madurai Medical
College, Madurai; Dr. S. Muthukumaran, Professor and Head of Medicine, Thanjavur
Medical College, Thanjavur; Dr. Vasantha Elango, Professor and Head of Community
Medicine, and Dr. K.Umakanthan, Professor and Head of Medicine, Coimbatore
Medical College, Coimbatore; Dr. K. Sathyamoorthy, Professor and Head of Medicine,
Government M.K. Medical College, Salem; and Dr. R.A. Sankaramanian, Professor
of Pediatrics, Government Theni Medical College, Theni in reviewing the manuscript
and offering suggestions are greatly appreciated.
v
STATEMENTS
1. For private circulation, not for sale
2. Acknowledging the source permits copying or translating the material
3. This module is designed to give concise information for medical practitioners and
not intended to provide comprehensive scientific information
4. For detailed and up to date information as well as to know the current developments,
users are requested to go through the original articles, review papers, case reports,
related publications, websites etc.,
5. For administration of each drug, users are informed to go through the latest product
information leaflets provided by the manufacturers
6. Users are reminded to recall the contraindications before using any drug.
7. Users have been motivated to make use of their experience and knowledge of
patients before deciding the dosage and treatment of each patient
8. The hand book has been revised as on November 2008
9. The publishers, Tamil Nadu Health Systems Project, Health and Family Welfare
Department, Chennai, Tamil Nadu, Funding agency, the contributors and reviewers
do not assume liability for any injury and / or any damage to persons or property
arising out of this publication
10. Readers are requested to submit their suggestions, views, feed back and
their experience on snakebite / scorpion sting to the following mail address
[mail@tnhsp.net] which will be helpful for modifying / revising future editions.
vi
ABBREVIATIONS
• AS – Anti Snake Venom
• AT – Antithrombin
• BP – Blood Pressure
• CT – Computerised Tomography
• DIC – Disseminated Intravascular Coagulation
• FFP – Fresh Frozen Plasma
• Hg – Mercury
• HR – Heart Rate
• HCL – Hydrochloride
• ICP – Intra Compartment Pressure
• IM – Intramuscular
• IV – Intravenous
• LAB – Laboratory
• PHC – Primary Health Centre
• PIM – Pressure Immobilisation Method
• PR – Pulse Rate
• RR – Respiratory Rate
• SD – Standard Deviation
• WBCT – Whole Blood Clotting Test
• WHO – World Health Organisation
vii
List of Tables, Figures, Pictures and Plates
List of Tables
Table 1: Statistics on clinical aspects of snake bites and outcome
Table 2: Categorisation of snakes (W.H.O.1981)
Table 3: Snakes, clinical aspects and therapeutic response
Table 4: Details of local envenomation
Table 5: 20 Minutes Whole Blood Clotting Test (20WBCT)
Table 6: Currently recommended First aid
Table 7: Principles involved in the management
Table 8: Manifestations of immediate reactions to ASV
Table 9: Dosage of adrenaline for adults and children
Table 10: ASV – Risk and Wastage (Ian D.Simpson Model)
Table 11: Surgical issues: assessment and action required.
Table 12: Initial evaluation - No systemic envenomation
Table 13: Haemotoxic envenomation
Table 14: Neurotoxic envenomation
Table 15: Referral aspects for snake bite
Table 16: Distinguishing features of lethal and non-lethal scorpion
Table 17: Influencing factors for symptoms and signs
Table 18: Local effects at the site of sting.
Table 19: Systemic signs of scorpion sting.
Table 20: Non-neurological signs
Table 21: Measures to be adopted while using Prazosin
Table 22: Initial evaluation of scorpion sting without systemic envenomation
Table 23: Evaluation of scorpion sting with systemic envenomation
Table 24: Referral aspects for scorpion sting
Table 25: Responsibilities of health care providers
viii
Table 26: Levels of analysis
Table 27: Formula to calculate case fatality rate at different levels
Table 28: Snake bite cases reported and ASV vials used in secondary care hospitals
(district wise)
Table 29: Fluid requirement chart for children
Table 30: Normal Respiratory Rate (per minute) by age.
Table 31: Normal Heart Rate (per minute) by age
Table 32: Normal Blood Pressure in children by age
Table 33: Hypotension by systolic Blood Pressure and age
List of Figures
Figure 1: Grading of scorpion envenomation
Figure 2: Nervous system signs
List of Pictures
Picture No. 1: Snakes of Medical Importance in Tamil Nadu
Picture No. 2: Typical signs of local envenomation
Picture No. 3: Cellulitis with compartmental syndrome
Picture No. 4: Showing bilateral ptosis with overaction of frontalis
Picture No. 5: Showing ophthalmoplegia
List of Plates
Plate No. 1: Snake Identification
Plate No. 2: Important Venomous Snakes of India
Plate No. 3: Primary / Community Health Care Centre - Snake bite Treatment
Guidelines
Plate No. 4: Secondary Health Care Centre - Snake bite Treatment Guidelines
ix
CONTENTS
1. INTRODUCTION iii
2. EDITORIAL COMMITTEE iv
3. ACKNOWLEDGMENT v
4. STATEMENTS vi
5. ABBREVIATIONS vii
7. SECTION I: SNAKEBITE
SNAKE BITE
Titles Page
1.1 General 1
• Introduction
• Magnitude of the problem
• Epidemiology of snake bite
• Ecological aspects
1.2 Classification of snakes 4
• Snakes of Medical Importance in Tamilnadu -
Distinguishing features
1.3 Clinical aspects of snake bite 7
• Pathophysiology
• Symptoms and signs
• Criteria for diagnosis
• Complications and outcome
• Investigations
1.4 Treatment 14
• First aid for snake bite
• Traditional methods followed for treating snake bite
• Newer methods - pressure pad or Monash technique
• Principles involved in the management
• Pharmacological aspects of Anti Snake Venom
• ASV Administration
£ criteria
£ dosage
£ administration
• Facts to be remembered before / while using Inj.ASV
• ASV reactions
• Prevention of ASV reaction(s) – prophylactic regimens
Titles Page
1.1 General
Introduction
In many parts of India, snake is worshipped and in some areas special prayers
are performed. In Northern India on Naga Panjami day people worship snake idol. In
certain areas of Maharashtra and Goa the live snakes, rarely live cobras are brought
for worship. Snake charmers carry snakes especially cobra, door to door for worship.
At every house the snake’s mouth is forced open and some milk is poured down in
its throat though milk is not snake food. It is also believed that snakes bite people
who harmed them in their previous birth. When snakes are killed, people offer special
prayers and bury them. People also believe that snakes take revenge against those who
harmed them.
In view of their strong beliefs and many associated myths, people resort to magico-
religious treatment for snake bite thus causing delay in seeking proper treatment. As a
result, valuable time is lost in some of the deserving cases. It is poignant to note that
some of the cinema and TV serial stories even now propagate non-scientific ideas on
snakes and snakebites, and display traditional treatment. Hence, there is a need for
the health department to disseminate the scientific aspects related to snakebites to the
community.
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 1
Treatment Guidelines for Snakebite and Scorpion sting
94 were referred after treatment in different hospitals and 187 were brought to the
hospital directly. 274 (97.5%) survived and 7 died due to various complications of
snakebite while they were in the hospital. The details on the type of snakes, clinical
signs, complications, number referred, number who received supportive therapy and
death are provided below (Table no.1).
Supportive
Type of Number Local Neuro Hemo. Number
snake treated signs Toxicity Toxicity Mechnical Expired
Hemo- Fasciotomy.
ventilation Dialysis
Cobra 118 80 118 - 90 - - 2
Krait 82 - 51 82 60 3 - 2
Russell’s
42 42 - 42 6 23 1 1
viper
Hump-
nosed 4 4 - 4 - 4 - 1
viper
Saw
scaled 16 16 - 16 - 3 - 1
viper
Sea
3 3 - - - - - -
snake
Non
16 6 - - - - - -
poisonous
2 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
be prevented, if some simple first aid measures are undertaken by the public and / or by
the health care providers. So, there is an urgent need to take effective steps to contain
these issues.
