Study of Snakebite Cases and use of "PINAK" the ayurvedic antivenin

MEDICAL JOURNAL OF WESTERN INDIA (2006) VOL.34

ORIGINAL ARTICLE-9
STUDY OF SNAKEBITE CASES AND
USE OF “PINAK” THE AYURVEDIC ANTIVENIN

PAWAR GP1         PAWAR PS2
 

MATERIAL AND METHODS:
The study was carried out in S.S.Venutai Y.Chavan sub-district Hospital, Karad and Shri V.Joshi Charities Trust B.K.L.W. Hospital, Derwan over a period of 3 & 1/2 years from July2002 to April 2005. Few cases from Shree Hospital, Siddhivinayak Hospital, and Karad were also included. Detailed information was collected form 75 cases. It included history i.e., pain, giddiness, difficulty in respiration or swallowing, thirst, general or local bleeding, etc. Pulse and BP recordings were done for each patient.
Local examination was done to observe for swelling or blebs at the site, discoloration at the site, bite mark, tourniquet or any first aid given. Systemic examination done to see for signs of ptosis, dysphasia, disarthira, respiratory paralysis.  Investigations included CBC, BT & CT, blood grouping & cross matching, electrolytes, creatinine, urinalysis, X-ray chest & local radiograph. Treatment given was resuscitation, release of tourniquet, general care. Tab PINAK, injection ASV, surgical treatment like fasciotomy, puncture of blebs.

RESULTS:
A total of 75 cases of snake bite were studied and their relevant data collected. Maximum number of cases were in the age group of 31-40 yrs., youngest being a 2.5yrs. old girl and oldest 85 yrs. of age.

Table I: Table showing age distribution.

Out of these 75 cases 49(65.3%) were males and 26(34.7%) were females. Of these 72 were Hindus, one was Muslim and 2 belonged to other religions.
Maximum cases i.e., 43 had the bite on lower extremities. Neurotoxicity was seen in 16 cases (21.3%). General symptoms were experienced by 44 (58.7%).

Table II: Type, site and Symptomatology

When the time of arrival of patients was analysed it was seen that only one third patients had reached the hospital within two hours. (table III)

Table No. III: Time of arrival of patients

Table IV: Ligature application

Similarly first aid incision was taken immediately only in one case while in rest of the cases incision was not attempted as first aid care.
In about 61% of cases ligature was applied immediately to obstruct the blood flow. Ligature was not tied to patient only in five cases. (Table IV). Among the known complications of snake bite, 16 had signs of neuroparalysis, 29 of vasculotoxicity (38.66%) Local toxicity was seen in 30 cases (40%) (Table V).
Among the investigations done 29 (49.16%) cases showed BT-CT raised, no other investigations showed abnormal results.

Table V: Table showing clinical signs on physical examination.

About the treatment given out of 75cases 23 patients were treated with injection ASV 37 patients were given tablet PINAK while 15 patients were given both ASV and tablet PINAK. A group of patients with mild to moderate envenomations were selected for use of placebo (tab B-complex) where life was not in danger. Out of 37 patients selected for PINAK treatment, 25 were given placebo treatment (table VI). It was seen that none of the patients showed any improvement in placebo group till 24-48 hrs. After tablet PINAK was added it gave very good results.

Table VI: Various regimens of treatment employed.

Among the cases that required surgical procedures it was seen that only one case required fasciotomy while in one case amputation had to be done. (Table VII)
Table No. VII: Surgical Procedures carried out. (N=75)

Among these 75 cases only one patient who was treated only with ASV died, rest 74 cases recovered completely which was confirmed even by follow up later after discharge.

DISCUSSION:

Though snakes are our friends, people are afraid of snake because of the deaths which can occur inspite of the availability of injection ASV. Incidence of snake bite is more in farmers. The time elapsed after the bite is important which determines whether damage is confined to local area or if systemic signs have developed. It is important to get a description of the snake involved as the snakes remain within 20 feet after biting. Identification of the snake guides the physician to know the type of snake so as to start appropriate treatment. It is also important know when was ligature tied and whether any treatment was given. Reduced muscular movements of the site of bite decrease the absorption of poison in systemic circulation; therefore immobilization is an important step.

Ligature was applied in 46 cases but if applied too tightly it obstructs arterial blood flow also and may cause ischaemic pain. Therefore ligature should be applied in such a way that only venous blood is obstructed and prevents systemic mixing of venom and hence it is a life saving first aid measure.

Incision was taken in only one case. It should be done with a clean blade1” long and 1: above and skin deep on both sides of the bite mark which helps in w\oozing out of the venom and hence dose of ASV required can be lessened.

Out of 75 cases 51 were brought to hospital after 2 hours of snake bite. It is advisable to bring the patient as early as possible to give ASV to avoid irreversible organ damage. Administration of local medicine like neem tree juice, etc. are responsible for delay which may cause severe vomiting leading to aspiration pneumonia.

After hospitalization, the physician must observe the patient meticulously for signs of toxicity. Usually neuroparalytic signs develop within one hour followed by vasculotoxicity. Plan of treatment is to start specific treatment only after signs of toxicity develop till complete neutralization of the poison. Treatment policies vary from hospital to hospital. Some may give one to two injections to all cases including nonpoisonous snake bites. Of course initation of ASV after signs of toxicity are seen need a confident, sincere and knowledgeable physician. The dose required is 5 vials for mild, 6-15 vials for moderate and 31-120 vials for very severe toxicity. Some physicians declare the patient ASV resistant if ASV requirement goes above 80 vials. While anti-venom is life saving, it may lead to immediate hypersensitivity (anaphylaxis) or delayed serum sickness, therefore must be used with caution.

A working SANJIVNI (Herb brought by Lord Hanuman for Laxman when he was bitten by a snake) named PINAK and KAPIS have been developed by us from traditional medicine for snakebite patients. These Ayurved medicines are being used for incurable or resistant cases or to treat cases living in inaccessible areas. We have used Tab PINAK August 2002 with successful results. It is a combination of four herbs. We have developed it as a sublingual tablet with sugar base as it is very bitter. Onset of action is within minutes and lasts for 6-12 hours. The dose required is 1-3 tablets for mild, 1-10 tablets for moderate and more than 10 tablets for severe toxicity. It is observed that BT and CT is controlled within 6 hours and swelling disappears completely at the earliest and reduces paralysis as well. Also we found that PINAK is a good and effective hemostatic agent. Along with this tablet KAPIS is given which is found to be good wound heeler. For faster results PINAK is given in powder form sublingually. The field care recommended is:

1. Immobilization of limb to prevent spread of venom.
2. Application of tourniquet one joint above the site of bite.  
3. Making a first aid and incision to remove venom.
4. Suction application at the site of bite by pump.
5. Do not give anything to eat or drink to prevent aspiration.
6. Remove anything that may constrict the limb.
7. Arrange transport to shift the patient to hospital.
8. Give ABC if required.

Thus tab PINAK as Ayruved medicine is an oral form of medicine which is cheaper, has no side effects, no expects, no expert or trained person is required for its administration. If given along with inj. ASV, requirement of ASV is reduced drastically.
As PINAK is a safe medicine if it is taken immediately after any snake bite, no person will die on road to a hospital.
Initially use of PINAK can be an adjuvant till a physician gets confidence of the drug.

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