Original Article

Profile of Snakebite Envenoming in Rural Maharashtra, India

HS Bawaskar*, PH Bawaskar*, DP Punde**, MK Inamdar***, RB Dongare+, RR Bhoite++

Abstract

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

INTRODUCTION

Snakebite is a common acute medical emergency faced by rural populations in tropical and subtropical countries with heavy rainfall and humid climate.^1,2 There are no accurate records available to determine the exact epidemiological or even mortality in snakebite cases in Maharashtra. Recently 35000-50000 snakebite deaths reported from India.³ Echis carinatus (Saw scaled viper) flourished in a hot humid climate like that in Raigad region. Farming is main occupation in Sholapur (S), Nanded (N), Aurangabad (A) and Pune (P) districts. Cobra, Russell’s viper flourished in a dry and hot climate like that in S, N. A districts. Mud houses with grooves in wall and the basement give easy shelter for snakes and rats particularly in N and A districts (Fig. 1E) and hut with a lose stone basement. Villagers always sleep on the floor and is more risky for krait bites. During night hours fast transport is not available, victims are carried in a bamboo basket, bullock cart or on the back. At times vital time is often lost by taking victims to the Mantrik (village healer), resulting in delayed western-style treatment.⁴ At primary health centers adequate quantity of anti-snake venom may not be available, at times medical officer remain absent during night hours being busy in private practice at near by big town (tehsil place) or may not have treated the snakebite case before.⁵ Thus ignorance of conventional treatment of snakebite by doctors further delays proper treatment of victims and contributes to morbidity and mortality.^4,6 Mortality rate is further increased by inadequate administration of initial dose of ASV particularly in elapid and Russell’s viper snakebite. Lack of simple method of tracheal intubations and ventilation by an amboo bag or artificial ventilator in neuro-toxic envenoming. Newly posted medical officer at PHC is not aware of gold standard 20 minute whole blood clotting (20WBCT) simple bed side test for to monitor the blood clotting and guide for administration of extra dose of ASV.^4,6 In villages dry wood, storage of dry cow-dung a fire wood used for cooking purpose are collected near the residence. The dry ash collected in a chulla (A small furnace made of mud) after cooking left after night cooking. This ash remains cold during hot environment and warm in cold environment thus during night hours snake find a pleasant environment. Early in the morning housewife blindly puts her hand in Chulla just to remove the ash and often gets snake bite (cobra or krait) (Fig. 1ABC).

Patients and methods

We selected the five physicians who are regularly treating the snake bite cases in their area > 5 years. Total cases admitted in one year were studied for clinical manifestations, their management and out come. Those with clinical manifestations with systemic involvement or signs and symptoms suggestive of venom has been injected at the time of bite were included in present study. Poisonous snake (Eh, Rv, Cr and Kr) flourished allover studied regions. In these five districts people are aware of their past experience of high morbidity and fatality in a case of snakebite without treatment or delayed hospitalization, hence rather wasting time by attending mantrik or in search of culprits, reported to respective clinics earlier. Being endemic area of poisonous snakes physician practicing in these region are well aware and knowledgeble and experienced regarding clinical manifestations and management of snake bite victims.^5,7 Three physicians Aurangabad (A), Sholapur (S) and Pune (P) have a ventilator while those from Raigad (R) and Nanded (N) have only amboo bag a manual artificial respiratory support for cases with neurotoxic envenoming with respiratory paralysis.

RESULT

Out of 182 cases of snakebite 68(37%) were female cases of snakebite were admitted in a one year at these five rural clinics. 125 (68%) are between age 21-40 years are actively involved in farming. 39(81%) cases of krait bite are reported in the month June, to September while viper bite cases are reported in all months (Tables 1, 2).

