Jayanti and her acquaintance from academy were arena in the garden on a hot summer atramentous in Cochin, Kerala. While acrimonious up a brawl from amidst the broiled leaves on the ground, Jayanti acquainted a abrupt affliction on her hand, as admitting she had been ashore with a needle. Hearing a crackle in the leaves, she aloof bent the glimpse of a snake slithering away. She realised she had been bitten, and ran central to acquaint her parents. Her mother Laila was at home, talking with a doctor acquaintance of chastening who was visiting. Laila was abashed and abashed about what to do.
Renuka, the doctor, brash the child’s duke and begin two tiny chaw marks, acknowledging that she had been bitten. Jayanti was taken to the hospital, brash and absolved home in three days’ time.
This commodity illustrates the do’s and don’ts in such a situation. The aboriginal breadth is accounting as a chat amid Laila, the child’s mother, and Dr Renuka, who was accomplished in alleviative snake bites. The additional breadth provides important advice about accustomed antagonistic snakes and explains how to anticipate snakebites.
Laila: “We are both so scared! What should I acquaint Jayanti, Dr Renuka?”
Doctor: “Keep calm and amuse act calm, assure her that it is annihilation austere and that she will be all right. Amuse do not alarm her by allurement what the snake looked like, whether it was a cobra or a viper and so on. If the accommodating gets panicky, the acceptance in apportionment will advance the acidity faster throughout the body. It is important to accumulate the accommodating as calm as possible.”
Laila: “I can hardly see the chaw marks on her hand! They are so tiny!”
Doctor: “Yes, the chaw marks are about so small, they may escape notice. Let us use a red brand and draw a amphitheater about it for reference.”
Laila: “Shall I tie a bound tourniquet (rope) on her duke so that the adulteration will not advance to the blow of her body?”
Doctor: “That is not recommended anymore; it can be alarming aback it is too tight. I accept heard of amputations acceptable all-important due to break activated tourniquets asthmatic claret accumulation to the limb.”
Laila: “But how can we anticipate the acidity from spreading?”
Doctor: “Venom spreads boring through her lymphatics and babyish claret vessels. The best affair is to accumulate the duke below the akin of the heart. Let her lie bottomward on her ancillary with the duke dangling down. We can use the adeptness of force to abate the advance of the venom.
Instead of attached a tourniquet, we can administrate an adaptable ache bandage, about 4 inches in width, over the apathetic limb. Let me advice you do that.”
Laila: “Oh dear! I don’t accept a ache cast at home. What can I do?”
Doctor: “A continued band of bolt of four-inch amplitude can be acclimated instead of a ache bandage. Our aim is to apathetic the breeze of lymph, and not to cut off the claret supply. Such bandages may be acclimated in cobra and krait bites. Starting from the apathetic finger, we can acclaim awning the absolute limb.”
Laila: “Thanks. But how do I accomplish abiding it is not too tight?”
Doctor: “A advantageous aphorism of deride for the bulk of binding of the ache cast is to accept abundant allowance to accelerate our feel below the bandage.”
Laila: “Is she accustomed to move her hand?”
Doctor: “It is bigger to accumulate the duke as still as accessible to abate the advance of venom. A splint can be acclimated forth with the ache cast to accumulate the duke immoblilised, aloof like the case of a burst limb.
Likewise, those who got bit on the leg should be brash to sit still and not to run, while added agency of carriage are actuality abiding to go to hospital. Walking and alive will accomplish the acidity advance faster through claret circulation.”
Laila: “Should she be sitting up or lying down?”
Doctor: “It is best for her to lie bottomward agilely on her ancillary while we get her to hospital. It is declared accretion position. This position will assure her lungs in case of vomiting.”
Laila: “Shall I blot on the anguish and draw the acidity out?”
Doctor: “No. That is of no use. Acidity will not arise out by applying suction.”
Laila: “Shall I accomplish a few cuts abreast the anguish with a brand so that the acidity will dribble out?”
Doctor: “No. That will not abandoned be useless, but will acceptance her adventitious of accepting an infection and astringent bleeding. Applying ice, electric shock, ‘snake-stone’, potassium permanganate or inducing burns on the anguish are amiss practices, too.”
Laila: “What should I do with Jayanti’s watch and bangles?”
Doctor: “Let us abolish them now, afore the abscess sets in. Once the breadth is swollen, we will not be able to abolish the ring, watch or her bangles, and it can become alarming for her circulation”
Laila: “I heard there is a acceptable healer in the apple nearby. Shall I booty her there?”
Doctor: “What will save Jayanti’s activity is actual diagnosis, admiring affliction and alert bang of antivenin. Wasting time with a acceptable healer is not appropriate and could bulk her life.”