Many of the first aid measures carried out at present are ineffective and dangerous.
The research also concluded that the other traditional methods followed for snake
bite are not appropriate. It is gratifying to note that the traditional snake catchers in
Tamil Nadu, the Irulas with their own sophisticated herbal medicine system, have now
understood the problems? They know that the snake injects venom which goes deep
into the system and this can be neutralised only by injection of Anti snake venom
(ASV) and not by oral or locally applied remedies, no matter how famous. But this
information needs to reach other communities also.
Hence, the need to recommend the most effective first aid to the victims bitten by
snakes and to recommend effective steps in the management of this problem. Poisoning
due to cobra and viper groups are seen frequently in the state of Tamil Nadu. Very
rarely sea snakebite cases are reported. Hence, this hand book focuses on the first two.
Though the specific antidote is not available for sea snake, the same general principles
for other snakebites are applicable here too.
Epidemiology of snakebite
Snakebite is observed all over the country with a rural / urban ratio of 9:1. They
are more common during monsoon and post monsoon seasons. Snakebites are seen
often among agricultural workers and among those going to the forest. Many of the
susceptible populations are poor living below poverty line, living in rural areas with
less access to health care. The male / female ratio among the victims is approximately
3:2. Majority are young and their age is between 25 to 44 years. Most of the bites (90
to 95%) are noticed on the extremities (limbs). The hospital stay varies from 2 to 30
days, with the median being 4 days. The in-hospital mortality varies from 5 to 10%,
and the causes are acute renal failure, respiratory failure, sepsis, bleeding and others.
Ecological aspects:
By destroying forests for creating agricultural land, the prey base of the snake
(that is frogs and rats) has increased. The rice fields, which harbour millions of rats
attract a lot of snakes. The number of snakes per acre in a rice field is abnormally
high when compared to the natural population in the forest. Humans go into the field
every morning and come out in the evening, just the time when snakes are active.
Thus, the chance of an encounter between farmer and snake is very high. As more
areas are inhabited at the periphery of towns, even there the chances of human / snake
interaction increase.
Cobras flourish as long as there are rice fields; there they feed mainly on the mole
rat (varapu eli in Tamil), live and lay their eggs in the rat burrow networks. Kraits also
get by very well in rice fields because they like the plentiful small rodents such as the
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 3
Treatment Guidelines for Snakebite and Scorpion sting
field mouse (sundeli in Tamil) and rock mouse (kallu eli in Tamil). Kraits are also found
in the mounds of earth and rubble near wells. The Russell’s viper lives in the rocky
outcrops and hedgerows of cactus and other bushes which often form the boundaries of
agricultural land. There, on the high ground, they have a plentiful supply of common
gerbil (velleli in Tamil) which are also attracted to the wealth of food humans provide
by their farming activities! But thanks to snakes, we are not overrun by rodents.
For many decades, the concept of the “Big 4” snakes of medical importance has
reflected the view that 4 species and responsible for Indian snakebite mortality. They are
- the Indian cobra (Naja naja), the Common Krait (Bungarus caeruleus), the Russell’s
viper (Daboia russelii) and the Saw scaled viper (Echis carinatus). However, recently
another species, the Hump-nosed pit viper (Hypnale hypnale), has been found to be
capable of causing lethal envenomation, and that this problem had been concealed
by systematic misidentification of this species as the saw-scaled viper. The concept
of the “Big 4” snakes has failed to include all currently known snakes of medical
significance in India. This has a negative effects on clinical management of snakebite
and the development of effective snake anti venoms
In 1981, the W.H.O. developed the following definition of snakes of medical
importance (Table No.2). This model is more accurate and useful than definitions such
as the ‘Big 4’ that are inaccurate and misleading to doctors and more importantly to
ASV manufacturers.
4 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
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There are six medically important species in Tamil Nadu shown above. Readers are
informed to get familiarised with the pictures given at the end of Hand-book. Further
details of some of the poisonous snake are provided in the ensuing paragraphs.
species do this, notably the Trinket Snake. The Cobras coloration may vary from pale
yellow to black.
enzymes promote formation of weak fibrin clot, which activates plasmin and results
in consumptive coagulopathy and hemorrhagic consequences. Venom of some snakes
causes neuromuscular blockade at pre or post synaptic level. In addition to above it
causes endothelial cell damage which results in increased vascular permeability. In
short, snake venom acts on various parts / systems / organs of the body. Venom also
causes endothelial cell damage which results in increased permeability.
8 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
• Epistaxis.
• The skin and mucous membranes may show evidence of petechiae, purpura
and ecchymoses.
• The passing of reddish or dark-brown urine or declining or no urine output.
• Lateralising neurological symptoms and asymmetrical pupils may be indicative
of intra-cranial bleeding.
• Vomiting.
• Acute abdominal tenderness which may suggest gastro-intestinal or retro
peritoneal bleeding.
• Hypotension resulting from hypovolaemia or direct vasodilation.
• Low back pain, indicative of early renal failure or retroperitoneal bleeding.
Other effects
• Muscle pain indicating rhabdomyolysis.
• Parotid swelling, conjunctival oedema, sub-conjunctival haemorrhage.
Local effects
• Swelling and local pain with or without erythema or discoloration at the site of
bite (Cobra).
• Local necrosis and / or blistering / bullae (Cobra).
Neurotoxic effects
• Descending paralysis, initially of muscles innervated by the cranial nerves,
commencing with ptosis, diplopia, or ophthalmoplegia. The patient complains
of difficulty in focusing and the eyelids feel heavy. There may be some
involvement of the senses of taste and smell.
• Problems of vision, breathing and speech.
• Paralysis of jaw and tongue may lead to upper airway obstruction and aspiration
of pooled secretions because of the patient’s inability to swallow.
• Numbness around the lips and mouth, progressing to pooling of secretions,
bulbar paralysis and respiratory failure.
• Hypoxia due to inadequate ventilation can cause cyanosis, altered sensoriun
and coma. This is a life threatening situation and needs urgent intervention.
• Paradoxical respiration, as a result of the intercostal muscles paralysis is a
frequent sign.
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 9
Treatment Guidelines for Snakebite and Scorpion sting
• Krait bites often present in early morning with paralysis that can be mistaken
for a stroke. Stomach pain which may suggest submucosal haemorrhages in
the stomach.
Other effects
• Stomach pain which may suggest submucosal haemorrhages in the stomach
(Krait).
• Eye pain and damage due to ejection of venom into the eyes by spitting cobra
(as observed in Africa)
[If features of renal failure are noted search for other causes / mechanisms]
Late-onset envenomation
The patient should be kept under close observation for at least 24 hours. Many
species, particularly the Krait and the Hump-nosed pit viper are known for the length
of time it can take for symptoms to manifest. Often this can take between 6 to 12 hours.
Late onset envenoming is a well documented occurrence. This is also particularly
pertinent at the start of the rainy season when snakes generally give birth to their
young. Juvenile snakes (young ones), 8-10 inches long, tend to bite the victim lower
down on the foot in the hard tissue area, and thus any signs of envenomation can take
much longer to appear.
10 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
[* If features of renal failure are noted search for other causes / mechanisms]
Sea snakes:
Sea snake bites are reported rarely among fishermen and / or their family members
living in the seashore area as well as among those who walk on the seashore. To begin
with there may be local pain which may be insignificat which appears within 60 to 90
minutes. There may not be obvious local swelling. Systemic manifestations noticed
among poisonous sea snake bite are neurological involvement, severe muscle pain,
rigidity, renal failure, hyperkalemia and finally cardiac arrest.
