SNAKE BITES AND IT’S MANAGEMENT: A CONCISE STUDY

Abhishek Pathak¹, Renu Yadav²

¹Department of Veterinary Pharmacology and Toxicology, ²Department of Veterinary Anatomy, C.V.A.Sc. G.B. Pant University of Agriculture & Technology,

Pantnagar, Uttarakhand- 263145

 

Introduction

 

Since the dawn of time, man has been fascinated by snakes. They have sparked the imaginations of people from many racial, cultural and religious origins around the world. Since the beginning of written history, they have been mentioned in several sources. Since they have long been associated with awe and horror in human minds, snake worship has been practiced throughout history, dating back to the Egyptian civilization more than 5,000 years ago. Snakes are still revered in some regions of India today. Numerous mythological stories and legends have been centered on snakes. Snakes are misunderstood and feared by the general public since they are not well-known to them. With the exception of four species that cause thousands of fatalities each year, most snakes in India are harmless. Snakes can range in size from a few centimeters to up to ten meters in length. Snakes may dwell in a broad range of environments, including sweltering deserts, muggy tropical jungles, chilly Himalayan climates and even the deepest oceans. Additionally, snakes have an array of intriguing skin tones that are perhaps only surpassed by the elaborate and vibrant butterfly wings. Snakes continue to be the most elegant creatures in nature due to their graceful motions and overall beauty. When Alexander the Great visited India in 326 BC, according to historical records, he was deeply impressed by the Indian doctors’ skill in treating snakebite patients. Since then, India has gained a reputation for having venomous snakes and the death and illness brought on by their bites [1].

Classification of Indian venomous snakes

 

In India, there are about 270 different species of snakes, 60 of which are poisonous. Some of species are widespread and have quite potent venom. Venomous snakes are divided into two groups according to their fang and venom types: Solenoglypha (retractable fangs and hemotoxic venom) and Proteroglypha (fixed fangs and neurotoxic venom). The following five families make up the grouping of venomous snakes:

 

Elapidae

 

This family include kraits and cobras. These elapids have fixed fangs and extremely neurotoxic venom that affects the nerve system and causes respiratory paralysis.

Viperidae

 

The “genuine vipers” are members of the family Viperidae. Their heads are substantially wider than their necks and their bodies are thick. They are available in a wide range of sizes, markings and colors. They have movable, hollow, long fangs that are similar to hypodermic needles in function. They assault the blood cells with their highly hemotoxic venom. The Russell’s viper is the most typical illustration.

Colubridae

 

The majority of snakes in the world are members of the Colubridae family. Since their fangs point backward, these snakes, which are generally safe for humans, are referred to as “back-fanged” snakes. The most prevalent illustration is the sub-Saharan African boomslang.

Crotalidae

 

The so-called “pit vipers” belong to the Crotalidae family and have a heat-sensitive pit between each of its nostrils on either side of the skull. The bamboo pit viper, Himalayan pit viper and hump-nosed pit viper are a few examples of crotalids.

Hydrophidae

 

The family Hydrophidae, as the name suggests, is made up of all known species of sea snakes, which come in a wide range of hues and forms. More poisonous than cobra venom, the venom from these snakes is particularly neurotoxic.

Important venomous snakes

 

In India, the four snakes that are most significant medically are also the ones that cause the most fatalities. These include the Russell’s viper, the spectacled/biocellate cobra and the Indian cobra (Naja naja).

 

Saw-scaled viper

 

Collectively known as carpet viper (Echis carinatus). All of India is covered by it, with the exception of Jammu & Kashmir, West Bengal and the northeast. It is particularly deadly since it frequently comes into touch with people and is the leading cause of snakebite fatalities in India. Highly hemotoxic with average length of 80 cm, prefers the night and glides quickly in a side-to-side motion. It consumes insects, lizards, frogs, scorpions, mice and lizards.

Common krait

 

The most potent venom of all Indian land snakes is produced by the Common Krait, also known as Bungarus caeruleus. Except for Arunachal Pradesh, Uttarakhand, Himachal Pradesh and Jammu & Kashmir, it is dispersed throughout all of India. The venom is 15 times more deadly than cobra venom and is highly neurotoxic. It kills by paralyzing breathing muscle. It is about 1.7 m long and typically active at night. It consumes frogs, lizards and rodents for food.

