SNAKEBITE PROTOCOL DEVELOPMENT WORKSHOP CMC, VELLORE 11.03.2013 A National survey of Snake bites in India (venomous and non-venomous), syndrome-snake species correlations, outcomes and ASV dose requirements SNAKEBITE PROTOCOL DEVELOPMENT WORKSHOP CMC, VELLORE 11.03.2013

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 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

STUDY FLOW CHART Suspected Snakebite Admission Treatment Discharge Informed consent Venomous bite Admission Treatment Discharge Non-venomous bite Observation Documentation Using proforma at admission and daily till discharge

DOCUMENTATION The study proforma: Details of bite Snake identification Clinical syndrome Laboratory evaluation Complications Treatment ASV dose requirement Mechanical ventilation Neostigmine Transfusions Antibiotics Outcomes

SUGGESTED LIST OF ESSENTIAL INVESTIGATIONS Admission WBCT or PT,PTT CBC Blood picture Creatinine Electrolytes Follow up Haemotoxic- WBCT or PT,PTT every 6 hours till normal Renal failure- creatinine daily till normal

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

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