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 11
Treatment Guidelines for Snakebite and Scorpion sting
Investigations
20 Minutes Whole Blood Clotting Test (20WBCT)
The 20 Minutes Whole Blood Clotting Test (20WBCT) is considered as the most
reliable test for coagulation and can be carried out at the bedside without specialised
training. It can also be carried out in the most basic settings. It is significantly superior
to the ‘capillary tube’ method of establishing clotting capability and is the preferred
method of choice in snakebite. The advantages, requirements and procedure for
20 WBCT are provided in in Table no: 5
12 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 13
Treatment Guidelines for Snakebite and Scorpion sting
1.4 Treatment
First aid for snake bite
The first aid currently recommended is based around the mnemonic ‘R.I.G.H.T’.
The details are provided in Table no.6 .
This method will get the victim to the hospital quickly, without recourse to
traditional medical approaches which can delay effective treatment.
Household remedies:
Various forms of household remedies are applied to the site of bite which may
enhance absorption of venom.
14 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Snake stone:
Snake stone is applied to the site of bite saying that it will absorb the venom and
falls once the venom is absorbed. This contributes to delay in seeking appropriate
health care.
Tourniquets:
Tight tourniquets made of rope, string and cloth, have been followed traditionally
to stop venom flow into the body following snakebite. The problems noticed with
tourniquets are :-
• Risk of ischemia and loss of the limb
• Risk of necrosis
• Risk of massive neurotoxic blockade
• Risk of embolism if used in viper bites.
• Release of tourniquet may lead to hypotension.
• Gives patient a sense of false security, which encourages them to delay their
journey to hospital
Thermal methods:
• Cautery treatment is followed in some areas. It is injurious and not
beneficial
• Cryotherapy involving the application of ice to the bite was proposed in the
1950’s. It was subsequently shown that this method had no benefit and merely
increased the necrotic effect of the venom.
Electrical Therapy:
Electric shock therapy for snakebite received a significant amount of press
coverage in the 1980’s. The theory behind it stated that applying an electric current to
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 15
Treatment Guidelines for Snakebite and Scorpion sting
the wound denatures the venom. Much of the support for this method came from letters
to journals and not scientific papers. It has been demonstrated that the electric shock
has no beneficial effect and hence, it has been abandoned as a method of first aid.
Newer Methods
‘Pressure Pad or Monash Technique’
Initial research has suggested that a ‘Pressure Pad or Monash Technique’ may have
some benefit in the first aid treatment of snakebite. This method should be subjected
to further research in India to assess its efficacy. It may have particular relevance to
the Indian Armed Forces who carry Shell Dressings as part of their normal equipment,
and would thus be ideally equipped to apply effective first aid in difficult geographic
settings where the need is great.
Treatment:
While dealing with a case of snake bite consider the mnemonic ‘RASI’.
• Remember principles ( “12 As” )
• Address the problems – clinical and social
• Seek help from others when required and
• Inform the patient and / or care givers on the status of illness, clinical course,
management, outcome, welfare measures and follow up clearly with empathy.
Principles involved in the management of snake bite
The principles while managing cases of snake bite at any Health Centre are clubbed
under “12 As”
16 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
1] Admit all victims of snake bite & Keep the victims under observation for 24 to 48
hours
2] Ask effectively to get the following –
a] Ask for the description of the snake, which has bitten the patient. If snake is
brought try to identify the snake with the help of snake picture chart.
b] Ask for the site of bite and check the site. Never be carried away, by bite marks
either for diagnosis or for assessment of severity.
c] Ask for the time of the bite and correlate with the progression of symptoms and
signs due to snakebite provided in page vide supra.
d] Ask for the details of traditional medicines or household remedies used, as it
may sometimes cause confusing symptoms or interfere with other drugs to be
administered.
3] Assess the following quickly.
a] Airway, Breathing and Circulation
b] Vitals HR, RR, BP and oxygen saturation by Pulse oximetry (if required)
c] Chest expansion, and the ability to put out the tongue beyond incisors and
counting the numbers at the bed side.
d] Site of snake bite along with regional lymphadenitis clinically from head to
foot as well as back
e] For associated co-morbid illness[es]
f] For consuming any medication[s]
g] The status of envenomation - local systemic (neurotoxic, hemotoxic, myotoxic)
or a combination of them
4] Act swiftly
a] Support Airway, Breathing and Circulation
b] Start IV line [fluid for children refer to Annexure II –Table No.29]
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 17
Treatment Guidelines for Snakebite and Scorpion sting
Currently available Anti Snake Venom (ASV) in India is polyvalent i.e., it is effective
against all the four common species; Russells Viper (Daboia russelii), Common
Cobra (Naja naja), Common Krait (Bungarus caeruleus) and Saw Scaled Viper (Echis
carinatus). Indian ASV is a F(ab)2 product derived from horse serum and has a half-
life of over 90 hours. Though it is purified, it still can be immunogenic.
At present, no monovalent ASV is available primarily because there are no objective
means of identifying the snake species, in the absence of the dead snake. Moreover it
is difficult for the physician to determine which type of Monovalent ASV to employ
in treating the patient. In addition there are difficulties to prepare, supply and maintain
adequate stock of species specific monovalent ASV.
There are other known species such as the Hump-nosed pitviper (Hypnale hypnale)
where polyvalent ASV is known to be ineffective. In addition, there are regionally
specific species such as Sochurek’s Saw Scaled Viper (Echis sochureki) in Rajasthan,
where the effectiveness of polyvalent ASV may be questionable. Further work has
to be carried out with ASV producers to address this issue of preparing ASV useful
against other poisonous snakes observed in India.
In India ASV is manufactured by Bengal Chemicals & Pharmaceuticals, Kolkata;
Bharat Serums, Mumbai; Biological Evans, Hyderabad; Central Research Institute,
Kausali; Haffkins Pharmaceuticals, Mumbai; King Institute of preventive medicine,
Chennai; Serum Institute, Pune and Vins bio-products, Hyderabad.
ASV is produced in both liquid and lyophilised forms. There is no evidence to
suggest which form is more effective and many doctors prefer one or the other based
purely on personal choice. Liquid ASV requires a reliable cold chain and refrigeration
and has a 2 years shelf life. Lyophilised ASV, in powder form, requires only to be kept
cool and hence, is useful in remote areas where power supply is inconsistent. The
details of pre hospital treatment and issues related to ASV may be recorded in the form
provided in Annexure IV.
ASV Administration
Criteria
ASV is prepared from animal and hence, it should only be administered when there
are definite signs of envenomation. Anti-Snake Venom carries risks of anaphylactic
reactions and should not therefore be used unnecessarily. Unbound, free flowing
venom, can only be neutralised when it is in the bloodstream or tissue fluid. Also it
is a scarce and costly commodity. Hence, ASV may be administered only if a patient
develops one or more of the following signs / symptoms.
20 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
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Systemic envenoming
• Evidence of coagulopathy primarily detected by 20 WBCT or visible
spontaneous systemic bleeding, bleeding gums, etc., Further laboratory tests for
thrombocytopenia, Hb abnormalities, PCV, peripheral smear etc may provide
confirmation, but 20 WBCT is paramount.
• Evidence of neurotoxicity: ptosis, external ophthalmoplegia, muscle paralysis,
inability to lift the head etc.,
• Cardiovascular abnormalities: hypotension, shock, cardiac arrhythmia,
abnormal ECG.
• Persistent and severe vomiting or abdominal pain.
Dosage
In the absence of definitive data on the level of envenomation, symptomatology is
not a useful guide to the level of envenomation. Any ASV regimen adopted is at best
only an estimate. What is important is to establish a single guideline which could be
adhered to, in order to enable sensitization results to be reliably reviewed.
The recommended dosage level has been based on published research that Russells
Viper injects on average 63mg (SD 7) of venom. Logic suggests that our initial
dose should be calculated to neutralise the average dose of venom injected. This ensures
that the majority of victims should be covered by the initial dose and keeps the cost of
ASV to acceptable levels. The range of venom injected is 5mg to 147mg.