Russell’s viper

 

The scientific name of this viper, Daboia russelii, honors Dr. Patrick Russell, who found it in 1796 while exploring the Coromandel Coast. It is distributed all of India, with the exception of Jammu and Kashmir. Highly hemotoxic and measures about 1.8 meters in length. The snake prefers to hunt at night, is typically slow but may strike quickly and prefers to ambush its prey. It hisses loudly when startled and only bites when absolutely necessary. It eats rodents as food.

King cobra

 

The longest venomous snake in the world, the King Cobra (Ophiophagus hannah), can reach lengths of up to 19 feet. It is found in eastern India, which includes West Bengal, Odisha, Bihar, Chhattisgarh and Jharkhand, as well as northern India. Additionally, it exists in every state in the northeast. In addition to these states, the Western Ghats’ tangled jungles are another place where King Cobras can be found in great numbers. King Cobras are incredibly swift, acutely aware and aggressive. It might be the only snake with any level of intellect. In a single bite, it has the capacity to inject up to 7 ml of extremely neurotoxic venom, which kills by assaulting the nervous system. This much venom can kill up to 20 adult humans or even an adult elephant because it is so poisonous and within ten minutes, death happens. Additionally, since the King Cobra has no antivenom so death is unavoidable. However, because it primarily inhabits

 

impenetrable jungles, it hardly ever interacts with people. King Cobra fatalities are therefore uncommon. It should be mentioned that this snake has a peculiar trait in that it consumes other snakes. Because of this, it is known as a “Ophiophagus,” which is Greek for “snake-eating” [2].

Sea snakes

 

Along the Indian coastline and in the Indian Ocean, there are two significant venomous sea snakes. Sea snake with a hook-nose: Its scientific name is Enhydrina schistosa and it is the most prevalent sea snake in India. It can be found in the waters surrounding the Andaman & Nicobar Islands as well as all of India’s coastline. It has a maximum length of 5.2 feet. Its venom is four to ten times as poisonous as cobra venom. Particularly vulnerable to getting bitten by this snake are fishermen. This snake mostly consumes fish for food.

Yellow-lipped sea krait

 

Laticauda colubrina is the scientific name for this, which is also known as the banded sea snake. It can be found all throughout the Indian Ocean. It has a maximum length of 4.9 feet. It prefers the night, and its victims are typically fisherman. It consumes other fish as well as eels.

Other poisonous species that are found in certain geographical regions can also result in a sizable number of fatal snakebite incidents. These include wall’s krait, banded krait, Sindh krait, and hump-nosed pit-viper in the Western Ghats, as well as the monocled/monocellate cobra in the north-east [3].

Non-venomous snakes

 

In India, there are hundreds of different species of nonvenomous snakes that fall into roughly 31 different categories. Six of the most significant species are briefly described below:

Checkered keelback

 

These snakes, formally known as Xenochrophis picastor, are so named because of their distinctive keel (fold) and checkered pattern. They are typically found in or around ponds and are small to medium-sized, nocturnal/diurnal snakes. They consume fish, frogs, rodents, birds and fish.

 

Indian rat snake

 

These snakes are reported to consume mice, frogs, toads, birds and lizards in addition to rats, as their name would imply. The most prevalent and well-known snakes in India are rat snakes, scientifically known as Ptyas mucosa. They are swift, fast-growing terrestrial snakes that may grow up to 11.5 feet in length. They are active during the day and are good climbers. They become calm when softly handled after being hyperactive and ready to bite if picked up.

Common vine snake

 

These snakes are brilliant green, as the name would imply and resemble vines. These medium-to-large (up to 6.6 feet in length; females larger than males) and slow, slender, diurnal snakes have pointed snouts and are known scientifically as Ahaetulla nasuta. Binocular vision and horizontally elliptical pupils are features of the eyes of vine snakes. They consume tiny birds, frogs, mice, and lizards.

Ornate flying snake

 

They are medium-sized (up to 5.7 feet in length), thin, energetic, diurnal tree snakes known scientifically as Chrysopelea ornata, which glide rather than really fly through the air. They can climb very well. They are constrictors like pythons and eat geckos, rodents, bats and birds.

Red sand boa

 

Because their head and tail are similar, they are commonly referred to as “two headed snakes,” even though their scientific name is Eryx johnii. They are nocturnal, medium-sized (3.3 feet in length; females are larger than males), sluggish, stocky burrowers that inhabit sandy soil. They are distantly related to South American boa constrictors. They prey on rodents, birds, amphibians and reptiles, making them strong constrictors.