Envenoming by Echis carinatus or saw scaled viper or carpet viper - (Figs. 2 and 3)

Fifty five cases had bitten by echis carinatus. 42(76%) cases reported during day time. Of these 40(72%) cases were bitten to upper extremities. 18 (32%) reported in the month of February and March while 24 (43%) reported in the months of July, August and September. 38 (69%) cases were between age 11-40 years. 53 (96%) had local edema with fangs marks, while 2 cases applied local herbal remedies was difficult to identify the fangs marks and edema which was confirmed after washing the bitten part. 40 (72%) had active bleeding from vein puncture site and abrasion over other part of body. While 19(34%) had active bleeding from gums, and hematuria. Total amount of ASV administered was 20-70 Ml (average 43.75 ml). Three patients were sensitive to ASV. ASV was administered with in an intravenous drip preceded intramuscular adrenaline.

Case no. 1

Fifteen years old tribal boy was brought by his mother with complaints of body-ache, weakness, unable to sleep during whole night. He denied history bite, febrile illness, and pain in abdomen or headache. On examination there was mild tenderness over neck muscles. No ptosis or signs of bulbar palsy, reflexes present and both planters were flexors. There was slight active bleed from the right margin of tongue and gums, there was fangs marks with fullness over right supra- clavicular fossa. He attributed this to the cat bite during night because he saw a cat was sleeping in the corner of his hut. His blood did not clot within 20 minute (20MWBT). He was given 20Ml ASV administered over one hour and another 20 ml over slow intravenous drip over 24 hours. Active bleeding stop within 30 minute, edema disappeared within 24 hours patients felt better. Blood clotted within 20 minute (20WBCT) at the end of 6 hours of administration of initial dose. He was given tetanus toxoid, ampicillin and cloxacilin four times day for five days.

Case No. 2

Forty five years old male migrated from Bihar to Mahad. He gave history of snake bite (echis carinatus) to his left index finger while harvesting grass over bund. He saw snake, it was one feet long. He experienced pain, swelling extending to left arm, enlargement of axillary lymph-nodes. He reported to mantrik. Mantrik gave him some herbal solution. He had severe projectile vomits soon after he drunk the solution. Mantrik told him that all venom from the body is expelled out through vomits. Two hours after bite he had bouts of hemetemesis and hematuria for 12 hours and it stops its own without any treatment. He coughed out blood stained sputum. Swelling over bitten limb was increased. He reported to hospital 3 days after snakebite. He complaints of severe weakness, pain in left arm. On examination he was marked pale. Blood pressure 110/80 mm Hg with pulse rate 122 per minute. No history suggestive of decreased urine out put. He was given 40 ml of ASV over one hour. He denied for any investigations and hospitalization. He was given oral iron therapy, vitamins and antibiotic. He reported after 8 days with no bleeding, edema of bitten limb reduced and weakness disappeared and even he joined to his job of harvesting grass.

Case No. 3

A 28 years old farmer had persistent local swelling with severe pain at the site of snake bite. He gave history of echis carinatus bite six days before, had local swelling and bleeding gums was recovered with ASV and antibiotic which he received at primary heath center. But since last thee days swelling increased with severe local pain with generalized fever and weakness. On examination there was local cellulites extending up to right - mid lower limb. No active bleeding. 20WBCT was negative. Laboratory report was as follows Hemoglobin 14.4 gms/dl, white cell count 12300 per.cu.mm. Blood sugar was fasting 196 mg/dl and post pandial 412 mg/dl. His diabetes was controlled with insulin and infection by intravenous antibiotic. He was discharged on 5^th day.

Envenoming by Russell’s viper - (Figs. 4a & b, 5, 6, 7)

Out of 38 cases of Russell's viper bites studied in one year, 28 (73%) were males. Russell’s viper bite studied in one year. Russell’ viper is very aggressive snake. Its fangs are long and sharp. It is diurnal in habit. It bites to a person working in a farm, handling the debris or harvesting or walking bare foot in a grown up grass. 29(76%) cases had bites to their lower extremities. All cases had marked oedema extending beyond one segment of bitten limb, with fangs marks and active bleeds from the site of fangs, ecchymosis and blebs over bitten limb. 45 cases had systemic bleeding, hemetemesis, hematuria, and subcutaneous ecchymoses. Seven cases developed acute renal failure of which two died. One patient had severe oedema with ischemia and loss of muscle power with hypo-aesthesia over the corresponding area (over right lower limb), improved with surgical decompression. Total ASV administered was 140- 330 ml (average 204 ml).