One vial of ASV neutralises 6mg of Russells Viper venom. So, to neutralize
63mg of venom, 10 vials are needed. Not all victims will require 10 vials as some may
be injected with less than 63mg. However, starting with 10 vials ensures that there is
sufficient neutralising power to neutralise the average amount of venom injected and
during the next 12 hours to neutralise any remaining free flowing venom.
Warrell et al based on their study have shown that test doses for ASV have no
predictive value in detecting anaphylactoid or late serum reactions and should not
be used. These reactions are not IgE mediated but Complement activated. They may
also pre-sensitise the patient and thereby create greater risk. For Neurotoxic / Anti
Haemostatic envenomation, 8 to 10 vials of ASV is recommended to be administered
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as initial dose. Children receive the same ASV dosage as adults, as snakes inject the
same amount of venom into adults and children. The ASV is targeted at neutralising
the venom.
Administration
ASV may be administered in two ways over a period of one hour at a constant speed
and the patient should be closely monitored for 2 hours:
• Infusion: liquid or reconstituted ASV is diluted in 5-10ml/kg body weight
of isotonic saline or glucose and administered as infusion usually. (Fluid
requirement for children refer to Annexure II)
• Intravenous Injection: Rarely reconstituted or liquid ASV is administered by
slow intravenous injection. (2ml / minute). Each vial is 10ml of reconstituted
ASV.
22 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
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ASV Reactions
* Reaction to ASV develop usually within 15 to 30 minutes or within 2 hours. So
monitor the case on ASV at 5min. interval for first 30min. and then at 15min.
interval for two hours. The details of pre hospital treatment and issues related
to ASV may be recorded in the form provided in Annexure IV.
* Some times, anaphylaxis (Type I) following ASV may develop rapidly and
deteriorate into a life-threatening emergency, and hence anticipate and observe
for it in every case. If the correct guidelines are followed, anaphylaxis can be
effectively treated.
* Therefore get alert if the patient develops of any reactions to ASV as shown in
Table no: 8.
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Picture 4 Picture 5
Case of cobra snake bite in the recovery Neuroparalysis recovering only showing
phase showing bilateral ptosis with Ophthalmoplegia
overaction of frontalis
Recurrent Envenomation
When coagulation has been restored, no further ASV should be administered,
unless a proven recurrence of a coagulation abnormality is established. There is no
need to give prophylactic ASV to prevent recurrence. Recurrence has been a mainly
U.S. phenomenon, due to the short half-life of Crofab ASV. Indian ASV is a F(ab)2
product and has a half-life of over 90 hours, and therefore is not required in a prophylactic
dose to prevent re-envenomation.
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Recovery Phase
If an adequate dose of antivenom has been administered, the following responses may
be seen:
a) Spontaneous systemic bleeding such as gum bleeding usually stops within
15 - 30 minutes.
b) Blood coagulability is usually restored in 6 hours. (Principal test is
20 WBCT).
c) Post synaptic neurotoxic envenoming such as the Cobra may begin to improve
as early as 30 minutes after antivenom, but can take several hours.
d) Presynaptic neurotoxic envenoming such as the Krait usually takes a
considerable time to improve reflecting the need for the body to generate new
acetylcholine emitters.
e) Active haemolysis and rhabdomyolysis may cease within a few hours and the
urine returns to its normal colour during the course of treatment.
f) Patients in shock blood pressure may increase after 30 minutes while on
treatment.
28 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
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Table No. 10: ASV – Risk and Wastage (Ian D.Simpson Model)
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Surgical issues
The surgical issues observed in snake bite cases are
• Ulcer following snakebite
• Necrosis of the skin and underlying tissues
• Gangrene of the toes and fingers
• Debridement of necrotic tissues
• Compartment syndrome and others
Practitioner while dealing a case of snake bite with one or other surgical
issues has been informed to remember the following and keep the patient
and the care givers accordingly.
Fasciotomy does not remove or reduce any envenomation.
Visual impression is an unrealistic guide to estimate the ICP.
Tissue injury after compartment syndrome may be disproportionate to
the clinical status.
Fasciotomy is not required for every case.
The details and approach to some of the surgical issues are provided in Table no. 11.
30 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
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Heparin has been proposed as a means of reducing fibrin deposits in DIC. However,
heparin is contraindicated in Viper bites. Venom induced thrombin is resistant to
Heparin, the effects of heparin on antithrombin III (ATIII) are negated due to the
elimination of ATIII by the time Heparin is administered and hence, heparin can cause
bleeding by its own action. Clinical trial did not show any beneficial effect.
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Botropase is a coagulant compound derived from the venom of one of two South
American pit vipers. It should not be used as a coagulant in viper bites as it simply
prolongs the coagulation abnormality by causing consumption coagulopathy in the
same way as the Indian viper venom currently affecting the victim. To conclude,
heparin and botropase have to be avoided.
the outcome in the majority of cases. It is not clear if venom can pass the placental
barrier. Pregnant women are treated in exactly the same way as other victims. The
same dosage of ASV is given. The victim should be re-assessed for the impact on the
fetus. One should be alert and rule out retro placental clot. The effects of venom and
antivenom on the mother and fetus need further exploration. ASV may be administered
to lactating woman if bitten by a poisonous snake and be treated like any other persons.
Breast feeding is not contraindicated.
Others:
Even if the patients belong to any of the following category viz., autoimmune
disorders, debilitating status, endocrine disorders, Immuno-suppressed status, HIV/
AIDS, cancer, asthma and allergic disorders or any other illness arrive with features of
snake envenomation, they also require ASV in the same manner like any other case of
poisonous snake bite.
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Fluid requirements per day should be kept in mind while giving ASV. For children
readers are requested to see the fluid requirement chart provided in Annexure II.
[Table No.29]
* Vital signs for children (see age specific chart) are provided in Annexure III.
[Table no.30 to 33].
36 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
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38 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
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• Bathing in ponds, streams and rivers, in the evening. It should not be assumed
that because the victim is bitten in water that the species is non-venomous.
Cobras and other venomous species are good swimmers and may enter the
water to hunt.
• Walking along the edge of waterways.
• Plucking flowers in areas of flower cultivation
• Plucking hay / straw from bundle of hay / straw
• Persons involved in picking up dry fire wood, loose stones, heaps of paddy,
sugar cane or jowar husk.
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40 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
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17. Ghosh S. Management of snake bite – an update. In: Bichille SK, Hasa NK,
Mehta SS. (Edrs). Medicine update. The association of physicians of india
2008; 18(chapter 90): 691-696.
18. Government Order (D) No.46, Health and Family Welfare Department, State
Government of Tamilnadu, Chennai, dated 19.01.2006.
19. Government Order (2D) No.125, Health and Family Welfare (EAP 1/1)
Department, State Government of Tamilnadu, Chennai, dated 02.11.2007.
20. Government Order (MS) No.10, Health and Family Welfare (MCA 1)
Department, State Government of Tamilnadu, Chennai, dated 09.01.08
21. Health and Family Welfare (P1) Department, State Government of Tamilnadu,
Chennai, Letter No. 637/P1/06-2 dated 27.01.06
22. Ho M, Warrell MJ, Warell DA, Bidwell D, Voler A. A critical appraisal of the
enzyme linked immunosorbent assays in the study of snake bite. Toxicon 1986;
24:211-221.
23. Howarth DM, Southee AS, Whytw IM, Lymphatic flow rates and first aid
in simulated peripheral snake or spider envenomation. Medical Journal of
Australia 1994; 161: 695-700
24. Jeganathan N.Siddha Medicine for poisons. In: Subramanian SV, Madhavan VR.
Heritage of tamils: Siddha Medicine. International Institute of Tamil studies,
T.T.T.I, Taramani, Chennai 600 113. March 1983; chapter 31; 504 – 522.
