A study on haematological and coagulation derangement in snake bite and its outcome in an tertiary care hospital

INTRODUCTION: Snake bite is one of the common medical emergencies encountered in day to day practice in India. The morbidity and mortality rates of snake bite patients is high .236 species of snakes have been identified in India out of which 52 are poisonous. Most of the snake bites occur in fields, mostly in rainy season. Currently intensive work is being done on the pharmacological, pathological toxicological and immunological aspects of snake venoms to give a better break to the snake bite victim ,which has resulted in the production of polyvalent and monovalent anti snake venoms. The incidence of snakebite in CHENNAI and surrounding area is high. Snake bite is completely treatable. Immediate steps should be taken to shift the victim to the hospital as early as possible and it can be prevented to a certain extent educating people. PRIMARY OBJECTIVE: 1. To assess the changes in coagulation profile following snake bite. 2. To analyse the time intervals between the snake bite and onset of coagulation profile to normal. INCLUSION CRITERIA: All patients more than 12 completed years of age with history of snake bites and with at least one of following criteria will be included in the study: 1. Patients or attenders have seen the offending snake and bitten. 2 Definite fang marks noted. 3. Features of local or systemic envenomation Exclusion criteria: Patients with history of suspected snake bite where in, 1. Patient or attenders have not seen the snake. 2. No fang marks. 3. No features of envenomation. 4. Pts with pre-existing coagulopathy,on anticoagulants and antiplatelet drugs,h/o renal disease. Pts with risk factors like Diabetes,Hypertension,Connective tissue disease,chronic infection. Mode of selection: By simple random method. Sample size: 100 cases. Duration: 6 months Iinvestigations: Sampling Technique. INVESTIGATIONS: CBC, Renal Function Test (Urea Createnine), Urine Routine and Microscopy, Coaugulation Profile (BT,PT,INR,CT), Liver Function Test, ECG. METHODOLOGY: After screening patient who fulfil inclusion criteria, willing to participate in trial and sign consent letter .Patient will be screened as per protocol. Prior h/o snake bite will be enquired. lab investigations will be done like bleeding time, clotting time. Prothrombin time and activated partial thromboplatsin time(when required) will be analysed using automated analysis. Serum fibrinogen and fibrin degradation products (FDP)will be determined when indicated. For Serum fibrinogen ammonium sulphate reagent will be used. STATISTICAL ANALYSIS will be done SPSS SOFTWARE. SUMMARY: Russel viper was the most common type of snake associated with haemotoxic snake. Mortality and morbidity was higher with severe form of envenomation. Most common complications with hemotoxic snake bite was DIC, renal dysfunction, cellulitis. Earlier presentation to hospital decreased both morbidity and mortality. Provoked bites were more dangerous than non-provoked, complications associated with provoked bites were also higher. DIC was the main mechanism of underlying coagulopathy. Whole blood clotting time was the main bed side test available for assessing reversal of coagulopathy. The most common nature of ASV reactions were chills and rigor, followed by nausea and vomiting. CONCLUSION: Among the hemotoxic snake bites, Russel viper was most common. • Provoked bites were more dangerous, as all the provoked bites were of grade 3 severity. • Males as snake bite victims were more common, as males are most commonly exposed to field work. • Among systemic bleeding manifestations gum bleeding was the most common form of systemic bleeding manifestations. • Bite to needle interval if lesser had better prognosis. • Whole blood clotting time, was the easiest method, which was available bed side for assessing onset of coagulopathy. • WBCT, was also most common method for assessing the response to ASV therapy. • DIC appeared to be the most common mechanism for the underlying coagulopathy in our studies. • Renal dysfunction was present in all grades of bite, it did not correlate with severity of envenomation in our study. • Mortality was present in grade 3 bites only, which positively correlated with severity of envenomation. • Hospital stay was more in grade 2 and grade 3 bites, • Average no of days for hospital stay was 5 to 8 days. Maximum days was 28 days. • Main cause for morbidity was cellulitis, refractory shock, acute renal failure and DIC. • Serum fibrinogen correlated positively with degree of envenomation, being lesser in grade 3 bites. • Clinical manifestations (like gum bleeding and hematuria) and laboratory parameters (like low hemoglobin, thrombocytopenia, prolonged • WBCT should be evaluated to identify the coagulopathy very early as it prolongs the hospital stay leading to increased morbidity and mortality. These manifestations require prompt treatment to reduce the morbidity and mortality.