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ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 19-22

Prehospital care in the management of snakebites


Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission07-Dec-2019
Date of Decision23-Dec-2019
Date of Acceptance07-Jan-2020
Date of Web Publication03-Feb-2020

Correspondence Address:
Dr. John Emmanuel Jesudasan
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_68_19

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  Abstract 

Introduction: Snakebite is a significant public health problem in India. A variety of prehospital practices are commonly followed after a person has been bitten by a snake before he/she reach a health center.
Methodology: This was a prospective, descriptive study done in the emergency department which included adult patients above the age of 18 years who presented with a history of either a snakebite or an unknown bite. All other known bites were excluded from the study. The period of the study was between August 2015 and March 31, 2016.
Results: The study cohort included 62 patients, with a majority being male (61.3%; 38/62). 32.3% (20/62) of patients were farmers and homemakers constituted 30.6% (19/62). Tying a tourniquet above the bite mark (66.1%; 41/62) was the most common prehospital care administered to the victims. Traditional methods such as performing ritual prayers (1.6%; 1/62), sucking out blood (3.2%; 2/62), or applying traditional medicines (1.6%; 1/62) were the other practices followed before they reached a health center.
Conclusion: A significant number of snakebite victims received prehospital care before they reached a health-care facility. Application of tourniquet is the most common prehospital practice followed in the community. However, the other traditional methods are rarely practiced nowadays.

Keywords: Emergency department, first aid, prehospital care, snakebite


How to cite this article:
Alex T R, Divya G R, Jesudasan JE. Prehospital care in the management of snakebites. Curr Med Issues 2020;18:19-22

How to cite this URL:
Alex T R, Divya G R, Jesudasan JE. Prehospital care in the management of snakebites. Curr Med Issues [serial online] 2020 [cited 2020 Sep 28];18:19-22. Available from: http://www.cmijournal.org/text.asp?2020/18/1/19/277534




  Introduction Top


Organization (WHO) statistics, 4.5–5.5 million people are bitten by snakes annually worldwide. South Asia has the highest incidence of venomous snakebites. India, Pakistan, Sri Lanka, and Bangladesh account for almost 70% of the global deaths due to snakebites. Since 2017, the WHO has recognized snakebites as a neglected tropical disease.[1] In India, snakebites alone are responsible for more than 50,000 deaths per year.[2] Most of the deaths occur before the victims reach a hospital. This is due to various traditional treatments administered or because doctors who practice at a primary care level have no access to antisnake venom (ASV).[3]

India is home to more than 60 species of venomous snakes, of which the four most common snakes encountered are Russell's viper, Indian cobra, Krait, and Saw-scaled viper.[4] Not all snakebites are venomous; a majority are dry bites.[4] Most snakebites occur during the monsoons and when people are working in fields or sleeping on the ground at night.[5] This is due to tropical climate, agricultural, and forest-based profession.[6] The aim of our study is to collect data on the pattern of prehospital treatment of snakebite in our region which will enable us to understand the common practices and recommend the ideal care before they bring the patients to our hospital.


  Methodology Top


Design

We conducted a prospective analysis of adult patients presenting with a history of a snakebite or unknown bite to determine the most common prehospital treatment administered.

Setting

We conducted this study in the Adult Emergency Department (ED) of Christian Medical College and Hospital, Vellore, which is a large tertiary care hospital in South India with 2700 inpatient beds. The adult ED has 49 beds with about 75,000 admissions yearly.

Participants

All patients above the age of 18 years who presented with an alleged history of a snakebite or an unknown bite. The study period was from August 2015 to March 31, 2016. Victims aged below 18 years and those presenting with other known bites were excluded.

Variables

A prestructured pro foma was filled which had details of relevant history, demographic details, and type of prehospital care given. The variables included age, sex, prehospital treatment administered, and outcome from the ED.

Statistical analysis

The data were entered into Microsoft Excel (version 15.12.3) and were analyzed using Statistical Package for the Social Sciences (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp). Continuous variables were presented as frequency tables. Categorical and nominal variables were presented as percentages. Analysis of the association between various demographic, clinical, and prehospital care was performed using Chi-square tests or independent t-test, as appropriate.

Ethical considerations

This study was approved by the Institutional Review Board (IRB Min. No. 9696 dated 20.10.2015), and patient confidentiality was maintained using unique identifiers and by password-protected data entry software with restricted users. Patients were recruited after obtaining an informed written consent.


  Results Top


During the study period of 8 months, 62 patients presented with snakebite [Figure 1], of which 61.3% (n = 38) were male and 38.7% (n = 24) were female [Table 1]. The most common victims of snakebite with respect to occupation were the farmers (32.3%), homemakers (30.6%), and students (14.5%). The incidence of snakebites was the highest in August 2015 with 25.8% and showed a downward trend as the monsoon season finished and was the lowest in March 2016.
Figure 1: STROBE statement

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Table 1: Baseline characteristics (n=62)

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Tying of a tourniquet was found to be the most common primary prehospital treatment given to snakebite victims (66.1%) as compared to other methods [Table 2]. Application of herbicides and doing ritual prayers were found to be uncommon with 1.6%.
Table 2: Prehospital treatment

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Seventy-one percent of patients were treated with ASV and 69.4% received antibiotics [Table 3].
Table 3: Treatment given

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Regarding the outcome from ED [Table 4], 75.8% of patients were admitted, 19.4% discharged, and the rest (4.8%) were discharged against medical advice.
Table 4: Outcome from the Emergency Department

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  Discussion Top


Snakebite is a common medical emergency seen all over the world and is a public health burden in India.