25. Kalantri S, Singh A, Joshi R, Malamba S, Ho C, Ezoua J, Morgan M. Clinical
Predictors of in-hospital mortality in patients with snakebite: a retrospective
study from a rural hospital in central India Tropical medicine and International
health. 2005; 11(1): 22-30
26. Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK,
Pathmeswaran A, etal. (2008) The global burden of snakebite; A literature
analysis and modeling based on regional estimates of envenoming and deaths,
PLoS Med 5(11): e218 doi:10.1371/journal.pmed.0050218
27. Kularetra SAM, Reaction of snake venom antisera: study of pattern, severity
and management at General Hospital, Anuradhapurra, Sri Lanka J Med 2000: 9:
8-13.
28. Management of Snakebite. Training module for staff nurse and auxillary nurse
midwife. Basic emergency services for poisoning, State Health Mission Health
and Family Welfare Government of Tamil Nadu, Chennai. 2007, 33-42, i-vii
29. Medical management of severe anaphylactoid and anaphylactic reactions.
www.australianprescriber.com/magazine/24/5/artid/546/ accessed on 08.02.08
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 41
Treatment Guidelines for Snakebite and Scorpion sting
30. Nayak KC, Jain AK, Sharda DP, Mishra SN. Profile of cardiac complications
of snake bite. Indian Heart J. 1990 May-Jun;42(3):185-8
31. Norris RL, Ngo J, Nolan K, Hooker G, Physicians and lay people are unable
to apply Pressure Immobilisation properly in a simulated snakebite scenario
Wilderness and Environmental Medicine 2005;16:16-21
32. Norris RL, Bite marks and the diagnosis of venomous snakebite. Journal of
Wilderness Medicine 1995; (6): 159-161
33. Pahlajani DB, Iya V, Tahiliani R, Shah VK, Khokhani RC. Sinus node
dysfunction following cobra bite:case reports. Indian Heart J. 1987:39:48-9
34. Pillay VV. (Edrs). Modern Medical Toxicology. Third Edition. Jaypee Brothers.
medical publication(P) Ltd., New Delhi 110 002. 2005; PP 499 + xviii
35. Rajendiran C, Simpson ID. Indian National Snake bites Protocol-2007
(OP-040). Abstract book of 6th annual conference of Asia Pacific Association of
Medical Toxicology held at Bangkok, Thailand, December 12-14, 2007 P.104
36. Sarangi A, Jena I, Sahoo H, Das JP. A profile of snake bite poisoning
with special reference to haematological, rental, neurological and
electrocardiographic abnormalities. J
37. Singh S, Dass A, Jain S, Varma S, Bannerjee AK, Sharma BK. Fatal
non-bacterial thrombotic endocarditis following viperine bite. Intern Med.
1998 Mar;37(3):342-4.
38. Senthilkumaran S. Cardiac complications among snake bite victims. Personal
communication
39. Simpson ID. The paediatric management of snake bite . The National Protocol.
Indian Pediatrics 2007,44:173-176
40. Simpson ID, Norris RL. Snakes of Medical importance in India: In the concept
of the “ Big 4” still relevant and useful? Wilderness and Environmental Medicine
2007; 18(1) : 2-9
41. Simpson ID. Snake bite management in India, the first few hours: a guide for
primary care physicians. Journal Indian Medical Association 2007;105: 324,
326, 328, 330, 332, 334 & 335.
42. Simpson ID. Indian National Snake bite Protocol. www.indianwildlifeclub.
com/blog/topic.asp?id_top=10 accessed on 28.01.08
43. Sharma S, Chappins F, Jha N, Bovier PA, Loutan I, Koriala S. Impacts of snake
bites determinants of fatal outcomes in Southern Nepal. Amer J Trop Med Hyg
2004; 71(2):234-38
42 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
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44. Srivastava RK. Director General, Office of the Directorate General of Health
Services, Nirman Bhawan, New Delhi – 110011. Letter D.O.No.D.32020/3/2008
– EMR, Dated 5th February, 2008.
45. Training module Poison First aid and Treatment Centre (BEmONC, PHC),
State Health Mission Health and Family Welfare Government of Tamil Nadu,
Chennai. 2008.
46 Thirumalaikolundusubramanian P, Areas for research on Snake Bite / Scorpion
Sting, Personal records.
47. Thirumalaikolundusubramanian P, Rajendiran C. Medical audit for snake bite
and scorpion sting. Unpublished records
48. Tun Pe, Tin-Nu-Swe, Myint-Lwin, Warrell DA, Than-Win, The efficacy of
tourniquets as a first aid measure for Russells Viper bites in Burma Trans. R
Soc Trop Med Hyg 1987; 81:403-405
49. Tun P, Khin Aung Cho. Amount of venom injected by Russells Viper (Vipera
russelli) Toxicon 1986; 24(7): 730-733
50. Veerapandian R. [Edrs]. Guidelines for common surgical interventions in
the elderly. Developed under WHO – Government of India collaborative
programme 2006-07. August 2007.
51. Visweswaran RK, George J. Snake bite induced acute ranal failure. Indian J
Nephrol 1999; 9(4): 156-159.
52. Warrell, D.A. (Edrs). 1999. WHO/SEARO Guidelines for The Clinical
Management sof Snakebite in the Southeast Asian Region. SE Asian J. Trop.
Med. Pub. Hlth. 30, Suppl 1, 1-85.
53. Warrell, D.A., Davidson, N. McD., Greenwood, B.M., Ormerod, L.D., Pope,
H.M., Watkins, B. J., Prentice, C.R.M.. Poisoning by bites of the saw-scaled or
carpet viper (Echis carinatus) in Nigeria. Quart. J. Med. 1977;46: 33-62.
54. Wen Fan H, Marcopito LF, Cardoso JLC, Franca FOS, Malaque CMS, Ferrari
RA, Theakston RD, Warrell DA, Sequential randomised and double blind trial
of Promethazine prophylaxis against early anaphylactic reactions to antivenom
for Bothrops snake bites. BMJ. 1999; (318):1451-1453
55. When a cobra strikes. The Hindu (Online edition of India’s National newspaper)
June 13,2004. www.thehindu.com accessed on 30th June 2008.
56. Yildirim C, Bayraktaroglu Z, Gunay N, Bozkurt S, Kose A, Yilmaz M. The
use of therapeutic plasmapheresis in the treatment of poisoned and snake bite
victims: an academic emergency department’s experiences. Journal of Clinical
Apheresis 2006;21(4):219-23.
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 43
SECTION - II
SCORPION STING
Titles Page
2.1 General 45
• Introduction
• Epidemiology
• Eco-biological aspects of scorpion
• Distribution of various species of scorpions
• Socio cultural aspects
2.2 Clinical aspects 47
• Components of venom and mechanisms of action
• Pathophysiology
• Symptoms and signs.
• Criteria for diagnosis
• Differential diagnosis
• Investigations
• Clinical course
• Complications
2.3 Treatment 54
• First aid measures
• Traditional methods
• Principles involved in the management
• Pharmacological aspects of Prazosin
2.4 Scorpion sting in special situations 60
2.5 Management at PHC and Block PHC 60
2.6 Referral aspects 62
2.7 Occupational risk, patient education and prevention 63
2.8 Prognosis 64
2.9 Resource Material 64
Treatment Guidelines for Snakebite and Scorpion sting - 2008
2.1 General
Introduction
Scorpion sting is a life threatening medical emergency. The effect of envenomation
is greatest among children below 5 years of age. Adults too can succumb to scorpion
sting. Many social and environmental factors contribute to scorpion sting. Hence, it
becomes an important public health problem. The epidemiology, presenting features,
clinical course, complications, therapeutic response and outcome are variable in
different series. However, early recognition and appropriate intervention influence the
outcome. Hence, scorpion sting deserves special attention and cases should never be
taken lightly.
