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Indian Pediatr 2011;48: 66-67 |
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Snake bite Envenomation in Children in Kashmir |
Sheikh Mushtaq Ahmed, Umar Amin Qureshi, Akhter Rasool, Bashir Ahmed
Charoo and Qazi Iqbal
Department of Neonatology and Pediatrics, SKIMS, Srinagar,
India.
Correspondence to: Umar Amin Qureshi, Post Box no 1402
GPO, Srinagar, Department of Neonatology and Pediatrics, SKIMS, Srinagar,
Kashmir, India.
Email:
[email protected]
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A three year retrospective study was done to study snakebite
envenomation among Kashmiri children. Ten children were admitted with
snakebite. Snakebite was vasculotoxic in seven and mixed in two.
Levantine viper bites were seen in five who had Grade 3 bites with
severe local signs, severe coagulopathy and hypotension. Both
environmental risk and seasonal incidence was observed.
Key words: Antivenom, Envenomation, Levantine viper.
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Data on envenomation among Kashmiri
children is limited. To examine the epidemiological and clinical profile
of snake bite envenomation in Kashmiri children, a three year
retrospective study was carried between May 2006 and April 2009. We
included all children admitted with a history of snakebite, having (i)
presence of fang marks; and (ii) presence of swelling, echymosis,
bleeding, and blister formation. In each case, snake was identified either
by victim or by accompanying person. Species identification was made on
basis of description of snake by eyewitnesses. In addition to demographic
characteristics, details of injury in the form of time and season of the
bite, site of the bite, time of arrival after bite was obtained. Degree of
severity of snake bite was graded on a four point scale [1]. All children
were subjected to monitoring with repeated 20 minute whole blood clotting
time (20WBCT).
A total of ten patients were admitted with snakebite.
Male to female ratio was 1:1. Mean age of presentation was 8.9 years. Mean
arrival time at hospital after bite was 3.8 hours (range 2-6 hrs). Mean
dose of antivenom given was 20.7. Mean hospitalization period was 3.6 days
(range 1–5 d). Snakebite was vasculotoxic in seven and mixed (neurotoxic
and vasculotoxic) in two. Levantine viper or "Gunas" (local name) was
identified as a source of envenomation in five.
Children with Levantine viper injuries came from areas
around Sindh valley. This is consistent with observation that they are
numerous in Lar area and seldom seen on the southern side of the Kashmir
[2]. Envenomation was reported between months of May and August (summer),
an active season for vipers. Envenomation occurred during daytime.
Levantine viper is usually inactive during daytime, but quite alert and
apt to attack swiftly if disturbed. Further, few children would venture
during night to be exposed to snakes. Site of Levantine viper bite was
hand (in three) and foot (in two). Envenomation resulted due to
unintentional encounters. Hand bites occurred while working in
agricultural fields during harvest time. Foot bites occurred while
climbing a rock (in one) and playing in field (in one). Patients with
Levantine viper injuries had Grade 3 bites. They were brought to hospital
early because of severe local envenomation. They also had severe
coagulopathy (PT>20 s, INR >1.8, aPTT >1 min or non clotting blood) and
hypotension. Hemolysis occurred in one.
All children were treated with polyvalent
antisnakevenom (ASV). Local management consisted of minor surgical
procedures in the form of bleb removal and surgical dressings. Symptomatic
treatment was given for hypotension and hemolysis. All patients completely
improved with no permanent physical or physiological abnormality.
We propose that current ASV should continue to be used
for Levantine viper bites, an observation in contrast to that reported
earlier [3]. Education of local populace is needed regarding habits of
Levantine vipers. They should wear gloves and shoes when working in fields
during seasons when snakes are active. They should be asked to be cautious
when reaching under logs or climbing rocks.
References
1. Holve S. Envenomations. In: Kliegman RM,
Behrman RE, Jenson HB, editors. Nelson Textbook of Pediatrics, 18th ed.
Philadelphia: Elsevier. 2007.p.2932-5.
2. Lawrence WR. The Valley of Kashmir. 2nd ed. Srinagar:
Nice Printing Press. 2005.p. 155-6.
3. Sharma LR, Lal V, Simpson ID. Snakes of medical
significance in India: the first reported case of envenoming by the
Levantine viper (Macrovipera lebetina). Wilderness Environ Med.
2008;19:195-8.
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