A Multidisciplinary Approach with Hyperbaric Oxygen Therapy Improve Outcome in Snake Bite Injuries

Clinical and demographic profiling of snakebite envenomation in a tertiary care centre in northern India

BACKGROUND

Snake bites are a major cause of emergency visits in tropical countries like India, with actual mortality and morbidity likely higher due to underreporting. The aim of the study was to analyze the clinical and demographic profiles of snake bites at the Department of Emergency Medicine, AIIMS Rishikesh, over two years (July 2021 to July 2023).

METHODS

Patients aged over 18 with witnessed or suspected snake bites were included. Data on demographics, clinical history, laboratory parameters, treatment, and outcomes were collected.

RESULTS

Most patients were male (68.3%) and aged 31-50 years (35.6%). Farmers made up 57.4% of the cohort. Bites occurred mostly in the evening (46.5%) and during the monsoon (71.3%). Symptoms varied: 48.5% were asymptomatic, 31.7% had hemotoxic symptoms, and 15.8% experienced neurotoxic symptoms, including ptosis. Hemotoxic bites frequently involved bleeding at the bite site (93.8%) and gum bleeding (46.9%). Local complications were noted in 7.9% of cases. Neuroparalytic bites required ventilatory support in 62.5%. Blood products were administered to 31% of patients with hemotoxic bites, hemodialysis to 19%, and plasmapheresis and hyperbaric oxygen therapy to 6.3%. Out of the 69 symptomatic patients (68.3%) who received anti-snake venom (ASV), 28 (40.6%) patients developed adverse reactions.

CONCLUSION

This study provides a detailed analysis of suspected snakebites in Uttarakhand and surrounding areas, highlighting the importance of early recognition, prompt treatment, and timely referral to prevent fatalities. The administration of anti-snake venom (ASV) is identified as the most critical intervention, though lack of awareness in rural areas complicates management. The study calls for targeted public health campaigns to educate communities about early snakebite recognition and the role of ASV. It also stresses the need for region-specific protocols and improved healthcare access, emphasizing the importance of referral systems for advanced interventions like hemodialysis and intubation. Overall, the study advocates for enhanced public awareness and healthcare infrastructure to reduce snakebite incidence and mortality in rural populations.

Prospecting Local Treatments Used in Conjunction with Antivenom Administration Following Envenomation Caused by Animals: A Systematic Review

Envenomation caused by venomous animals may trigger significant local complications such as pain, edema, localized hemorrhage, and tissue necrosis, in addition to complications such as dermonecrosis, myonecrosis, and even amputations. This systematic review aims to evaluate scientific evidence on therapies used to target local effects caused by envenomation. The PubMed, MEDLINE, and LILACS databases were used to perform a literature search on the topic. The review was based on studies that cited procedures performed on local injuries following envenomation with the aim of being an adjuvant therapeutic strategy. The literature regarding local treatments used following envenomation reports the use of several alternative methods and/or therapies. The venomous animals found in the search were snakes (82.05%), insects (2.56%), spiders (2.56%), scorpions (2.56%), and others (jellyfish, centipede, sea urchin-10.26%). In regard to the treatments, the use of tourniquets, corticosteroids, antihistamines, and cryotherapy is questionable, as well as the use of plants and oils. Low-intensity lasers stand out as a possible therapeutic tool for these injuries. Local complications can progress to serious conditions and may result in physical disabilities and sequelae. This study compiled information on adjuvant therapeutic measures and underscores the importance of more robust scientific evidence for recommendations that act on local effects together with the antivenom.

Hyperbaric oxygen therapy of soft tissue necrosis due to centipede bite in a patient with diabetes

OBJECTIVE

The purpose of this study is to demonstrate that hyperbaric oxygen therapy (HBOT) is an option for the management of rapidly progressive tissue necrosis after centipede bites in patients with diabetes.

METHOD

In this case report, we introduce a patient with diabetes with soft tissue necrosis and secondary infection due to a centipede bite, who was treated with a multidisciplinary approach including HBOT.

RESULTS

In this case study, HBOT, applied in the treatment of rapidly developing cellulitis after a centipede bite in a patient with diabetes, accelerated wound healing. Deep soft tissue infection stopped progression to necrotising fasciitis and prevented possible amputation, and facilitated the patient's return to social life in a short time.

CONCLUSION

HBOT can be used in combination with other local and systemic, due to its anti-venom effect and treatment of extremity-threatening infection.

Case Report: Treatment of a Severe Puff Adder Snakebite Without Antivenom Administration

Antivenoms are the treatment of choice for managing lethal snakebites. However, antivenoms may not be available in instances where non-native vipers are kept in captivity. We report a case of a puff adder (Bitis arietans) bite treated without antivenom. A 23-year-old man was bitten on his left hand by a puff adder that he illegally kept in his house. The swelling spread rapidly to the upper arm and there was a risk of bleeding, suggesting the need for antivenom administration, but this could not be acquired because of lack of stock. We initiated fluid resuscitation and administered recombinant thrombomodulin (rTM) to prevent venom-induced consumption coagulopathy. In addition, hyperbaric oxygen (HBO) treatment was also performed to reduce local swelling. The patient recovered without complications after the multidisciplinary treatment. Further studies are needed to prove the safety and efficacy of rTM administration and HBO therapy as an adjunct or alternative therapy with antiserum for fatal snakebite.

Snake Bite Management: A Scoping Review of the Literature

BACKGROUND

Around the world, snake bite envenomation remains an underreported human health hazard. Envenomation can cause local and systemic complications, especially when there is a lack of antivenom availability. Although there are established guidelines regarding snake bite management acute care, there is a paucity of data regarding surgical intervention and the plastic surgeon's role treating this unique patient population.