Though the research on scorpion venom and knowledge on treatment of scorpion
sting have advanced, these newer ideas are yet to reach the health care provider and
the community. In this context, it is worthwhile to remember Dr.H.S.Bawaskar, a
private practitioner from Maharashtra who for the first time in world has introduced
the usefulness of alpha blocker in scorpion sting nearly 25 years ago. This has been
accepted globally now in the treatment of scorpion sting.
Epidemiology
In general for every case of snakebite, there may be 10 or more numbers of scorpion
stings. If that is the case, the number of cases of scorpion sting may run to millions.
There is no reliable statistics on the scorpion sting in India. Scorpion sting is under-
reported. Published reports are institution based, hence include only serious cases of
scorpion sting treated in such institutions. As most of the cases of scorpion sting have
mild symptoms, the general practitioners or family physicians or a traditional medical
practitioners provide treatment and they never appear in health statistics.
In Mexico, 1000 deaths due to scorpion sting occur per year whereas in USA four
deaths were reported in 11 years. Of the 13,000 stings reported in USA, majority was
due to non lethal scorpions. Most deaths occur during the first 24 hours of the scorpion
sting and are secondary to respiratory and cardiovascular failure. Children and elderly
are at great risk of death due to their decreased physiological reserve. Death due to
scorpion sting occurs in 25% of children below 5 years, if not treated, whereas only
1% of scorpion stings are lethal to adults.
In India too, deaths due to scorpion sting occurs across the country but do not get
due attention. Larger the scorpion population, greater is the number of scorpion sting
cases. Scorpion stings are reported more from rural areas and the rural to urban ratio
is approximately 3:1. Mostly stings occur between 6 P.M. to mid-night and between
6 A.M. to 12 Noon, which correlate very well with human activity. Scorpion sting
occur more in temperate and tropical zones, and more during summer than winter.
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The Institute of child health, Madras Medical College, Chennai, has recorded nearly
1900 cases between 1980 and 1999 and the death rate varied from 4 to 7%. Of the 727
cases of scorpion stings treated during the period of 2000-2007 which included 406
males and 321 females [M: F= 4:3]; the death among them were 11 and 8 respectively.
The death rate in children due to scorpion sting was 2% which has come down from
4 to 7% earlier.
In general, male to female ratio of scorpion sting is approximately 2:1 but females
suffer more due to lower body weight. There is no racial predilection but clinical
symptoms, course, and outcome vary because of individual’s genetic constitution and
other factors [vide infra]. Human stinging occurs accidentally, when scorpions are
touched, threatened, cornered or disturbed (stepped upon) while in their hiding places.
So, people involved in handling construction materials, carpentry works, clearing
bushes or house cleaning as well as children playing nearby these areas are susceptible
to scorpion sting.
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Scorpions use their pincers to grasp the prey. It arches its tail over its body and
stings into its prey. Thus it injects its venom, sometimes more than once. The venom
glands are situated in the tail. The striated muscles in the stings regulate the amount of
venom injected. When entire venom is used, it takes several days to replenish venom.
Scorpion with large venom sacs such as Parabuthus species can even squirt their
venom.
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Pathophysiology
The venom is produced by columnar cells of the venom glands. Scorpion venom
is water soluble, antigenic and positively charged. It is a heterogenous mixture and
this can be easily demonstrated by electrophoresis method. Also, the heterogenisity of
the venom explains the variable response to venom as observed in different people.
Normally injected venom is between 0.1 to 0.6mg. Generally most lethal scorpions
have a lethal dose (LD50) below 1.5mg. The potency varies with species causing mild
flu to death with in an hour. Humans are much more sensitive than mice.
Once the venom is injected, it is distributed rapidly into the tissues. If the venom
is deposited into a vein, the symptoms develop within 4 to 7 minutes after injection,
with a peak concentration in 30 minutes. The half life of venom varies from 4.2 to 13.4
hours.
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Local signs at the site of sting are further classified into non-lethal local effects as well
as neurotoxic and cytotoxic local effects. The details are provided in Table No: 18.
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Haematology
- Complete Blood Count (CBC)
- Leukocytosis
- Hemolysis (variable)
- Coagulation profile
- Defibrination [if required]
Blood Chemistry
- Blood sugar
- Serum creatinine
- Serum creatine kinase
- Serum amylase / lipase
- Serum aspartate / alanine amino transferase
- Arterial blood gas (ABG) analysis [if required]
Imaging studies
• Chest x – ray
Other investigations
• Electro cardiogram & serial ECG (monitor ST, T & others) during follow up.
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Clinical Course
Clinical course of scorpion sting is usually less alarming but in some cases it
may progress to maximum severity in about 5 hours to 12 hours and starts subsiding
within a day or two. Even if the patient has features of autonomic nervous system
manifestations, it may start subsiding by 12 hours after initiating treatment. Tachycardia
usually subsides within 24 to 48 hours. Hypertension may last for 4 to 8 hours.
Hypotension and bradycardia are encountered usually within 2 hours. Once treatment
is started, the signs of recovery begins within 48 or 72 hours. In some cases pulmonary
edema may develop within 30 minutes to 3 hours, usually secondary to myocardial
dysfunction. Unfortunately some cases of scorpion sting may die within 30 minutes
and this may be related to ventricular arrhythmias or non cardiac pulmonary edema
due to ARDS [often reported from Brazil]. Central nervous system manifestations with
or without convulsions may occur within one to two hours in fatal cases.
Complications
Various complication of scorpion sting are:
• Respiratory failure
• Multi organ failure
• Dilated cardio myopathy
• Rhabdomyolysis
• Persistent paresthesia
• Anti venom anaphylaxis and serum sickness
• Ankylosis of small joints if sting occurs at a joint
• Iatrogenic high dose sedative hypnotic respiratory arrest
2.3 Treatment
The first aid currently recommended is based around the mnemonic ‘R.I.G.H.T’. The
details provided earlier in Table no.6 is again furnished below for easy reading.
54 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
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Traditional methods
The traditional methods such as application of counter irritants, herbal materials
or paste over the site of sting or tight tourniquet (it may intensify local effects of
venom), or hot fomentation should be avoided as they may enhance the effects of
venom. Also avoid cutting and suction (oral extraction of venom from the site), or
cutting and letting out the blood, or washing the wound with chemicals or alcohol or
other methods as they facilitate the absorption of toxin. In view of the consequences
noticed, these traditional methods have to be discarded.
However, local application of ice bags (one of the traditional methods) to reduce
the pain is acceptable for some time if not contraindicated. This method slows down
the absorption of venom via vasoconstriction. This is the most effective one during the
first 2 hours following the scorpion sting. One should not cause freezing injury, while
using ice cubes / bag.
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• Prazosin should not be given as prophylactic dose when pain is the only
symptom.
• Give Prazosin through nasogastric tube, if baby has vomiting.
• Keep the patient in lying posture for about 3 hours (even while examining
the case) in order to prevent ‘first dose phenomenon’ (hypotension) due to
Prazosin.
• Monitor pulse, BP, and respiration every 30 minutes for 3 hours.
• Reassess for warmth and return of pain at the site of sting.
• Continue monitoring of pulse, BP, and respiration every 60 minutes for next
6 hours.
• Recheck the same every 4 hours till improvement is visible.
• Repeat Tab. Prazosin in the same dose at the end of 3 hours according to
clinical response and later every 6 hours till extremities are warm, dry and
peripheral veins are visible easily.
g] Beta-blockers in small doses along with alpha blockers if needed and if not
contraindicated.
h] Nitrates if patient has hypertension and myocardial ischemia
i] Ionotropics such as digitalis (has little effect), or dobutamine (refer snake bite
section for details). Avoid Dopamine as it aggravates the myocardial damage.
j] Nor-epinephrine as IV drip to correct hypotension refractory to fluid therapy.
k] Antimicrobials if infection is suspected
l] Inj. Atropine (required at times) to counter venom induced parasympathetic
effects.
m] Inj. Insulin has been shown to prevent multiorgan failure (especially cardio-
pulmonary) in animal experiments.
n] Barbiturate and / or benzodiazepine as continuous infusion for severe /
excessive motor activity
o] Steroids to decrease shock and edema is of unproven benefit.
p] Antivenom for scorpion sting is not used commonly in India (as species specific
antivenom is not available and usage has not demonstrated any benefit)
q] Vaccine – not available (tried in experimental animals).
r] IV fluids as per need [fluid for children- refer Annexure II Table No.29].
