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Table of Content - Volume 8 Issue 1 - October 2017
A prospective study assessing cardiovascular manifestations after snake bite at a tertiary care center
Madhusudan C1, K V Giriraja2*
1Assistant Professor,2Professor, Department of Internal Medicine, Sapthagiri Institute of Medical Sciences and Research Center, Bengaluru, Karnataka-560090 INDIA. Email: drgiriraja@gmail.com
Abstract Background: Snake bite is an occupational hazard especially of agricultural workers. Through snake bite venom, a complex mixture of various enzymes, polypeptides and toxins are injected into body of the victim. Objectives: The present study was undertaken to evaluate the effect on cardiac profile in patients with snake envenomation and its cardiac complications. Material and Methods: 50 snake bite patients presenting in emergency department over a period of one year were evaluated for cardiac profile, ECG and enzyme estimation were done. Results: In the present study 72% of cases were in 3rd and 4th decade of life. Male patients were 62% formed majority. Cardiac manifestations were seen in 34% of cases in the form of ECG changes and elevated cardiac enzymes. Sinus tachycardia (40%) was most common cardiac manifestation. Conclusions: Cardiovascular system involvement following snake bite was seen in this study, it is recommended to record ECG and estimate cardiac enzymes as soon as possible for detecting cardiotoxic effects of snake bite. Key Words: Cardiotoxicity, snake envenomation, Sinus Tachycardia.
INTRODUCTION Snake bite is one of the major public health problems especially in tropical andsubtropical countries. Snake bite is a common medical emergency encounteredin the tropics and an estimated 35,000 - 50,000 people die of snake every year in India. Approximately 15% of 3000 species of snakes found worldwide are considered to be dangerous to humans. Among those species 52 poisonous species found in India, majority of bites and consequent mortality is attributable to 5species viz. Ophiophagushannah (king cobra), Najanaja (common cobra), Daboiaruselli (Rossell’s viper), Bungaruscaeruleus (krait) and Echiscarinatae (saw-scaled viper).1-3 Few patients of snake bite die out of terrible scare, apprehension and shock, even though there are no signs of envenomation.4-5 Though prevention would be ideal, in a setting of developing country like India with occupational emphasis on agriculture and hence exposure to deadly snakes, the alternative is to stress on timely and appropriate management of snake bites. Snakebite remains an important cause of accidental death in modern India, and its public health importancehas never been fully appreciated. The deaths due to snakebite account for 5% of all accidental deaths and nearly0.5% of all deaths in India.6 Cardio toxicityis also seen in many cases dying of severe viper bite. This may occur in the form of sudden hypotension, cardiac arrhythmia, myocardialinfarction and changes in the electrocardiogram mainly of ST segment and Twave. Many cases of myocardial infarction following snake bite have seen reported.7,8 So far, not sufficient work has been done in India on complications and cardiovascular profile following poisonous snake bite. Therefore, present study was undertaken to find out the effect on cardiac profile and complications in the victims of snake bite presenting at emergency room.
MATERIAL AND METHODS Hospital based prospective study has been conducted in emergency ward of medicine department of Department of Internal Medicine, Sapthagiri Institute of Medical Sciences and Research Center, Bengaluru for a duration of 1 year. Total of 50 snake bite patients were included in the study. Those patients having history of any cardiovascular disease, renal disease, coagulopathy, liver disease and liver muscular disease were excluded from this study. Cases that were bitten by non-poisonous snakes were also excluded. All patients underwent physical examination, routine and specific laboratory investigation pertaining to snake envenomation. Moreover, specific cardiac profile determined by 12 lead Electrocardiogram (ECG), Severity of bite was classified according to criteria suggested by Ramming with some modification by Saini et al 9. All recruitments were conducted after obtaining informed written consent who qualifies the selection criteria. Data analysis was done by using MS Excel sheet.
RESULTS Tables 1: Scoring classification based on severity of sign and symptoms in patients of snake envenomation.