Laila: “But Dr Renuka, I heard that this healer has healed abounding snake chaw victims. The villagers accept a aphotic assurance in her ability.”
Doctor: “Many of their declared success acceptance are from non-venomous snake bites. Besides, abounding antagonistic snake bites action afterwards envenomation, that is, alike admitting the snake bites, it may abort to inject its acidity at that moment. We alarm them dry bites. In fact, about bisected of Russell’s viper bites and a third of cobra bites are dry. Such cases balance afterwards any medication, and the healer gets the credit.”
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Laila: “Wow, I did not apperceive that non-venomous snakes bit people.”
Doctor: “Yes. In a contempo abstraction from Calicut Medical College, one out of every four bites were from non-venomous snakes.”
Laila: “Are you adage that acceptable treatments are fake?”
Doctor: “That is not what I meant. In fact, snakes accept lived on the planet best than man, and appropriately snake bites accept bent medical absorption for bags of years. Several herbal treatments accept been approved all over the apple by acceptable medical practitioners, but abominably none of them accept been authentic yet by currently accustomed authentic methods.
For a life-threatening condition, it is childish to try article that is unproven, based on buzz alone. As of now, the W.H.O. does not endorse any added analysis for snake chaw than antivenin, additionally declared ASV. The accession of ASV has bargain the afterlife bulk from antagonistic snake bites from 50% to 5%.”
Finishing up with the child’s bandage, Laila asked: “Should we go alfresco to the garden and try to bolt the snake that bit Jayanti, so that we can booty it to the hospital?”
Doctor: “It is acceptable to be able to analyze the snake, but attempting to bolt a antagonistic snake can become alarming afterwards the advice of a able snake rescuer. Besides, snakes do not break in one place; and we don’t accept time to lose.”
Laila: “But if we don’t bolt the snake, how will the doctors apperceive what anesthetic to give?”
Doctor: “Polyvalent antitoxin is an bang that is able to neutralise the acidity of the best accustomed snakes in India. The aforementioned antitoxin is accustomed to all snake chaw victims, and is able adjoin the chaw of cobra, krait, Russel’s viper and saw-scaled viper, the declared big four. Thus, doctors do not necessarily crave to see the snake to be able to administrate antivenin.
However, anecdotic the snake can advice them clothier the admiring analysis accordingly. Besides, they can additionally abstain giving ASV in specific cases that they apperceive it won’t work, such as the hump-nosed pit viper (HNPV)”
Laila: “Have you brash HNPV bite? Is it accustomed in Kerala?”
Doctor: “They are apparent forth the arresting sections of Kerala, in forests and elastic plantations. I bethink a case referred from the western ghats afterwards the accommodating accustomed ASV for a doubtable viper bite. The snake could not be found, and ASV was accustomed bold it was Russel’s or saw-scaled viper chaw as usual. However, alike massive doses of ASV produced no advance in the deranged claret array parameters.
That case angry out to be a bulge nosed viper bite, for which abandoned admiring analysis is accessible in India at this time. Unfortunately, that accommodating developed complications from ASV that were worse than the furnishings of the snake bite. If abandoned they had articular the snake as HNPV, they could accept abhorred giving ASV and the aftereffect adeptness accept been better.”
Laila: “Is there annihilation abroad we can do to advice analyze the snake?”
Doctor: “Taking a photo of the snake application a adaptable buzz adeptness advice analyze the species.”
Laila: “Why not go to the doctor’s clandestine dispensary on the abutting street? I heard he is a actual acceptable doctor and has lots of patients.”
Doctor: “The doctor adeptness be excellent. But to amusement an emergency, any doctor is abandoned as acceptable as the accessories and adeptness he or she gets to assignment with. The OP dispensary is a abode breadth a doctor consults on non-emergency patients. It is not able to amusement emergencies like snake bite, chest pain, or asthma attack. Such cases charge abandoned be brash in the blow breadth there is resuscitation accessories and accomplished agents accessible to advice the doctor.”
Laila: “But how do we adjudge which hospital to go to?”
Doctor: “It is bigger to go to the abutting hospital, but we charge accomplish abiding that they accept antitoxin in stock. We can alarm the hospital on the way and allocution with the doctor at blow to affirm they do accept antitoxin in stock.”
Laila: “Why do we accept to rush? Why don’t we at atomic try the acceptable anesthetic aboriginal and afresh go to hospital if there is no improvement?”
Doctor: “The best adventitious of adaptation Jayanti has is to get to hospital at the earliest, and accept antitoxin injection. We charge to do it afore acidity spreads to all genitalia of her body. Waiting is not an option.”
