Background: Snake bite envenomation leads to considerable degrees of morbidity and mortality. Objectives: The objectives were to assess snakebite types, their pattern of symptom presentations in the region, complications and the clinical treatment outcome. Method: The cross-sectional and prospective study using convenient sampling method assessed patients for types of snake inflicting the bite, time interval between bite and arrival at the hospital, duration of hospitalization, complications and outcome of drug and other management procedures. Results: The mean age and standard deviation of the patients was 22.4 ± 14.5 years. The proportions of symptoms presented are: pain 128 (57.9%), bleeding 168 (76.0%), hypotension 30 (13.6%), blurred vision 89 (40.3%), paralysis 22 (10.0%) and shock 56 (25.3%). First aid treatments were herbs 75 (33.9%) and tourniquets 25 (11.3%). A total of 125 (56.6%) had 1-2 weeks hospital stay while in 14 (6.3%) patients it was >4 weeks. Major complications and other health related problems from carpet viper bites were GIT bleeding 20 (10.7), seizure 32 (17.1), and respiratory distress 11 (5.9%). The corresponding values for Puff adder were 5 (17.2%), 5 (17.5%) and 1 (3.4%) respectively. Multi-organ failure 9 (4.8%) occurred only with carpet viper victims. Death was recorded in 16 (7.2%) while 205 (92.8%) patients were discharged. Significant difference (X2=31.97 P<0.001) in death rate were recorded between early transfer (first 24 hours) to hospital and late arrival (after 24 hours). Risk of death was 10.7 times higher in early compared to late arrival to the hospital. Significant differences in symptoms were observed among snakebites with weakness (P=0.021), redness around the wound (P=0.014), blurred vision (P=0.008), vomiting (P=0.009), and Sweating (P=0.008). Conclusion: Carpet viper constitutes the major snakebite in the region, and early hospital visit and the length of hospital stay are important to survival and/or complications. Pharmaceutical care is required in area of monitoring of anti-snake venom (ASV) and other adjunct therapies in the area as well as in patients’ education.
Keywords: Anti-snake venom; carpet viper; Envenomation; Snakebites; Kaltungo
The envenomation caused by snakebites is a common occurrence in most parts of the world. It has been estimated that over two million people are bitten each year by poisonous snakes leading to very high envenomation, and at least 100,000 deaths, and 300,000 amputations as well as other permanent disabilities [1].
Deaths resulting from snakebite are common occurrences in Asia as well as Sub-Saharan Africa [1]. Snake-bite events can occur at any time of the year depending on environment, but more cases happen in the summer season around the world and their venoms are usually distributed to various organs and tissues after it is injected into victims.
Snake venom is complex poison of different proteins such as enzymes, polypeptide toxins and non-toxic proteins.
The venom also contain other proteins and enzymes including; glycosides, sterols, ATPase, amino-acid =31.97 P<0.001) in death rate were recorded between early transfer phosphodiestrases, phospholipase A, B, C, and D, cholinesterases and hyaluromidases and so on [2]. Phospholipase A2 is one of the snake venom enzymes that damages mitochondria, red blood cells, leucocytes, platelets, peripheral nerve endings, skeletal muscle, vascular endothelium, and other membranes, produces presynaptic neurotoxic activity, opiate-like sedative effects, and leads to the auto-pharmacological release of histamine and anti-coagulation.
Snake bite is associated with certain degree of morbidity and mortality particularly in resource-poor countries and is sometimes related to socioeconomic problems [3] since more cases are seen in the rural poor communities of tropical countries in South Asia, Southeast Asia, and subSaharan Africa [1, 4, 5]. Certain occupation which increased exposure to snakes like agricultural practices makes certain people more vulnerable than others. However problems like lack of good health care services, poor access to available services, influence of healthservices, and lack of effective anti-snake venom may often contribute to high morbidity and mortality rate following snakebites in most places [3, 6].