Indian rock python

 

They are huge (up to 25 feet in length; females are larger than males), slow, mostly nocturnal snakes that can climb and swim well. Their scientific name is Python molurus molurus. They prey primarily on mammals and birds, occasionally on reptiles and amphibians, and are constrictors (kill through constriction by wrapping around the target) [4].

 

Snake venom

 

The toxic substance known as snake venom is kept in the venom glands, which are actually modified salivary glands and are found near the rear of the head. Through the teeth and venom channel, the snake releases its poison into its prey. There are two different kinds of fangs: fixed and retractable. The elapids, including cobras and kraits, often have the fixed fangs, which are immobile. The vipers, including the Russell’s viper and saw-scaled viper, have retractable fangs that can move back and forth.

The unique mixture of poisons that make up snake venom is what causes the vast range of reactions that result from snakebites. The two main categories of snake venom toxins are hemotoxins, which assault the blood and neurotoxins, which attack the nervous system. The former is found in vipers, whilst the latter is found in elapids. Other toxins include cytotoxins, which are harmful to cells, and cardiotoxins, which are harmful to the heart. The majority of the toxins, roughly 90% are composed of proteins and peptides. Some of these have distinct impacts on a variety of biological processes, including blood coagulation, nerve impulse conduction and blood pressure regulation, among others. Enzymes, particularly hydrolytic enzymes, are abundant in snake venom.

About 80-90% of viper venom and 25-70% of elapid venom are made up of enzymes in snake venom. These include nuclease, protease, peptidase, metalloprotease, phospholipase and phosphodiesterase. These defense-enhancing enzymes in snake venom assist in immobilizing and digesting the prey as well as defending against dangers [5].

Medical uses of snake venom

 

Antivenom, which is used to cure snake envenomation, is made from venom. Snake venom has also been used to make several medications. Hemotoxins, for instance, have been utilized to create medications for the treatment of blood problems, heart attacks and excessive blood pressure. Drugs to treat stroke and brain problems have been created using neurotoxins as a starting point. Captopril, which is extracted from the Brazilian pit viper and used to treat high blood pressure, was the first venom-based medication to be created. Eptifibatide from the rattlesnake and Tirofiban from the African saw scaled viper are two other medicines made from snake venom that are used to treat heart attacks and chest pain.

 

Snakebite problem in India

 

In India, snakebites are a very serious medical issue. Around 100,000 people are thought to die each year from snakebites worldwide, compared to 49,900 deaths from snakebites each year in India. Therefore, around half of all snakebite deaths worldwide are caused by India alone! These numbers unequivocally demonstrate the scope of the snakebite issue in India. Furthermore, since most snakebite fatalities are not reported, especially in isolated rural areas, these statistics may be significantly understated because they are mostly dependent on hospital records.

The issue is made worse by traditional “Ojhas” snakebite healers who are incapable of handling deadly snakebites, thus raising the mortality toll. Snakebite deaths predominately (97%) occur in rural parts of India, are more common in men (59%) than in women (41%) and peak from June to September during the monsoon season. The majority of snakebite deaths occur in people between the ages of 15 and 29. The most snakebite fatalities occur in the states of Uttar Pradesh (8,700), Andhra Pradesh (5,200), and Bihar (4,500) [6].

Symptoms and signs of venomous snakebites

 

The injected venom’s primary hemotoxic or neurotoxic properties will determine the signs and symptoms of envenoming. Local symptoms include: pain at bite site, ecchymosis (bruising), swelling, blister formation and necrosis (Russell’s viper), bleeding from bite site (saw-scaled viper), rapid discoloration at bite site whereas systemic symptom shows epistaxis (bleeding nose), hematemesis (blood in vomit), hemoptysis (blood in sputum) and hematuria (blood in urine)

Management of snakebite

 

Both psychological and medicinal methods are used to treat snakebites.

 

Psychological management

 

This is crucial because anxiety or panic can contribute to many snakebite deaths. The patient needs to be comforted. Panicking must be avoided at all costs since it impairs judgement and increases the likelihood that mistakes will be made when caring for the patient. It should be remembered that even from non-venomous snakebites, a patient’s excessive panicking might prove lethal.