METHODS

A review was conducted identifying relevant published articles involving snake bite management and treatment in PubMed and EMBASE.

RESULTS

One hundred ten articles were identified and 77 met inclusion criteria. Snake bite envenomation can result in complications that are dependent upon a variety of variables. The literature has shown the best field treatment to be timely transportation to the nearest medical facility, along with antivenom administration. The cytotoxic, hemotoxic, and neurotoxic effects of venom can cause a variety of local soft tissue and systemic complications. Surgical interventions such as fasciotomies, wound debridements, skin grafts, and tissue flaps may be necessary in these patients to optimize functional and aesthetic outcomes. Disparities in access to care in resource limited settings are discussed.

CONCLUSIONS

Global health disparities and insufficient antivenom distribution create an inequality of care in snake bite patients. Plastic surgeons have an important role in managing acute and chronic complications of snake bite envenomations that can lead to improved patient outcomes.

Trends in snakebite deaths in India from 2000 to 2019 in a nationally representative mortality study

The World Health Organization call to halve global snakebite deaths by 2030 will require substantial progress in India. We analyzed 2833 snakebite deaths from 611,483 verbal autopsies in the nationally representative Indian Million Death Study from 2001 to 2014, and conducted a systematic literature review from 2000 to 2019 covering 87,590 snakebites. We estimate that India had 1.2 million snakebite deaths (average 58,000/year) from 2000 to 2019. Nearly half occurred at ages 30-69 years and over a quarter in children < 15 years. Most occurred at home in the rural areas. About 70% occurred in eight higher burden states and half during the rainy season and at low altitude. The risk of an Indian dying from snakebite before age 70 is about 1 in 250, but notably higher in some areas. More crudely, we estimate 1.11-1.77 million bites in 2015, of which 70% showed symptoms of envenomation. Prevention and treatment strategies might substantially reduce snakebite mortality in India.

Management of Snakebites in the Upper Extremity

Encounters with venomous snakes can lead to substantial morbidity or mortality if managed inappropriately. Medical management is the mainstay of treatment, but surgery may be necessary in rare cases. The hand surgeon should be well versed in the types of venomous snakes, the mechanism of action of venom, and the management of these injuries, given the frequency of hand envenomation. The indications for surgery are not well established and rely on clinical judgment and practitioner's experience. An understanding of previously reported outcomes and an algorithmic approach to treatment will help improve patient care and avoid complications.

Increased Efficacy of Antivenom Combined with Hyperbaric Oxygen on Deinagkistrodon acutus Envenomation in Adult Rats

BACKGROUND

Snakebites are a neglected threat to global human health with a high morbidity rate. The present study explored the efficacy of antivenom with hyperbaric oxygen (HBO) intervention on snakebites, which could provide the experimental basis for clinical adjuvant therapy.

METHODS

Male Sprague-Dawley rats (n = 96) were randomized into four groups: the poison model was established by injecting Deinagkistrodon acutus (D. acutus) venom (0.8 LD50) via the caudal vein; the antivenom group was injected immediately with specific antivenom via the caudal vein after successful establishment of the envenomation model; and the antivenom + HBO group was exposed to HBO environment for 1 h once at predetermined periods of 0 h, 4 h, 12 h, and 23 h after antivenin administration. Each HBO time point had six rats; the control group was left untreated. The rats in the experimental group were euthanized at the corresponding time points after HBO therapy, and brain tissue and blood were harvested immediately. Hematoxylin and eosin (H&E) staining was used to investigate the pathological changes in the rat brain. Immunohistochemistry (IHC), real-time polymerase chain reaction (PCR), and Western blotting were used to detect the expression of Nestin mRNA and protein in the subventricular zone (SVZ) of the brain. The levels of coagulation function (prothrombin time, activated partial thromboplastin time [APTT], and fibrinogen) and oxidation/antioxidation index (malondialdehyde [MDA] and superoxide dismutase [SOD]) were analyzed. Data were analyzed using one-way analysis of variance.

RESULTS

The brain tissue from rats in the poison model was observed for pathological changes using H&E staining. Tissues showed edema, decreased cell number, and disordered arrangement in the SVZ in the snake venom group. The antivenom - HBO intervention significantly alleviated these observations and was more prominent in the antivenom + HBO group. The serum levels of SOD and MDA in the snake venom group were increased and the antivenom - HBO intervention further increased the SOD levels but significantly decreased the MDA levels; however, this was enhanced within 1 h after HBO administration (MDA: F = 5.540, P = 0.008, SOD: F = 7.361, P = 0.000). Activated partial thromboplastin time (APTT) was significantly abnormal after venom administration but improved after antivenom and was even more significant in the antivenom + HBO group 5 h after envenomation (F = 25.430, P = 0.000). Only a few nestin-positive cells were observed in the envenomation model. The expression levels were significant in the antivenom and antivenom + HBO groups within 1 and 5 h after envenomation and were more significant in the antivenom + HBO group as determined by IHC, real-time PCR, and Western blotting (P < 0.05). D. acutus envenomation has neurotoxic effects in the brain of rats.

CONCLUSIONS

Antivenin and HBO, respectively, induced a neuroprotective effect after D. acutus envenomation by attenuating brain edema, upregulating nestin expression in SVZ, and improving coagulopathy and oxidative stress. The intervention efficacy of antivenom with HBO was maximum within 5 h after envenomation and was more efficacious than antivenom alone.