In Africa, the incidence of snakebites in the Benue Valley of northeastern Nigeria was 497 per 100,000 people per year, with a mortality of 12.2% [7]. The high levels of snakebite mortality in tropical developing countries was said to be associated with scarcity of anti-snake venoms, poor health services, and difficulties with rapid access to health centers [8]. Large numbers of victims survive with permanent physical and psychological sequelae, mostly due to the tissue-damaging effects of anti-snake venoms. The General Hospital Kaltungo, Gombeis one of the snakebite treatment centres in the North-eastern region which served several communities in the environs. The other centres are Zamko in Plateau State, Bambur in Taraba State, Lafiya-Lamarde and Savannah in Adamawa State, and Bauchi in Bauchi state. In the Kaltungo snakebite treatment centre, Snakebite victim admitted could go as high as 6 snakebites per day while at certain periods, 74% of hospital beds in this region are occupied by snakebite victims [9]. The major species responsible for bites in North-Eastern Nigeria is the saw scaled or carpet viper i.e. Echisocellatus [10, 11].
This study is aimed to assess the pattern of symptom presentations of snakebites in the region, identify their complications and the clinical treatment outcomes of hospitalized snakebite patients at Kaltungo General Hospital.
The study was conducted at the General Hospital Kaltungo in Kaltungo Local Government Area of Gombe State, Nigeria which lies between longitude 10º and 12º west and latitude 90º and 11º North, covering about 881sq Km.The General Hospital Kaltungo hosts the regional snakebite reference center in Kaltungo. Kaltungo is located within the Sudan savannah vegetation of the Benue river valley known for carpet vipers’ envenomation.
The study design is a prospective and cross-sectional study design. However, retrospective survey was made on patients who have had repeated episode of snakebites in the past and who currently presented with fresh episode. The duration of the study lasted from January to April 2018. Convenient sampling technique was adopted and all patients who met the inclusion criteria within the study period were enrolled into the study until the sample size was obtained. Ethical Clearance was obtained from the Gombe State Ministry of Health, Department of Research and Statistics. A of total 221 patients was studied.
The data was collected from the patients’ case folders in a predesigned data collection form over a period of 4 months. A total of 221 patients and their folders from the Snake bite clinic were sampled and screened. Information retrieved from folder or directly obtained from patients are: Age, gender, occupation, marital status, educational level, ethnic group/tribe, type of snake, area of the body affected, environment of bite, season of bite, level of exposure to snake (intentional/ unintentional), occupational setting, time between bite to hospital visit/treatment, first aid treatment carried out, medication list, hospital duration, symptoms presented by the patients, complication experienced by the patients, laboratory results, clinical outcome and general outcome. Statistical analysis was carried out with SPSS version 23. Chi square analysis was performed to find an association between two variables with significant level set at P<0.05.
A total of 221 comprising 105 males and 96 female (Table 1) snakebite victims from carpet viper, puff adder and cobra were studied. Herbal and tourniquets use as first aids treatment measures were 75 (33.9%) and 25 (11.3%) respectively. A total of 111 (50.2%) experienced complications while 110 (49.8%) do not (Table 2). Repeated episode of snake bite occurred in 38 (17.2%) patients while 212 (95.9%) patients were transferred to the hospital within 24 hours of bite. Only 14 (6.3%) stayed in the hospital above 4 weeks (Table 2).
Anti-snake venom (ASV) was used in 220 (99.5%) of all snakebite patients (Table 3) with other drugs like analgesic 221 (100%), Anti-tetanus sera 35 (15.8) and management with blood transfusion 55 (24.9) as part of the therapeutic management plan for patients (Table 3). Patients’ proportion that experienced some symptoms varied considerable among the snakebites but pains, bleeding, weakness and headache were the commonest among the three types of snake studied. All the victims of cobra bites experienced bleeding, blurred vision, and salivation. The duration of hospitalization varies but majority of patients 125(56.6%) spent 1-2 weeks while 14 (6.3%) patients were hospitalized for more than 4 weeks (Table 4).