Within ten minutes, they were on their way to hospital in Dr Renuka’s van with Jayanti lying bottomward in the backseat with her grandmother abating her. Dr Renuka put on some of Jayanti’s favourite music to abstract her. On the way, Laila agilely asked: “I abhorrence to ask you this, but is there a adventitious my adolescent could die?”
Doctor: “Don’t worry, she will be altogether fine, as we are already on our way to hospital. I anamnesis a contempo abstraction from Kannur Medical academy of fifty accouchement with antagonistic snakebites. No deaths occurred as best of the accouchement were brought promptly to hospital, and antitoxin was accustomed by protocol.”
Laila: “But aback I searched Google, I apprehend that antitoxin has ancillary effects?”
Doctor: “A few patients can accept an allergic reaction, which can be brash promptly if they occur. Antitoxin (ASV) is the abandoned life-saving analysis available. The adventitious of a accessory bang abhorrence can’t alike be compared to the adventitious of afterlife from envenomation. Therefore, we should not be afraid to booty antitoxin if the doctor recommends it afterwards analytical her.”
Laila: “Should she get a analysis dosage first, as in the case of a penicillin shot?”
Doctor: “No. A analysis dosage is not all-important in the case of antivenin”
Laila: “How abundant ASV will she need? She is abandoned a child, maybe they will accord her a paediatric dose?”
Doctor: “She will charge 8-10 units initially, which is the aforementioned dosage as an adult. The dosage of the ASV is bent by the bulk of adulteration injected by the snake, not by the patient’s age or anatomy weight.”
Laila: “When will they adjudge to accord her antivenin?”
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Doctor: “Not all cases of snake chaw charge antivenin. They will adviser Jayanti anxiously for any signs of envenomation. If any signs appear, they will administrate ASV.”
Laila: “What are some of the furnishings of envenomation or advance of acidity throughout the body?”
Doctor: “Vomiting is an aboriginal evidence of envenomation. Neurotoxic venoms from kraits and cobras annual abashing of vision, angled of eyelids, weakness of the close and limb muscles. Afterwards antivenin, the accommodating can adulterate to complete aeroembolism and die from affliction to breathe. In astringent cases, affection arise sooner, that is aural three hours of the bite.
For hemotoxic venoms such as viper bite, claret in the urine, bleeding from the gums or adenoids can occur, forth with astringent affliction and abscess of the afflicted limb. Aback analysis gets delayed, bleeding can action in the academician and lungs. Affection accent problems and branch shut bottomward can action too. Best snake venoms accommodate a admixture of assorted toxins.”
Laila: “That sounds so scary! I achievement Jayanti will not advance any of these complications.”
Doctor: “There is no charge to worry, Laila. Remember, these complications action mainly amid those who do not go to the hospital aboriginal enough. I am animated that Jayanti realised she was apathetic and anon abreast us, so there was no delay. Since she is already actuality taken to hospital, aggregate will be aloof fine.”
Laila: “Why would accession with a snakebite not seek analysis immediately?”
Doctor: “That is a acceptable question. We adeptness admiration why bodies who ache a snakebite do not blitz to hospital every time. But in the absolute world, there are times aback the being fails to apprehension the bite. This is a accustomed botheration amid those who are accomplishing chiral labour in the field, accession firewood in the backwoods and in the case of accouchement who are alive at play. The snake adeptness not get noticed anniversary time. Accouchement adeptness not feel the chaw in the action of playing. Labourers adeptness avoid it cerebration that it is abandoned a blemish while accession firewood. In fact, krait bites are accepted to annihilate bodies in their sleep.
I accept apparent several cases breadth bodies are brought to blow with blow of alertness or added complications afterwards a appear history of snakebite. The analysis in such cases is fabricated abandoned later, afterwards we accomplish investigations. On the cast side, abounding cases of declared snakebite about-face out not to be the case too.
In alien rural areas, delays can action because of abridgement of availability of avant-garde medical facilities, bald agency of transport, bereft banal of antivenin, cultural factors that accord alternative to aboriginal analysis methods, and banking limitation to annual medical care.”
Laila: “If antitoxin bang cures snakebite, afresh why not accord it in a bounded clinic? What is the charge to hospitalise her?”
Doctor: “Antivenin will abandoned neutralise the snake’s acidity in the body. However, affluence of admiring analysis is all-important to adjustment the blow acquired by the acidity in assorted organs of the body. For example, aback anatomy are paralysed and the accommodating can’t breathe, antitoxin abandoned will not save the patient. ICU affliction and chase abutment will be appropriate till the anatomy balance from the neurotoxin and the apparent is able to breathe again.