 

Medical management

 

This entails providing care in the form of hospital-based “Antivenom Therapy” and first aid administered in the field. Acute Care First aid procedures should be brief, easy and rapid. It shouldn’t take up too much of your time. Assuring the patient, immobilizing the biting limb, and making transfer arrangements are all parts of first aid. The mnemonic “Do it R.I.G.H.T.” serves as the foundation for the currently advised first aid and includes the following:

R = Reassure the patient, due to the following reasons. Only around half of bites from poisonous snakes result in envenomation, accounting for 65 to 70 percent of all instances of snakebite. I = Immobilize the limb as for a fracture. Between 85 and 90 percent of venomous bites don’t result in any envenoming symptoms. Immobilize the limb as if it were fractured. Use fabric to keep the splints in position. Avoid applying too much pressure as this could stop the blood flow. Don’t exert too much pressure because doing so could cut off the blood supply. Applying compression in the form of tight ligatures is not recommended because they are harmful and ineffectual. G.H. stands for go to the hospital right away. Don’t waste time seeing “Ojhas,” or other traditional healers. There is no evidence that using conventional treatments can prevent poisonous snakebites. T = Inform the physician of any systemic signs you may have seen [7].

Things to Do and avoid

 

It is crucial that some actions be taken while others should be avoided. The following is a brief summary of these so-called dos and don’ts: Reassure the patient that medical care is available and that death is uncommon because the majority of bites are not venomous.

Remain composed and manage your anxiety. Encourage the sufferer to unwind. Excitation can raise blood pressure and boost circulation, which can hasten the distribution of the venom throughout the body. Keep the bitten limb below the level of the heart when you lay the patient flat on their back. Take off your shoes, watches, tight clothing, rings, bracelets and amulets since they could block your breathing if you have swelling. Have the equipment available to perform cardiopulmonary resuscitation (CPR) on the patient.

Don’t use a tourniquet since it will cut off the blood supply to the bitten limb. This may necessitate an amputation and may result in gangrene and necrosis. Applying chemicals to the

 

bite site, such as potassium permanganate, is not advised. Don’t cut the bite to extract the venom because doing so could result in the patient bleeding to death because viper bites can cause uncontrollable bleeding owing to non-clotting blood. Electric shock therapy shouldn’t be used because it is ineffective. Avoid freezing the bite site or applying severe cold there.

There is no scientific evidence to support the effectiveness of herbal or folk therapies, including applying snake stones to the place that has been bitten. If you have an ulcer, you risk the venom spreading throughout your body if you try to suck it out with your mouth. The bacteria in your mouth might potentially spread infection to the bite site. Use of suction devices to extract the venom is not advised because they are ineffective and may injure the patient. Don’t administer any alcohol or medications to the patient. Only water in moderation and paracetamol can be administered to treat pain. Avoid attempting to kill, handle or capture the accusatory snake to bring it to the hospital for identification. If the snake is still around, take a picture with your smartphone instead. Traditional healers, Ojhas, and quacks are useless for treating deadly snakebites, so don’t spend your time going to them. Since the majority of bites are not venomous, they merely seem to be successful. When a venomous snake bites a person, only antivenom therapy can save their life.

Antivenom treatment

 

The only remedy for venomous snakebites that has been established by science is antivenom therapy. Dr. Albert Calmette, a French physician, bacteriologist and immunologist who was affiliated with the Pasteur Institute in Paris, created snake antivenom. At the Pasteur Institute in 1894, Calmette, a personal friend of Louis Pasteur, invented snake antivenom. He showed that an animal might be “hyperimmunized” by administering progressively higher quantities of venom. The serum from the immunized animal can help a second envenomated animal survive. Calmette’s serum was the commonly used name for this antivenom. Calmette gave horses an immunization to make the antivenom. Modern antivenoms are still made using the principles of this discovery [8].

Antivenom manufacturing

 

Extraction of the venom from snakes is the first stage in the creation of snake antivenin. To “milk” the snake, its head is tightly gripped, its fangs are fastened to the edge of a petri dish, and the venom glands are gently squeezed. In the petri dish, the poison gathers. After the venom

 

is dried, solutions in saline or double-distilled water are created with varying quantities. Then, over the course of one to two months, horses are given escalating dosages of the venom to immunize them. In response, the immune system produces antibodies that are resistant to the venom. The horses are bled from the jugular vein in the neck once the vaccination regimen is complete. The serum is separated when the blood is allowed to clot. The active ingredients of the antivenom are the purified antibodies found in the serum. Both liquid and lyophilized (freeze- dried) versions of the antivenom are offered. The shelf life of the liquid form is two years, although it is less stable and needs to be stored in a cold chain. The more stable lyophilized antivenom is offered as a powder. It has a 5-year shelf life and needs just to be kept cool while in storage. Antivenom can be polyvalent or monovalent (developed against a specific species of snake). Indian antivenin is polyvalent, which means it is generated using venoms from various snake species. The “Big Four” snake venoms-viper, Russell’s Indian cobra, common krait and saw-scaled viper are used in India to make the antivenom. Indian antivenom is therefore effective against all four of the aforementioned snakes that are significant medically.

