snakebite protocol development workshop cmc, vellore 11.03.2013 a national survey of snake bites in...

S N A K E B I T E P R O T O C O L D E V E LO P M E N T W O R K S H O P

C M C , V E L LO R E1 1 . 0 3 . 2 0 1 3

A NATIONAL SURVEY OF SNAKE BITES IN INDIA (VENOMOUS AND NON-VENOMOUS), SYNDROME-

SNAKE SPECIES CORRELATIONS, OUTCOMES AND ASV DOSE

REQUIREMENTS

GOAL OF THE STUDY

• To map the heterogeneity of snakebite

syndromes, species of snakes, management

practices in different centres and the clinical

outcome

• To create a National network of hospitals and

centres for coordinating snakebite research

OBJECTIVES

• To describe the clinical profile of snake envenomation presenting in geographically representative regions in India

• To identify snake species and sub-species from the different geographical regions causing bites

• To analyze the correlation between the clinical syndrome of snake envenomation and the snake species

• To assess the management practices and outcomes in various regions and anti-snake venom dose requirements according to snakebite syndrome and different snakebite protocols used in different centres.

METHODOLOGY

STUY DESIGN

• Multicentric study

• Observational

• Descriptive study

• Over a period of 2 years

CLINICAL COLLABORATING CENTRES

Centres are selected depending on the case load and commitment to the study

HERPETOLOGY & VENOM DETECTION

Herpetology• Mr.Romulus Wittakar• Mr. Gerry Martin• Dr. Anita Malhotra• Mr.Vishal Santra• External Consultants• Dr.David Laloo• Dr.Faiz• Dr.Arirani

Venom Detection• Dr.Ashish K

Mukerjee• Dr.Oommen• Dr.Dhananjaya • Dr. Sridevi• Dr.Amudhavalli• Mr.Radhakrishnan• Dr.Jayaraman

Informed consent

Venomous bite

Admission

Treatment

Discharge

Non-venomous bite

Observation

Discharge

Suspected Snakebite

DocumentationUsing proforma at admission and daily till discharge

STUDY FLOW CHART

DOCUMENTATION

The study proforma:• Details of bite• Snake

identification• Clinical syndrome• Laboratory

evaluation• Complications

TreatmentASV dose requirementMechanical ventilationNeostigmineTransfusionsAntibiotics

Outcomes

SUGGESTED LIST OF ESSENTIAL INVESTIGATIONS

Follow up

• Haemotoxic- WBCT

or PT,PTT every 6

hours till normal

• Renal failure-

creatinine daily till

normal

Admission

• WBCT or PT,PTT

• CBC

• Blood picture

• Creatinine

• Electrolytes

MANAGEMENT

The management of the cases and the

dosage of ASV will be according to the

discretion of the treating physician and

the institutional snakebite

management protocol

DEAD SNAKE STORAGE PROTOCOL

Dead snake available

Photograph will be taken

Stored in formalin - dilution of 40% formalin solution with water in 1:5 dilution

Part or whole snake can be preserved in 70% ethanol for DNA analysis

SAMPLES REQUIRED FOR VENOM DETECTION STUDIES

• Bite site swab

• Serum

• Urine

THANK YOU

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SOME VALUABLE COMMENTS FROM PARTICIPANTS

• Legal and social implications in killing snakes

• High quality photographs /videos of snakes to be available in all

centres

• Idea of closed face-book for dead snake identification

• Previous ASV administration

• Multicentric study with lot of challenges. Proper co-ordination is vital

• Cell-phone photo should be encouraged

• Suggestion regarding electronic data entry

• Collection of swabs should be encouraged

VALUABLE COMMENTS FROM PARTICIPANTS

• Increase sample size to improve identification

• Use of 10%formalin (4% formaldehyde) for storage

• Long term storage in formalin can spoil the specimen

and so I week formalin followed by 1 day in water to

leach out the formalin, then transfer to 80% ethanol

• A small amount of tissue should be collected separately

BEFORE formalin fixing in 80% pure ethanol for DNA

analysis

• Photographs should be taken before formalin fixing