If the kidneys are damaged, dialysis will be bald till they recover. Aback claret array is deranged, admixture and added specialised treatments adeptness become necessary. Some patients advance astringent infection and tissue blow at the chaw site, acute abiding analysis and surgery. These can abandoned be done in well-equipped hospitals.”
Laila: “How continued should we break in the hospital?”
Doctor: “A minimum of 24 hours ascertainment is bald alike if there are no antecedent signs of envenomation. The break may be best as the case adeptness be.”
Snakebite: a preventable annual of death
Snakebite is an important preventable annual of death, affliction and bread-and-butter distress. Best of the snake chaw victims in developing nations arise from rural areas, and are the arch wage-earners of the family. Afterlife ante abide aerial in areas afterwards acceptance to avant-garde medical care. Several of those who survive snakebites accept limb blow or deformity, abiding branch disease, balance furnishings of stroke, hormonal deficiency, abiding pain, fatigue, depression, headaches and added ailments.
Fortunately, the majority of snakes are non-venomous. Of the 100 breed of snakes begin in Kerala, abandoned four are accustomed abundant to affectation cogent crisis to animal activity aback they bite. These accommodate the Russel’s viper, saw-scaled viper, accustomed krait and cobra—all of which are frequently begin abreast areas of animal habitation. Additionally declared the Big Four, they are amenable for over 90% of the 45,000 snake-bite deaths that action in India every year.
The baron cobra is antagonistic too, but as it is a shy snake that mostly lives in close forests, animal encounters are uncommon—and deaths are almost attenuate in India. The hump-nosed pit viper is accession antagonistic snake begin in Kerala. A few others such as the grass snake are agilely venomous, abandoned causing bounded bark irritation.
Failure to booty basal precautions is the acumen for the majority of snake bites. The best important annual of afterlife is adjournment in extensive the hospital, a accustomed botheration in rural areas.
Understanding snake behaviour
Snakes are begin in undisturbed abounding areas, below bags of firewood, artery and rocks. They are additionally apparent abreast paddy fields and added places breadth rodents are found. Snakes may adventure into the garden and alike central in chase of aliment and acknowledgment comatose places. While indoors, snakes adopt aphotic corners, including the central of shelves, cupboards and shoes.
Snakes are shy animals. They are able to feel accordance on the arena and about move abroad as they apprehend animal footsteps approaching. They coursing for casualty application their faculty of smell. Vipers accept the adeptness to ascertain calefaction from the casualty and chaw accurately alike in complete darkness. For the best part, snakes abandoned chaw in self-defence—most frequently aback bodies footfall on them by accident.
While abounding would accept that all antagonistic snakes advance aback stepped upon, studies accept in actuality apparent that they do not attack to chaw every time they are provoked. In some cases, they may artlessly try to escape aback stepped upon.
When threatened from a distance, the Russel’s viper aboriginal lets out a admonishing hiss, while the saw-scaled viper makes a abrasion babble by abrading its scales. They bang abandoned aback they abide to be harassed. In accession to their affecting awning affectation aback threatened, cobras are additionally accepted to try and alarm abroad the blackmailer by occasionally carrying a closed-mouth strike—that is afterwards attempting to abuse or kill.
A cogent cardinal of open-mouth strikes absorb a dry bite, aback the snake does not inject acidity through its fangs. Acidity metering or the adeptness of snakes to adapt the bulk of acidity in anniversary chaw is a amount of abundant study. Contrary to accustomed belief, dry bites do not action because the snake afresh had a meal.
Doubtless, these decidedly amiable ancestry of antagonistic snakes advice abate the all-embracing cardinal of animal deaths that chase snake encounters.
‘The big four’.
1. Russel’s viper (anali, chenathandan) is a ample snake, about 4 anxiety in length. The arch is ample and triangular. It is amber in colour with three rows of solid or alveolate egg-shaped atramentous spots abiding in a chain-like arrangement forth its body. This colour arrangement is mimicked by non-venomous snakes such as accustomed beach boa and Indian bedrock python. Due their accomplished camouflage, vipers can be difficult to atom while lying apoplectic in their accustomed habitat, amid broiled leaves in open, blooming or bristling areas.
Russel’s vipers are alive at night, analytic for rodents and frogs. Aback threatened, it gives out a loud hiss not clashing that of a burden cooker. Armed with aciculate fangs and a lightning-fast authentic strike, they annual for the majority of snakebite deaths in India. Added bites action during the months of May to August, aback ample numbers of babyish snakes are born.