Treatment

 

Antivenom is extremely expensive and in short supply. As a result, it should only be given once envenomation has been determined. Depending on how envenomated a creature is mild or severe envenomation, the antivenom dose may change. There are 10 ml of antivenom in each vial. An envenomated patient usually needs 8-10 vials of antivenom to be treated. In extremely severe situations, greater doses (20 vials or more) can be necessary. Children should receive the same dosage of antivenom as adults, it should be underlined. Since antivenom is produced in horses, human bodies cannot recognize the antibodies. Negative reactions to serum may result from this.

Antivenom reactions can result in anaphylaxis, a condition that can be fatal. The antivenom must be stopped right away in this case, and epinephrine (adrenaline) must be given to control the anaphylaxis [8]. Manufacturers of antivenom in India, there is “Big Four”-specific polyvalent snake antivenom available. There are now seven snake venom producers in India. They are as follows:

• Mumbai-based Haffkine Bio-Pharmaceutical Corporation
• Mumbai-based Bharat Serums and Vaccines
• Pune-based Serum Institute of India
• Kolkata-based Bengal Chemicals and Pharmaceuticals
• Kasauli-based Central Research Institute of India
• Hyderabad’s Biological Ltd.
• Hyderabad’s VINS Bioproducts

Prevention of snake bites

According to the saying “An ounce of prevention is worth a pound of cure,” prevention is always preferable to treatment. As a result, it is advised to take the following precautions to avoid being bitten by a snake:

• Steer clear of areas where snakes may reside. Snakes can conceal themselves amid mounds of leaves, firewood, coal or cow dung cakes used for cooking in rural
• Always wear sturdy boots and long pants when out on foot at night. To view the path in front of you, use a flashlight. Tread carefully because doing so will cause the ground to vibrate, which snakes can sense and cause them to flee.
• When walking on unlevel ground, use a stick to prod the ground in front of you. Any snakes will flee if this happens.
• Avoid sleeping on the floor, especially if you live in a remote location, as kraits, which penetrate homes at night in quest of food, may bite you.
• Avoid taking a dip in ponds, streams or rivers after sunset to reduce your risk of being bitten by dangerous snakes like cobras, which can be mistaken for harmless checkered keelbacks due to the poor visibility. Cobras are proficient swimmers, like checkered
• Even if a snake is dead, you should never handle it. It has a reflexive ability to bite!

Conclusion

The burden of snakebites in India is still the largest in the world, yet it is still greatly underreported. Since India accounts for the majority of all snakebites worldwide, estimates of this condition may also be too low. In particular in the 13 states with the highest prevalence of snakebites, there is an urgent need for effective community education, awareness initiatives, suitable training of medical staff, and better availability and distribution of antivenom. This may greatly lower the number of snakebite fatalities in India.

References

1. OP Jaggi., “Medicine in India: Modern Period”. In: History of Science, Philosophy and Culture in Indian Civilization (Vol. IX: Part 1); Oxford University Press, New Delhi,
2. R Whitaker, A Captain, “Snakes of India: A Field Guide”; Draco Books, Chennai,
3. R Snakes: A Natural History; Sterling Publishing Co., Inc., New York, 1994.
4. How does snake venom work? Available from: https://www.thoughtco.com/how-snake- venom-works-4161270
5. JL Bottrall, F Madaras, CD Biven, MG Venning, PJ Mirtschin, Proteolytic activity of elapid and viperid snake venoms and its implication to digestion. Journal of Venom
6. B Mohapatra, DA Warrell, W Suraweera, P Bhatia, N Dhingra, RM Jotkar, et , Snakebite mortality in India: A nationally representative mortality survey. PLoS Neglected Tropical Diseases, 5, (4), e1018, 2011.
7. S Mahadevan, I Jacobsen, National Snakebite Management Protocol (India), 2008 (shortened version). Indian Journal of Emergency Pediatrics, 1, (2), 63-84,
8. DA Warrell, WHO/SEARO Guidelines for the Clinical Management of Snakebite in the Southeast Asian Region. South East Asian Journal of Tropical Medicine and Public Health, 30, 1-85, 1999.

https://www.pashudhanpraharee.com/snake-bites-management-treatment-in-livestock/

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