Case No. 4

A 35 years old farmer treaded a snake while walking on peddler road passing through grown up grass. Snake bitten to his dorsum of left foot at 2pm in a September month. He saw snake, cried loudly and frightened because snake while bitten looped around his limb. Bystander ran to him by this time he managed to remove the snake, his friend killed the snake it was Russell’s viper. It was three and half feet long. He experienced severe pain. He vomited and felt giddy. There was active bleeding from the site of fangs marks. He profusely sweated from all over body, sweating persisted for 6 hours. Swelling progressed to knee. He had massive hemetemesis, and bleeding from abrasions over chest. He was chronic smoker and alcoholic. He reported to hospital at 3.30Pm, he was in delirious state; blood pressure was 70 mm Hg with pulse rate 128 per minute. He was given intravenous crystalloid solution, dopamine 3.5 microgram per minute per kg. His blood was incoagualable. He was given 100 Ml ASV intravenous over one hour and 130 Ml by slow infusion rate over 24 hours. He had repeated bouts of hemetemesis. He was given two bottles of blood transfusion. Blood clotted within 20 minute at the end of 8 hours of initial dose of ASV. He was given intravenous furosemide 40mg 12 hourly intervals. At 8 PM his blood pressure improved to 110/80 MM hg. He passed 1200 ml urine over 10 hours. He was given intravenous and was discharged on third day.

Case No. 5

A 25 years old professional snake catcher was bitten by a Russell’s viper. He catched and hooked the snake but while putting it in to a bag, (the bag which he took was not his routine but due to hurry he picked up available bag) the Russell’s viper bitten to his left index, middle and terminal phalanxes at 11.05am in the month of January. Snake was >3 feet long. He himself gave incision over the bitten finger. There was continuous bleeding from the fangs marks and incision. He reported to hospital at 11.30am. On examination there was local edema, blood was incoagualable (20WBCT). He was given 100ML ASV over 60 minute in drip. Blood coagulated at the end of 8hours of initial dose of ASV. 180 ML ASV was administered by slow intravenous infusion drip over next 30 hours. He developed blebs and gangrene of terminal phalanx.

Case No. 6

A 4 years old female child was bitten by Russell’s viper to her right second toe at 8.30pm. She cried loudly due to severe pain at the site of bite. Parents saw a big Russell’s viper which was killed by bystanders. She bled profusely from fangs marks and developed severe edema of whole right limb blood did not coagulate within 20 minute (20WBCT). She was given 100ml ASV in 100Ml of 5% dextrose over 60 minute and 50mL slow drip over 24 hours. Bleeding stopped within 40 minutes of ASV administration. Edema persisted for four days. Blood clotted within 20 minute at the end of 7 hours of administration of ASV. She was given intravenous ampicillin for four days. She had big muscle hematoma at the site of intra-muscular injection which was administered by peripheral doctor before hospitalization.

Envenoming by common India krait (bungarus caeruleus) (Figs. 8 and 9)

Fourty eight (24 male) cases had bitten by krait. 36 (75%) cases were bitten by krait between 00-6AM, 11 (29%) reported between 6 pm to mid night. One female bitten by krait in the morning while removing ash from chulla (Fig. 1C). 47(97%) cases were bitten to a persons sleeping over floor bed in a hut or mud house (Fig. 1D,E). All patients or their relative gave history of pain in abdomen soon after bite 13 (27%) had transient sweating. Subsequently developed ptosis and bulber palsy 2-18 (8.30) hour after bite. 44 (91%) cases c had neuro-paralysis. 26 (54%) cases had respiratory depression, were intubated and given artificial respiration (23 on ventilator, 3 on ambu bag) of these 7 died (4 died before hospitalization). Total ASV administered was 100- 260ml (148ml). Neostigmine was given in a dose of 50 microgram/kg bodyweight over 4 h by infusion. Antibiotics were given to prevent respiratory infection. Intravenous fluids and oxygen therapy were continued until there was complete recovery.