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within their context and setting. The principles envisaged to treat scorpion sting at
all Health Centres / Hospitals irrespective of the status (Government or Private) are
given in Table no: 7 (vide supra under treatment) The initial evaluation and systemic
manifestations following scorpion envenomation (described in Table 18, 19 and 20,
and Figure 1 and 2), and treatment aspects are provided in detail vide supra. However,
a format for quick assessment is provided in Table 22 and 23 (refer Annexure VIII
and X).
Table No. 22: Initial evaluation of scorpion sting without
Systemic Envenomation
Fluid requirements per day should be kept in mind while managing the case.
For children readers are requested to see the fluid requirement chart provided in
Annexure II.
* Vital signs for children (see age specific chart) provided in Annexure III.
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SECTION - III
MISCELLANEOUS
Titles Page
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3.5 What patients and care givers should know about snake bite /
scorpion sting?
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• Scorpions are shy creatures, which hide in crevices and burrows, and sting if
cornered, disturbed or threatened
• Destruction of snake / scorpion will not have any effect on mortality
• Venom variation has been identified among the subsets of snakes / scorpions
• Venomous snakes / scorpions do not inject venom sometimes or inject only
small quantity of venom
Antivenom
• Separate ASV is not available for individual venomous snakebites in India.
• Antivenom made for Indian Russell’s Viper, may not be effective for Russell’s
Viper bite of Srilanka
• Anti venom is effective but not without side / adverse effects
• Adverse effects have to be observed and tackled immediately
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Follow up
• Follow-up checks are required for assessment of long term effects on different
organs / systems and appropriate management has to be instituted wherever
required / needed.
Limitation
• Laboratory investigations are of little value in the diagnosis of severity of
envenomation or the sub-type of snake due to biological variations, but assist
for intervention
• Currently available treatment modalities and supportive care attempt to reduce
morbidity, alter the clinical course, enhance natural process of recovery and
minimize mortality.
Welfare measures
• More deaths occur following snake bite / scorpion sting outside the hospitals,
and at times deaths occur inside the hospital despite treatment, because of the
patients’ biological characteristics
• Many state governments in India provide solatium to the family members of
the deceased snake bite victims.
Prevention
• At present no effective vaccine is available against snake bite and scorpion sting.
Hence, the community must be motivated to understand and adopt preventive
measures always.
• Also, the people should be made aware of the first aid measures and adopt early
health seeking behavior before complications set in.
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Objectives
• To determine the probable reasons that might have contributed to death
• To find out the lapses and failures in the management
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Goals
• To introduce remedial measures at all levels.
• To counsel and guide the affected victim and their family.
• To create awareness among the community.
• To implement preventive strategies so as to reduce mortality and morbidity.
Vision
• To provide appropriate care and support for snake bite and scorpion sting cases
at all Health Centre / Hospital at all times.
Principles of audit:
• Not to blame each other, but to improve
• Avoid reduplication of cases
• Refrain from false statement / data
• Find out the reasons for lapses / deficiencies
• Provide feed back to members at all levels
• Get suggestions from end users
• Find out ways for improvement and to implement them
• Place the data and resolutions / remedial measures on the web site
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Role of reviewer
• Adhere to reviewing of achievement of objectives, goals and vision
• Remember principles and outcome of audit
• Review the data with reference to responsibilities of health care providers/
professionals
• Consider medical / social problems faced with each case
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Table No. 27: Formula to calculate case fatality rate at different levels
Case fatality rate for snake bite Total number of death(s) due to snake bite /
/ scorpion sting at local health scorpion sting for the particular month x 100
centre / hospital for the particular -------------------------------------------------------
month = Total number of cases (alive & dead) of snake
bite / scorpion sting brought to the health
centre / hospital for the particular month
Total number of death(s) due to snake bite /
Case fatality rate for snake bite / scorpion sting for the particular month in that
scorpion sting at the level of health health unit area x 100
unit for the particular month = --------------------------------------------------
Total number of cases (alive & dead) of snake
bite / scorpion sting brought to the health
centres / hospitals of that health unit for the
particular month
Case fatality rate for snake bite / Total number of death(s) due to snake bite /
scorpion sting at the level of scorpion sting of that revenue district for the
revenue district for the particular particular month x 100
month = --------------------------------------------------
Total number of cases (alive & dead) of snake
bite / scorpion sting brought to the health
centres / hospitals and those applied for
welfare to the collectorate for the particular
month
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Case fatality rate for snake bite / Total number of death(s) due to snake bite /
scorpion sting at the level of Tamil scorpion sting for the particular month in
Nadu state for the particular different revenue districts x 100
month = --------------------------------------------------
Total number of cases (alive & dead) of
snake bite / scorpion sting brought to the
health centres / hospitals of different revenue
districts and data from collectorates for the
particular month
2) Ratio of time interval for treatment: In Tamil Nadu due to the available health
infrastructure, the maximum time required to reach the nearest health centre is
estimated to be 30 minutes. Hence the ratio of time interval for treatment is the
ratio of actual time taken to reach health centre / hospital to the estimated time
required [i.e., 30 minutes] and calculated as per the formula given in the box below.
The ratio should always be below one and infact it should be as low as possible. If
the ratio is one or more than one, it indicates delay in reaching the health centre /
hospital. Then elicit the probable reasons for each and try to rectify them. This has
to be reviewed at different levels. (details may be collected from Annexure IV)
*Estimated time required to reach the health centre / hospital (30 minutes) is an
arbitrary one and the ratio of time interval for treatment is calculated to understand
the awareness and utilization of health care. However, the ratio should not be used as
a lone factor to assess or predict the clinical aspects, course and outcome, as these are
influenced by multiple factors.
3) Referral rate: Once the treatment is started early, it is expected that referral will
come down. This has to be analysed in relation to the reasons for referral (Annexure
XIV) and efforts to be taken to minimize the referral without compromising patient
care service. Moreover, referral rate has to be analysed at all levels like CFR and
measured in percentage.
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V. Managerial issues:
1. Analysis of welfare programmes: awareness and utilisation members of
deceased snake bite victims.
2. Utilization of facilities for snake bites at primary care level: problems and
solution.
3. Influencing factors for utilisation of ASV.
4. Production and utilization of ASV in India.
5. Managerial issues in the treatment of snake bite.
6. Analysis of referral status of snake bite.
7. Outcome of snake bite in ralation to transport modalities adopted.
8. Utilisation and issues related to ambulance services for snake bite victims.
9. Medical audit of snake bite records.
10. Public private partnership in the management of snake bite.
11. Utilisation of NGOs in snake bite management.
12. Welfare policies for snakebite victims and their families in different union
territories / states of India.
13. Inter-regional variations on outcome of snake bite.
14. Designing and developing a software for documentation and analysis.
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3.11 Conclusions:
The ultimate goal is to provide appropriate first aid and treatment at the nearest
health centre / hospital at the earliest. Complicated cases have to be referred to higher
centre after first aid and supportive measures. Community should receive health
education on preventive and curative aspects of snakebite and scorpion sting. Each
health centre / hospital irrespective of the status should maintain a registry for snake
bite / scorpion sting and initiate research activities in a trans-disciplinary manner.
All these joint efforts will bring down the morbidity and mortality. In addition health
care institutions should undertake research activities on various aspects of snake bite /
scorpion sting, and share the knowledge and experience with others in order to advance
further in health care delivery.