2. The saw-scaled viper (chruttamamdali) is a babyish snake of ablaze amber colour with anemic white or chicken spots on its body, giving it near-perfect appearance adjoin dry arena with collapsed leaves. It is apparent predominantly in arresting areas. Aback provoked, it launches into a connected coil motion, authoritative a babble by abrading its scales together, captivation its audible triangular arch in strike-ready position. Actuality abandoned a bottom in boilerplate length, it is about mistaken for a controllable breed by biting passers-by.
3. The accustomed krait (shankuvarayan) is atramentous with attenuated white rings on its body. Kraits are additionally accepted to appointment homes at night in chase of casualty such as lizards and mice. Aback a being who is sleeping on the attic accidentally rolls over on to the snake, bites can occur. Such bites may be accessible or go absolutely unnoticed, and the being may deathwatch up afterwards in a accompaniment of paralysis. In such instances, although advanced awake, the abstruse beef aeroembolism adeptness abominably actualize the consequence that the victim died while sleeping. The controllable wolf snake copies the krait’s design, in a archetypal archetype of Batesian mimicry.
4. Cobras (moorkhan) arise in altered colours: brown, black, tan, and accept a atramentous spectacle-shaped mark on the aback of their hood. They augment on rats, mice, banty and frogs, and appropriately can be apparent about breadth bodies live. They are additionally apparent on paddy fields, with added bites occurring during autumn season.
In accession to the big four above, two snakes deserve appropriate acknowledgment in this context. One is the antagonistic bulge nosed pit viper and the added is the controllable rat snake. Details of added snakes are accessible in the added account section.
The hump-nosed pit viper (churutta) is not allotment of the big four. Frequently misidentified as the saw-scaled viper, this babyish snake is apparent in the plantations of Kerala and Sri Lanka. It sits apoplectic amid rocks and dry leaves with its arch acicular upward. Unfortunately, its acidity is not covered by the ASV accessible in India. Initially anticipation to be almost below toxic, its chaw is now accepted to annual branch abortion (10%) and claret array abnormalities (39%). Afterlife can rarely action (1.7%).
The rat snake (chera) is a accustomed non-venomous snake that is sometimes mistaken for the cobra by lay people. Rat snakes are 6-8 anxiety continued and arise out mainly during daytime to augment on rats and frogs. They advice accumulate rodent citizenry below control. They can be articular from their attenuate arch and big annular eyes. Ample scales with blubbery atramentous borders are begin on the head, which aftermath characteristic vertical atramentous curve aloft and below their white lips.
How to anticipate snake bites:
Avoid all acquaintance with snakes; leave them alone.
Use a torchlight while walking at night forth trails abreast abounding areas.
Clear walking paths of broiled leaves and twigs at approved intervals.
Use accurate cossack while walking forth snake-infested areas.
Be added accurate while walking in the aphotic afterwards a rain, aback snakes tend to arise out more.
Children charge be accurately accomplished not to aces up snakes out of curiosity.
Do not ability blindly below rocks, accumulated up bricks, attic shells or firewood.
Do not blow central close bushes with bald hands; use a stick instead.
Avoid accession firewood afterwards dark.
If a babyish snake is sighted, bethink to analysis for added snakes in the area.
Workers in elastic and cashew plantations and paddy fields charge booty appropriate care.
Dispose debris appropriately so that rats do not abound the area, alluring snakes.
Do not accession banty central or abreast the home as they allure snakes.
» Details of snakes begin in India: http://indiansnakes.org/
» WHO guidelines for snakebite management: http://apps.searo.who.int/PDS_DOCS/B4508.pdf
» Studies from Calicut Medical College: https://jemds.com/data_pdf/Snake chaw Edited Latest.docx, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5993036/
» Long-term complications of snake bite,file:///D:/Downloads/toxins-11-00193.pdf
» Aboriginal acceptance to hospital prevents afterlife in snake bite: https://www.ijpediatrics.com/index.php/ijcp/article/view/1359
» Mechanism of dry bites by antagonistic snakes: https://static1.squarespace.com/static/54694fa6e4b0eaec4530f99d/t/59ca860c12abd9e9dab524e9/1506444813088/“Dry bite” in antagonistic snakes- A review.pdf
» Snake-stone treatments in Kerala, a adumbration of the past: https://www.thehindu.com/news/national/kerala/a-vanishing-breed-of-snakebite-healers-in-kerala/article5338801.ece
» Snake sightings in Kerala: https://www.thehindu.com/sci-tech/energy-and-environment/close-encounters-of-the-slithery-kind/article24300695.ece
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» Hump-nosed pit viper, the snake which is not covered by the polyvalent ASV in India: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062887/
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