“Reptiles are abhorrent because of their cold body, pale color, cartilaginous skeleton, filthy skin, fierce aspect, calculating eye, offensive smell, harsh voice, squalid habitation, and terrible venom; wherefore their Creator has not exerted his powers to make many of them.”
–Linnaeus, 1797; Also the opening quote in Jurassic Park.
Much controversy has surrounded the recent death of a young child following a snake bite. My brother wants me to add my two cents to the story - hence this post.
Not all snakes are venomous
In spite of Linnaeus' unflattering description, most snake and reptile bites (in Sri Lanka) are non-venomous. In fact there are just seven venomous land snakes and 13 venomous sea snakes in the country. The Venomous land snakes are:
- Russel's Viper
- Hump-nosed Viper
- Saw-scaled Viper
- Green-pit Viper
- Common Krait
- Ceylon Krait
- Cobra
The Venom
Snake venom comprises several enzymes and protein toxins that impair blood clotting mechanisms (coagulopathy) and alter nervous system function (neurotoxicity). They also cause necrosis (destruction) of skin and soft tissues at the site of bite and rarely may also cause destruction of muscles. (Rhabdomyolysis)
The Viper bites generally cause coagulopathy and Kraits cause neurotoxicity. Cobra bites result in both conditions, as does the Sri Lankan Russel's Viper.
The Anti-Venom Serum (AVS)
This consists of equine (horse) antibodies that neutralize toxic venom of most venomous snakes in Sri Lanka, except the Hump-nosed Viper, Saw-scaled viper and Sea Snakes. The currently available AVS is manufactured in India and questions are therfore raised about its efficacy with regard to Sri Lankan Snake bites. However, the preponderance of clinical evidence seems to suggest that it's effective with regard to the above snakes.
Since the antibodies are equine, it tends to cause a severe allergic reaction (at times resulting in death) in certain individuals. Therefore the administration of AVS is a vexing problem for the clinician where the potential benefit of reversing the possible toxicity must be balanced against the risk of allergic reactions.
First Aid
Nowhere is the cardinal medical (and commonsense) principle of "above all do no harm" more relevant than in the treatment of snake bite.
DON'Ts
- Suck or cut the wound
- Apply a torniquet (a compressive band) - In the case of the unfortunate child, the father did apply a torniquet
- Apply Ice
- Consume Alcohol
- Take Aspirin
DOs
- Reassures the victim. (Not all snakes are venomous and not all venomous bites are deadly)
- Remove any bracelets, rings from the affected limb. (A swelling could develop which would make removing these stuff difficult)
- Wash the area with soap and water only
- Immobilize the limb with splints - to reduce venom absorption
- Keep the limb below the level of the heart - to reduce absorption
- Transport the victim to hospital with the reptile if possible.
Killing of snakes purely for the purpose of identification is no longer necessary, as doctors are able to make treatment decisions based on the clinical features and investigations of the patient.
Identification of Snakes is beyond the scope of this post.
At the Hospital
While in hospital the doctors would monitor the patients vital signs and look for features of envenomation - principally those of impaired blood clotting (coagulopathy) and nervous system involvement (neurotoxicity).
Features suggestive of impaired blood clotting would be vomiting blood, passage of blood with urine, red patches in the skin etc. Nervous system involvement would manifest with double vision, drooping of eye lids, drowsiness etc.
A valuable bed-side test known as the 20 minute whole blood clotting time (20-WBCT) is performed to assess blood clotting profile. Basically this is done by taking a blood sample to a clean plain bottle and observing for clot formation after 20 minutes. Usually the blood is clotted after 20 minutes. If the clotting mechanisms are impaired due to envenomation, the blood would not clot within 20 minutes.
Additional tests to assess renal and clotting profile are also sent.
When to give the AVS?
The main allegation of the parents of the child was that the AVS wasn't administered until 3 hours after admission. As mentioned earlier, the AVS tends to cause a severe allergic reaction (anaphylaxis) in certain individuals which could even lead to death. Therefore AVS is administered only after definite features of envenomation are evident. AVS is not given in hump-nosed viper, green pit viper and sea snake bites even if features of envenomation are present.
In this instance the hospital doctors properly followed established protocols by monitoring the child and administered AVS when features of envenomation was present. (Passage of Blood with Urine and altered 20 minute WBCT)
Complications
Impaired clotting mechanisms can result in reduced blood pressure and renal failure. Sometimes this could lead to a condition known as Disseminated Intravascular coagulation (DIC) finally leading to multiple organ failure and death. The administration of AVS does not guarantee survival, and as in some situations the patient succumbs despite being given the proper treatment.
References
- Gnanathasan A, Sellahewa KH, Sherrif MHR. National Guidelines on Management of Snake bites, Ministry of Health, Sri Lanka, 2007.
Related Press Articles
The Island: DG Health calls for report on child’s death
* No bed for snake bite victim at Ragama hospital ICU
by Don Asoka Wijewardena
click here to view the original article
The Director General of Health Services has called for a complete report from the Ragama Hospital authorities on the death of a 6-year-old girl, a victim of snake bite, on Sunday.
The child, Medina, who was admitted to the hospital at 3.45 p.m. died at 8.30 p.m. without proper care because there was no bed for her in the Intensive Care Unit, Hospital sources said.
The Hospital’s Deputy Director Dr. Ms. Lalani Gurusinghe told The Island that the child was brought to the Ragama hospital at 3.45 p.m. on March 2 and the parents had said that the child was bitten by a viper. In accordance with the snake bite treatment procedure, the child was admitted to a ward and constantly examined for vital signs.
She said the snake bite treatment procedure had been followed and she was kept under constant observation. It was the accepted procedure of the medical experts to monitor and observe the patient for sometime before administering anti-venine injections. Only after recording the vital signs, medical experts would decide whether the patient was in need of the injection, she said.