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SECTION - IV
ANNEXURES
Titles Page
Annexure : I
Table No. 28: Snake bite cases & deaths reported and ASV vials used in
secondary care hospitals in Tamil Nadu (District wise)
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Annexure: III: Vital signs reference table for paediatric age group
Respiratory rate
Normal spontaneous ventilation is accomplished with minimal work, resulting in
quiet breathing with easy inspiration and passive expiration. The normal respiratory
rate is inversely related to age. It is rapid in the neonate, then decreases in older infants
and children. A respiratory rate consistently greater than 60 breaths per minute in a
child of any age is abnormal and is a “red flag”.
Toddler (1 to 3 years) 24 to 40
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Preschooler (4 to 5 years) 22 to 34
School age ( 6 to 12 years) 18 to 30
Adolescent (13 to 18 years) 12 to 16
Heart Rate
Heart rate should be appropriate for the child’s age, level of activity and clinical
condition (Table 2). Note that there is a wide range for normal heart rate and that it
varies in a sleeping and awake child.
References :
• Hazinski.M. Children are different In:Hazinski M, ed. Manual of Pediatric
Critical care. St.Louis, MO: Mosby year book ; 1999. Chapter 1,5-6.
• Allen HD, Driscoll DJ, Shaddy RE, Feltes TF (Edrs). Moss and Adams’ Heart
Disease in Infants Children and Adolescents Including the Fetus and Young
Adult. Lippin cott, Williams and Wilkins, Baltimore, MD, USA, 2007.
Blood Pressure
Normal blood pressure values for children by age is provided in Table 32. This
table summarizes the range from the 33rd to 67th percentile in the first year of life and
from the 5th to 95th percentile for systolic and diastolic blood pressure according to age
and gender and assuming the 50th percentile for height for children of one year of age
and older. Like heart rate, there is a wide range of values within the normal range.
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Hypotension
Hypotension is defined by the following thresholds of systolic blood pressure
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Annexure IV: Pre hospital treatment for Snake bite and issues
related to ASV
(one for each case)
1. Name: S.No: Date:
2. Age:
3. Medical unit: IP NO:
4. Gender: Male / Female:
5. Hospital:
Details about the snakebite:
6. Time of snake bite ________ am / pm
7. Victim walked home - yes / no
8. Shifted home manually - yes / no
9. If yes, state poisonous / non-poisonous
10. Nature of snake specify - Viper (type)...../ Cobra / Krait / Sea snake / others...
11. Nature of snake specify - Viper............./ Cobra / Krait......./ Sea snake group
Pre hospital treatment:
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ASV related:
20. ASV administered – yes / no
21. If yes, Time of starting ASV___________ am / pm
22. Time interval between snakebite to time at which ASV started (21 - 7)......
23. Probable reason for delay in bite to needle time
a. Travel related
b. Beliefs and practices of traditional medicine
c. Failure to recognize symptoms
d. Sub optimal family support systems
e. Financial constraints
f. Any other, specify______________
24. Test dose for ASV given – yes / no
25 If yes, mention the details of reaction(s):...................
26 Mention if any prophylactic medications given - yes / no
27 If yes, mention the details of drugs given ....................
28. Reaction(s) while on ASV – yes / no
If yes, describe the nature of reaction to ASV and details of
management...............
29. Time taken to complete first dose of ASV...............
30. Time interval between starting and completing first dose of ASV
(29 - 21)......
31. Form of ASV used - Lyophilized / liquid form
32. Name of the manufacturer of ASV________________ Lot No.__________
Batch No._______________ Date of Expiry_____________
33. Mention if any repeat dose of ASV given -yes / no
If yes, reasons for repeat dose .........................................
34. Total quantity of ASV given (in ml)
35. Any others (specify) …..........
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u u C
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prazosin
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R
I
G H
T
symptoms
2
for
&
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Paresthesia
persists
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• Tamil language is an ancient language. The poems and proverbs of the Tamil
language describe the status of living at that time, highlight their knowledge,
express talents, reflect cultures, bring out tradition and reveal their beliefs and
practices, though the place of origin may not be available clearly. One can
also appreciate the changes that had happened over a period of time through
literature. Based on the circumstantial evidences the time of origin has been
calculated.
• Communicating to a group of persons in their own language using the poems,
proverbs and the procedures adopted in that region, will help to win their
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confidence. Thereafter changing them and bringing them into the scientific
arena is easier. Once a community gets convinced, it is easy to convey health
messages and they get adapted to newer methods which will be of immense use
for their health and welfare.
• Good amount of information is available in Tamil Literature and Tamil medicine
on symptoms, clinical course and outcome of it. Infact the descriptions are
better than what is available today. Their knowledge on types of snakes and
scorpions are simply astonishing. This can be used to educate the community
and make them realize the usefulness of modern medical treatment for better
outcome.
• Proverbs irrespective of the language help to explain or convey messages within
and outside a community. Historically collected proverbs of Tamil literature is
displayed as early as 5 A.D. one each under one poem of “Pathinen keezh
kanakku Nool”. Tamil being an advanced language with high level of grammer,
it has given criteria / guidelines for poems and proverbs and these are made
available in Tholkappiam (poem 177) and Agananooru (poem No.101: 2 – 2
and 66 : 5-6)
• Most of the proverbs are thought provoking, contain rich information and are
unique to the language. Also, these proverbs help to transfer relevant facts with
beauty and brevity between the speaker and the audience or readers. Moreover
poems and proverbs act as a bridge between health care professional and the
patients or the public to convey health messages convincingly, clearly, and
confidentially within few minutes.
• When a speaker uses an apt poem or proverb or both to convey a message to
the community, their understanding is greater, ability to accept is better and
the capacity to transfer the message in real life is superior. Keeping all these
in mind efforts are made to bring / provide Tamil proverbs and certain aspects
of Tamil medical practices in relation to snake bite and scorpion sting is given
below.
• The health care professions involved in patient care and community education
programme are informed to make use of the information provided. When the
professionals use the literary phrases / poems available in their own language,
community acceptance the greater. Hence changes will occur which can be
measured quantitatively. Health care providers can make use of the proverbs
and collect more proverbs and poems related to snakebite and scorpion sting,
and forward to us which will be of great use to subsequent editions.
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14. gh«Ã‰F gšèš k£L« jh‹ éõ« Mdhš ghéfS¡F clš KGtJ« éõ«
32. njS¡F kâa« bfhL¤jhš, rhk¤J¡F (bghGJ éoÍ« k£L« ãäl¤J¡F ãäl«)
bfh£L«
gh£L
f©lJ gh«ò
fo¤jJ fU¡F
‹wJ kUªJ
bfh‹wJ kU¤Jt‹
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Annexure XIII: Form to assess the quality of services rendered to snake bite /
scorpion sting for the month of ……….200…/ for the quarter ending March /
June / September / December200........
Name of the Health Centre / Hospital …………………………Code No……….
Observations /
Sl.
Quality of services Problems / Remarks
No
Complaints
1. Clinical matters
• Admission
• Assessment & Administration of
appropriate drugs
• Observation on adverse reactions to
ASV and / other drugs
• Lapses in clinical care
• Referral of cases
• Morbidity status for the reporting
month
• Mortality
• Sharing of experiences with others
• Guiding on welfare programme
• Others –specify
2. Preventive aspects
• Organising awareness programmes
• Reduction in the time interval
between bite / sting to
hospitalisation
• Immobilisation of the victim
• Avoidance of traditional practices
• Any other – specify
3. Administrative issues
• Availability of medications
• Submission of report to higher
authorities
• Monitoring and review of
a. Patient care
b. Preventive aspects
• Any other – specify
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Annexure XIV: Form to analyse and audit the statistics on snake bite /
scorpion sting for the month of ……….200…../ for the quarter ending
March / June / September / December 200…
Name of the Health Centre / Hospital ………………….....Code No……
1.
2.
3.
4.
5.
6.
7.
8.
9.
b.
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Guidelines
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