Case No. 7

A 55 years old male was sleeping on the floor of hut, with head resting on his left folded hand. Krait bitten to the finger of his folded left hand. He experienced pain at the site of bite, he suddenly withdraw the hand along with snake, and snake was thrown away, his son killed the snake. He experienced parasthesia over left arm. He reported to hospital at 7am. He was conscious, no neurological deficit. He was admitted and 100 Ml of ASV was given over one hour. At 9am he complaints of suffocation, excessive salivation, developed bilateral ptosis. Tendon reflexes present. His blood pressure was 180/110 mm hg. Which was controlled with one dose of 5 mg of nifedipine. He had bilateral planter extensor. Another dose of ASV 100ml by slow intravenous drip over 24 hours. Neostigamine 50 microgram per/kg over four hours. He was given oxygen, amboo bag respiration. He took four days for total recovery.

Case No. 8

A 55 years old female had bitten by krait to her right index finger at 10 PM while collecting dry cow-dung fire wood for cook (Fig. 1B). She experienced pain and parasthesia over right arm. She vomited once and had pain in abdomen. She reported to hospital at 1AM. On arrival she was gasping with ptosis, bulbar paralysis, inter-nuclear opthalmoplegia, with pulling of saliva unable to talk or spit. She had profound muscle weakness. Being poor her relative denied to purchase the ASV (10ml ASV cost Rs.450). So she was put on ventilator. She required 3 days ventilatory support and she totally recovered and was discharged on 4^th day.

Envenoming by cobra (Naja naja) (Figs. 10 and 11)

Fourty one cases (22 male) of cobra bite reported in one year, of these 36 (87%) cases reported from March to August months. 36 (87%) cases reported between 6 AM to early darkness. 21 (51%) and 22 (53%) are bitten by cobra to lower and upper extremities respectively. 40 cases had sever local swelling with bleeding mark at the site of bite and ecchymosed. One patients died within 30 minute of bite was brought dead. 25 cases had sudden development of neuroparalysis with bilateral ptosis, while 22 cases suddenly developed respiratory paralysis. Nine recovered with ventilator. 11 cases recovered with manual respiratory support by amboo bag. Total quantity of ASV administered was 140-240ML (126.6ml) and intravenous neostigmine and atropine.

Case No. 9

A 4 years old female child was bitten by cobra to her right leg at 7PM while she was playing in front of farm house. Patient was brought at 8.15 Pm in unconscious state, cold extremities, dilated and fixes pupils (this patient was declared dead by a general practitioner). While examining heart sounds were audible. She was immediately intubated and given intravenous neostigmine and atropine, and 80 ml ASV. She required 6 hours ventilatory support. She was observed for 3 days for relapse of neuroparalysis and was discharged on
4^th day.

Discussion

Venomous snakes are distributed throughout the warm continents. Snake bite is a neglected problem of rural tropics; its incidence is usually underestimated because of lack of epidemiological data. Majority of victims first report to mantriks (village healer) and reported to a near hospital at a late stage when patient is at stake.^5,7 Thus many cases of snake bite may remain unnoticed. Bungarus caeruleus (Krait) and Naja naja (cobra) a elapidae and saw scaled ( echis cariunatus) and Russell’s viper a viperidae are common poisonous snake flourished all over rural Maharashtra.⁵ Echis carinatus flourished in a hot and high humid climate like that all over coastal region of Maharashtra (Table s 3a and 3b). While cobra, krait and Russell’s viper cases are often reported from the Aurangabad, Nanded, Pune and Sholapur districts where farming is main occupation. Farmers are busy round the clock in the farm, resulting in high incidence of snake bite. While because of heavy rain fall and with heavy thick jungle and hilly areas and small pieces of land, no facilities for irrigation thus farming is not profitable occupation in raigad district, hence majority of young people are employed in small scale industries or maidservant at big city like Mumbai.

