Pakistan has quite a sizable share of the poisonous snakes and every year significant number of people dies due to snake bite. By one of the estimates about 1.9 of the 100,000 people die each year in Pakistan from snake bite. It may not seem too high of a number but still it is unacceptable and reflects a sorry state of affairs. These deaths are attributed to lack of resources and delayed presentation to proper centers who can provide care.Majority of snake bite occur in the rural areas among farm workers and mostly men. The usual site of bite is lower limb around ankle and below the knee area. In most of these instances people are unable to identify the snake and give conflicting accounts. It makes the task of the treating doctor somewhat difficult.
There are other important aspects to consider also. The local health facilities in those areas fail to provide them with the right treatment and they have to be moved to bigger hospitals to get the treatment. Equally important was the fact noted in studies in Sindh province was that people go to traditional care providers like Hakeem and even snake bite treatment specialties before ultimately showing up to the medical facility. In most cases the delay could be as much as 24 hrs. This leads to increased complications and bad outcome.
Lack of anti snake venom (ASV) then further complicates the issue. The supply of ASV is from two different sources. A locally produced ASV that is liquid form and needs cold storage with low shelf life. The second type is lyophilized ASV mostly from India. The lyophilized ASV is supplied in powder form and has a long shelf life. It takes time to be reconstituted before it could be infused.
In order to improve the of the snake bite victim we need to enhance the knowledge base of people treating such patients. The job of the first contact or the first responder is to minimize the spread of venom and transport the patient to the facility that can deal with the snake bite.
It is very important not to waste time and also not to do things that can harm the victim. These include:
- Cutting the wound.
- Mouth suctioning the bite.
- Use tourniquet to stop the flow.
- Use Hakeem drugs
- Wasting time with snake charmers un-authenticated care
Once in the medical facility the best treatment option is to institute the ASV if indicated. ASV act by neutralizing the venom and thus stop the toxic effects. It does not require test dose and should be given to people who need them, after calculating the dose. Antisnake venom or ASV is either monovalent or polyvalent. The monovalent variety is for specific snake venom and only acts against that specific snake bite. The polyvalent ASV is made from 5 common snake venom and thus should be utilized in cases where the identity of the snake is in question or not available.
The most important test to determine if someone needs the ASV is called 20wBCT. It stands for 20 minutes whole blood clotting test. It is a simple test and does not require specialized instruments or expertise. It requires clean dry glass tube in which blood is kept for 20 minutes and then observed to see it, it has clotted. Abnormal result means that the bite has been venomous and the patient requires ASV.
The ASV must be infused with in an hour and 20wBCT repeated to see if the effect of snake venom is neutralized. Sometimes a second dose of ASV may be needed.
Pakistan Medical Research Council has worked on this important topic and also had formulated an ideal snake bite kit for Pakistan. Their hope is that through these measure we may be able to save more victims of snake bite. This kit includes:
- Anti Snake Venom: If cold chain is available then liquid ASV, otherwise imported lyophilized ASV. This is usually a polyvalent variety to deal with any type of snakebite.
They recommend about 20 vials for 1 snake bite victim and there should be enough for all victims presenting in 1 month. So if 3 victims come in one month 60 vials should be present.
- Test Tubes: To test for 20wBCT. It takes around 24 tubes per victim.
- Neo Stigmine and Atropine : 20 amp of 0.5 mg neostigmine.
- Adverse Reaction Drugs: Adrenaline (1:1000) is priority and at least 10 vials should be made available.
Similarly Hydrocortisone and Pheniramine should also be present.
- Pain Medication: Paracetamol should be preferred. Usually oral tablets are safe to use.
- Resuscitation Bag
- Airway Support Kit: Including Nasopharyngeal airway and Laryngeal Mask airway.
If we provide this kit to the area hospitals which deals with snake bite, there is very good chance that the patients will get the better care earlier and will have better chances of survival. We are also creating a snake bite guideline which is local oriented and will be made available to anybody who wants it. This way we will make sure that the snake bite victim will get the best possible care in the hands of well informed physician.
I can be reached at ERDOC@shifa.com.pk