She said that the doctors at the Ragama hospital performed their duties without negligence, but the patient could not be admitted to the ICU because there was no bed. Had the child been admitted to ICU her life could have been saved. In accordance with the hospital policies and procedures a comprehensive inquiry was held and a complete report on the child’s death had been prepared to be submitted to the Director General of Health Services, she said.
A medical expert at the Ragama hospital, speaking on condition of anonymity said that the non-availability of beds in the ICU for emergency cases had caused enormous problems in the care of patients. A number of similar cases had been recorded at the hospital due to the inadequate bed capacity in the ICU.
He said that whenever snake bite, cardiac and accident patients were brought to the Ragama hospital, authorities had no alternative but to call the Gampaha, Negombo, Kalutara and Mirigama hospitals to check whether emergency patients could be transferred to those hospitals. Although the Ragama hospital authorities had been requesting the other hospitals, in most cases those hospitals, too, did not have vacant ICU beds. He blamed the Health Ministry for not increasing the bed capacity in ICUs throughout hospital network in the country. He also said that inadequate bed capacities in the ICUs had threatened the lives of emergency patients as a whole.
He added that the child had also passed blood with urine (haemoglobin urea) and the possible cause of death could be due to Disseminated Intravascular Coagulation of blood because the child was not treated in the ICU.
The Daily Mirror: Negligence or lack of resources ?
Death of six year old Madlina
By Jeevani Pereira
click here to view the original article
“I don’t want to press charges, I don’t want compensation; I will give Rs One lakh of my own money to the Ragama hospital for them to develop their ICU, so that no other child will have to lose their life like my little girl did,” were the emotional words of V Manoharan, father of six year old Manoharan Madlina who died after being bitten by a Russels Viper on Sunday.
Manoharan maintains that his daughter died due to the negligence of Ragama hospital officials who seemed to be inconsiderate of the child’s plight. According to him when he asked them for an explanation the doctors in charge said that it was out of their hands and blamed the lack of a proper Intensive Care Unit.
"They told me that they could not do anything about it and told me to ask the Health Ministry for reasons as to why the ICU was lacking," he remarked.
Apparently Manoharan, as his daughter’s pulse began to fail, had questioned the doctors frantically if they could admit her to the ICU. "They told me that because Madlina was small they may not be able to admit her and then they told me they did not have space. They also said that they had called Kalubowila, Negombo, Gampaha and Colombo hospitals asking if it was possible to be admitted, but none had responded positively."
Madlina a student of St Anne’s Girls School Wattala had been brought to the Ragama Hospital at around 3.30 pm after the snake had bitten her outside their house on Sunday evening Manoharan had caught the snake in a bottle and had tied Madlina’s leg above and below the wound to prevent the poison travelling after washing it with soap. "They told us that they had to monitor her for at least five hours before they administered any anti-venom, they also said that they had the treatment for any allergies caused by the anti-venom as well."
"When she became quite serious the four doctors around her seemed like they were experimenting with her, they took more than half-an-hour to prepare the anti-venom looking at a book, they spilt most of the blood they were trying to give her and did not even know when they were running out of Oxygen when she was struggling to breath,” he said.
According to her grieving parents, Madlina was awake and coherent until her very last. "She was speaking to us and she even told us not to worry that she would be alright, that Jesus would look after her,” said her mother Jenita Ratnam.
"When we reached hospital they scolded us for being ‘old fashioned’ and told us to cut the ropes tying her leg,” she continued. Jenita said that they had taken several samples of blood and put Madlina on saline. "Even they couldn’t identify the snake and kept asking my husband what it was before they took it away and identified it a few minutes later.”
It was when she started passing blood through her urine and complained of not being able to breathe by about 7.30 pm they administered anti venom into her wound and started a blood transfusion. Manoharan recalled that even when the blood bank was called no one answered and an attendant had to go to the unit and bring it himself.
By around 12 am Madlina turned for the worst and blood started coming out of her nose. “A nurse inserted a tube into her mouth to help her breath and blood just poured out of it,” he said.
"My daughter is no more and all I ask is that room is never left for this to happen to any other child. I was there when the doctors were around my girl, when her pulse was failing one of them asked the nurses if his food had been prepared because he was hungry. It was like they were doing a training course; they hardly knew what to do,” spoke a tearful Jenita.
We followed Protocol
Deputy Director Dr. LDES Gunasinghe said that she could not comment about the death of Manoharan Madlina until the inquiry was completed. However, she pointed out that it was in no way due to any negligence by the staff of the hospital.
"What was followed was treatment protocol and we do not administer anti venom until bleeding appears, as the anti venom in itself can cause an allergic reaction. Furthermore, it would be very risky to do so on such a small child,” she explained.
"Her bleeding and clotting time were constantly monitored and when complications arose at around 7.30 pm was when anti venom was administered,” she added saying that the way a person reacts to toxins was different from each individual.
She further explained that the anti venom administered was being looked into. “Don’t you know, these are Indian anti venoms,” she dismissed.
The culprit
According to experts, the Russell’s Viper is among the six most toxic snakes in Sri Lanka and its poison resulted in internal bleeding. However, they pointed out that procedure after a snake bite did not include immediate administering of anti venom. Instead protein levels of blood were monitored to find out how fast clotting occurred. It was only if clotting took place instantly that anti venom was given.
Furthermore, if the type of snake could not be identified a blood test was done and the wait for the report took at least half-an-hour. However, it was pointed out that blood transfusions, which is compulsory, took place before any complications or it would be too late.
According to Manoharan it was after his daughter passed blood through her urine that the blood bank was even called. The blood signified that the poison had begun breaking down cells in her kidneys – which signalled serious complications.