Farmers and villagers in Kokan region have very small huts, because of restricted space they avoid to use cot and prefer to sleep on a floor bed make them more prone for krait bite poisoning (Table 3b).⁵ Recently the curtailment of electric power has increased incidence of snake bite cases (14 died of 310 cases of snake bite in 2007) in rural areas particular, farmers have to work even in night for watering the crops.

Rural people live in huts, wattle and daub houses or mud houses under unsanitary conditions. Waste material, dry cow-dung, dry fire wood (Fig. 1) and farm tools are often kept close to their houses. This encourages rats, mice and lizards, which are the prey of snakes. Moreover because of the heavy rain during monsoon, the holes and burrows occupied by snakes and rats are filled with water. During this period grass is grown up, due to water-logging and mud , it is routine practice to walk bare foot, blindly in grown grass and crops, at times snakes are trodden. Fatal snake bites in the developing countries like India are far too common to feature in local news paper headlines. Thus in rural people snake bites are more likely to occur during essential activities, such as agricultural work, and are thus hard to avoid. Krait and Russell’s are common culprits for fatality in this part of Maharashtra.⁵

Krait bite occurred during night hours. Abdominal colic, vomiting and transient hypertension is due to autonomic stimulation by krait venom.⁸ While cobra and viper bite occurred during day time activities, while farmers are busy in working. At this situation no rapid transport is available and main or approachable road is quite away from farm. Primary health center is not approachable distance during night hours by bullock cart or person carried in a bamboo basket (dholi).⁹ Medical officers may not have seen or treated the snake bite case before or failed to administer the required initial dose of ASV in krait, cobra and Russell’s viper bite case may result in high morbidity and mortality.

Appropriate training of peripheral doctors regarding indication of ASV may help to avoid unnecessary use of expensive ASV.¹⁰ More over availability of snake venom antigen detection kit (ELISA) test further helps to avoid the unnecessary excessive dose of ASV. However preparation of purified (Fab)2 or mono-specific anti-venom further reduce the fatality with limited dose of ASV.³ More over sufficient quantity of ASV should be made available at free of cost at government hospitals and private hospitals (case no 8). These are the reasons why the victims are reported late or rather avoid to go to hospital earlier and kills the vital time in freely available mantrik trial.

Early intubations and artificial respiration helped to reduce the fatality due to neurological involvement in a krait and cobra bite.¹¹

ASV is specific antidote to snake venom actions. The exact dose of venom injected at the time of bite by the snake is not known; similarly the amount ASV required to neutralize the circulating venom can not be detected clinically. Hence dose of ASV administered varies from doctor to doctor. However high dose does not add any benefits over low dose of ASV.¹²

One ampoules of ASV cost Rs 450 that is the ten days salary of poor villager. Hence at private hospital treatment of poisonous snake bite is not affordable. Many times medical officers are absent and not available at head quarters during night hours. In such situation One of the author reported that (case no. 8) improved by artificial ventilatory support without ASV.¹³

Early administration of 100 Ml of ASV in a Russell’s bites with continuous slow drip for 24 hours to neutralize the circulating venom and venom absorbed from bite of site which act as depot. Renal angle tenderness preceded the oliguria is a valuable clinical sign of impending renal failure.¹⁴

Elapid snake venom action on pupillary muscle resulting in non-reacting dilated pupils does not indicate the irreversible brain damage (case no. 9).¹⁵

In present report administration of required ASV on arrival of a case to hospital, tracheal intubation, artificial ventilation and close observation for early development of renal failure particularly in Russell’s viper bite helped to reduce the fatality to 5.4%.

Thus snake bite should be considered as time limiting acute life threatening medical emergency as an agricultural occupational hazard. Rapid task force for training of peripheral doctors regarding how to diagnose and initial management, endo-tracheal intubations and amboo bag operation, bed side simple 20WBCT⁶ to decide the administration of extra dose of ASV is required. ASV should be available at free of cost to all victims whether treated at government or private hospitals, rather than providing benefits and cash compensation to orphan or deserted family members of snakebite death victim due to lack of facilities or medical negligence.

Acknowledgement

We are grateful to Mr. Mehendale Snake catcher for permission to publish the Fig. 4a, Russell's viper fangs.

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