Figure 1: Percentagewise distribution of gender in snake bite patients Figure 2: Distribution as per type of snake bites Male were 62% of total snake bite cases. Most common snake bite was viper bite (57%), next common was cobra (35%).
Table 1: Cardiovascular manifestations in snake bite cases
Tachycardia was most common manifestation in cases 44%, while breathlessness was seen in 24% cases.
Figure 3: Bar diagram showing electrocardiographic manifestations of snake bite cases p value = <0.01; highly Significant. sinus tachycardia was most common ECG finding (40%), next common was ST depression with (27%).
Table 2: Distribution of snake bite cases according to changes in cardiac enzymes
p value = <0.01; highly Significant Elevated CK (MB), SGOT were seen in 42% of cases, only CK(MB) elevation seen in 12% of cases.
DISCUSSION The present study on50 poisonous snake bite cases were studied for cardiovascular profile at Department of Internal Medicine, Sapthagiri Institute of Medical Sciences and Research Center, Bengaluru during study period of 1 year. In the present study age of the patients ranged from 10 years to 64 years, 72% of patients belonged 3nd to 4th decade of life. This result was similar to study done by Banerjee et al10 study where 80% of patients belonged to third and fourth decade of life, also Mishra et al study11 concluded similar results as our study. We observed that males were victims of snakebite more often than females with 62% incidence in males while in female sit was 38%, this was in accordance with Reid et al12 and Hati et al13 studies. Also similar results with 58% male population for snake bite victims was seen in Ramakrishna CD et al14 study. In this study, 85% of patients reached hospital within 24 hours of snake bite; similar was seen with Mishra et al11 study where 76.7% of the patients reached hospital within 24 hours after bite. We observed that 42 (84%) patients had snake bite on distal part of the limbs while snake bite at other sites ranged from 6 to 10%; this might be due to snake bites often occurs in working subjects specially in farms and forest. Bhat et al15 and Warrel et al16 study found pain and swelling as most common presenting symptoms similar was seen in our study. In this present study 10% of patients complained of palpitations and 8% patients complained of breathlessness which was comparable to Mishra et al study11, while in Ramakrishna CD et al14 study most common manifestation noted was vomiting which was present in 26.5% patients which is in contrast with our study. Ramakrishna CD et al14 results reflect, abnormality in ECG in 31.5% patients, this was in accordance with our study with 34%.Similar results was seen in Kumar V17 study significant ECG abnormalities were found in 35%. This study observed atrial fibrillation in 3% of cases which was similar to study done by Gupta et al18 55% cases showed tachycardia in Gupta P et al19 study which was in accordance with our study. Ramakrishna CD et al14 noted bradycardiain 3% cases, while we found higher cases with bradycardia with 12% cases. The disturbance in heart rate was seen in 23% per cent. Out of the 100 patients tachycardia was present in 12% and bradycardia in 11% of cases in Kumar V et al17 study which was lower than our study finding. Lalloo et al20 and Mishra et al study11 noticed first degree AV block in 2.9% and 3.33% of snake bite cases respectively while in this study 3% of cases had first degree AV block. Ventricular premature ectopics were seen in 8% of cases in the present study, no case seen in Ramakrishna CD et al14 study, while 1.4% cases were seen in in Lalloo et al20 study. Cardiac enzyme estimations in the present study were similar to Anitha MS et al21 study. Mishra et al11 and Lalloo et al20 study estimated only SGOT levels in the serum while Mohapatra et al22 study estimated only CKMB levels in the serum. Nayak KC et al23 elevated AST titers were found in 10% of patients, in our study it was seen only in 4% cases. It was found that the patients were asymptomatic even with the significantly elevated CKMB.
CONCLUSION In the present study even in the absence of cardiac symptoms, ECG and cardiac enzymes helped to detect early myocardial damage in cases of snake bite. It is better to go for enzyme estimation for diagnosing cardiac injury than just clinical presentation. So we recommend to go for cardiac enzyme estimation and prompt ECG in all cases of snake bite presenting to emergency department of hospitals.
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