Attempts at first aid are a common practice to victims of snakebites, confirming the observations in a previous study.[7] The various prehospital practices done worldwide are:

  • Chanting incantations (doing Poojas)
  • Bite site suction
  • Bite site incision
  • Black stone application
  • Topical applications or ingestion of herbs
  • Topical application or ingestion of alcohol
  • Shock therapy
  • Cryotherapy
  • Application of pressure bandage
  • Application of a tourniquet.[7]


In many parts of the world, faith is put in the hands of nonregistered medical practitioners rather than doctors who have access to ASV. In India, there is a lack of data on the number of patients being treated by nonmedical practitioners.

In a study done in Kenya, it was found that 68% of the snakebite victims sought treatment from traditional healers before reaching a medical facility.[8] In a similar study done among a pediatric population in India, only 12% received such type of treatment,[9] which was akin to our study which had 10%.

The male-to-female ratio of the snakebite victims in our study was 1.5:1, which is similar (2.1:1) to a study done in South India[10] and various other studies done in India.[11],[12],[13],[14] A study done in Gujarat[15] and Andhra Pradesh[16] showed a higher male-to-female ratio as compared to ours. Farmers (32%) followed by homemakers (30%) had the highest incidence of snakebites as compared to other professions. This is because agriculture is the predominant occupation in South India where men are more frequently engaged in work in open fields and are easily susceptible to snakebites.

The highest incidence of snakebites was found to be in the postmonsoon months of August to October, a fact that is supported by other studies.[17],[18],[19],[20] The reason for a higher incidence in the postmonsoon months could be due to the increased agricultural activity during this period.

In our study, tying of a tourniquet was the most common prehospital practice administered to victims of snakebite, which is similar to other studies done worldwide.[21],[22]

Most of the patients showed features of envenomation and were administered ASV (71%). This was similar to other studies done in India.[20]

A majority of patients (76%) were admitted as inpatients from the ED and 19% of the patients were discharged.

Antivenom is the definitive treatment for patients presenting with signs of envenomation. Prehospital care should be directed to reduce systemic envenomation by limiting the lymphatic flow.

The application of splints to the affected limb reduces any movement.

Positioning of the extremity below or at the level of the heart should be individualized for patients presenting with snakebites. By positioning, the affected extremity below the level of the heart in patients might delay further systemic toxicity in patients presenting with features of systemic toxicity. While patients presenting with severe local tissue damage and less systemic toxicity, positioning the limb below the heart could increase local toxicity.

Experimental studies have shown that pressure immobilization bandages or compression pads delay systemic absorption of venom without causing further local tissue damage, but there are limited data on humans.[9] Application of pressure bandages requires the use of 15-inch bandages, and because most of the snakebites in India occur in the fields or rural setting, bandages might not be readily available to everyone.

The use of tourniquets if tied extremely tight can lead to limb ischemia and amputations; other practices such as doing rituals/prayers or cutting the bite site cause more or further complications/delays in reaching a hospital setting when the main aim of the patient should be to reach a hospital setting as soon as possible because the only available antidote is ASV.

Further studies should be done which take in account more details regarding the time, location of the bite, duration between the bite and reaching a hospital, and time duration between the bite and onset of symptoms.


  Conclusion Top


In this prospective study of the prehospital care given to snakebite victims presenting to the Accident and ED, we found that tying of a tourniquet was the most common prehospital treatment administered to victims of snakebites. Males were found to be more affected by snakebites than females. Farmers were found to have the highest incidence of snakebites compared to other professions. The rainy months of August 2015 and October 2015 presented the highest incidence of snakebites when compared to the other months. Majority of the patients were admitted if they had symptoms of envenomation, while those who were asymptomatic were discharged following a period of observation in the ED.

Limitations

This was an awareness study and the details of the snakebite were not obtained. Hence, information regarding the delays in reaching a hospital, symptoms of toxicity, and reason for delays in reaching a medical facility could not be assessed.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is IRB Min. No. 9696 dated 20.10.2015. We also certify that we have not plagiarized the contents in this submission and have done a plagiarism check.

This study was approved by the Institutional Review Board (IRB Min. No. 9696 dated 20.10.2015), and patient confidentiality was maintained using unique identifiers and by password-protected data entry software with restricted users.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, Premaratna R, et al. The global burden of snakebite: A literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med 2008;5:e218.  Back to cited text no. 1
    
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Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, et al. Snakebite mortality in India: A nationally representative mortality survey. PLoS Negl Trop Dis 2011;5:e1018.  Back to cited text no. 2
    
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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