The proportions of symptoms presented in all the species are pain 128 (57.9%), bleeding 168 (76.0%), hypotension 30 (13.6%), blurred vision 89 (40.3%), paralysis 22 (10.0%) and shock 56 (25.3%) (Table 5). The major complications from carpet viper bites were GIT bleeding 20 (10.7), seizure 32 (17.1), and respiratory distress 11(5.9%). The corresponding proportions for Puff adder were 5 (17.2%), 5 (17.5%) and 1 (3.4%) respectively. Multi-organ failure 9 (4.8%) occurred only with carpet viper victims (Table 6). Death was recorded in 16 (7.2%)
under treatment. The highest death rate was recorded in patients with multi-organ failures as complication. High cure rates were recorded in patients who arrived the hospital during the first and second 5 hours post bite
being 107 (94.7%) and 60 (92.3%) respectively while high death rates were observed in patients who arrived the hospital 1-2 days 2 (66.7%) and beyond 2 days 3 (50.0%) (Tables 7-9).
Cobra (%) Total (%) X (P-Values)
=31.97 P<0.001: There was a significant difference in death rate when early visiting of hospital within the first 24
**Risk of death is 10.7 times higher in patients who visit hospital after 24 hours of snakebite compared to those who
2 *X
risk of allergic reactions due to the snake venom is known to occur after a previous episode of envenomation. Adrenaline and hydrocortisone are particularly relevant in patients who possibly developed anaphylactic reactions due to early reaction of ASV or who presented with shock and possibly for patients who are transfused with blood products. In this present study, fairly high proportion of individuals have previously been bitten by snake and therefore could put them at high risk of early anaphylactic reactions, and this seemed to justify the use of the parenteral as adjunct in the therapy of most patients. Furthermore, early anaphylactic reactions to equine serum proteins are reported to range from 3% to 54% by some authors [16-18].
Nearly one-quarter of victims were transfused with blood since snake envenoming can be associated with excessive blood loss from bleeding and or blood coagulation. Antibiotics usage was justified in patients in case secondary bacterial infections.
The clinical outcomes vary considerably and seemed to depend on many factors such as time interval between bite incident and arrival at the hospital, a factor that may similarly control the levels of complications. For instance, the time taken after snakebite and arrival at the hospital constituted a risk factor for the development of complications and/mortality rates. In our study, high mortality rates were observed among patients who arrives the hospital after 24 hours of snakebite incident. There 2 was a significant difference (X =31.97; P<0.001) in death rate when visiting hospital within the first 24 hours of snakebite was compared with after 24 hours. Furthermore, the risk of death is 10.7 times higher in patients who visit hospital after 24 hours of snakebite compared to those who visit clinic within 24 hours of bite. The highest death rate was recorded in patients who presented with multiple organ failures followed by patients with acute respiratory distresses. The death rate of 7.2% in this study appeared high when compared with the 5.4% mortality rate recorded in Ecuador [19], 3.0% or the 0.9% death rate of victims of snake bite in other regions [14, 20]. Some studies have similarly indicated that time of transport was a crucial determinant of snake bite mortality in eastern Nepal [7], while in southern India delayed antivenom administration was associated with an increased risk of complications [20, 21].
Several symptoms are common among the three types of snake, but symptoms like pains, headache, weakness, and sweating, vomiting, bleeding and clouded vision occurred in high proportions in all the snakebites. These symptoms are similarly reported in snakebites from other regions of the world. Hypotension for instance occurred in 22.6% cases which are within the range of 6.3%-45.2% reported cases in other studies [22-27]. Similarly the 76.0% bleeding cases in this study is compared to 27.8%-88.6% cases in other studies [23-25, 27, 28-31].
Our study however showed significant differences in For instance, the occurrence of symptoms like apnea and salivating was significantly different (P<0.001) among the three types of snake. Similarly significant differences in symptoms were observed among the three types of snakebite in symptoms like weakness (P=0.021), redness around the wound (P=0.014), blurred vision (P=0.008), vomiting (P=0.009), and Sweating (P=0.008). These symptoms are commonly reported in other parts of the world.
Bites from Cobra appeared to be the most lethal of the three types of snake in terms of symptomatic presentation such as pain, bleeding, salivating, blurred vision, vomiting, sweating, weakness and apnea; which were most of the symptoms that indicated significant differences when compared with similar symptoms from other snakebites. None of the patients bitten by Cobra was presented with dysphagia and limb numbness while convulsion was noticed with carpet viper and cobra bites only. Headache is more common symptoms with puff adder bite than with carpet viper and cobra bites.
These symptomatic variations may be determined by several factors such as patient’s factor, drug/medication and the bite pattern etc. A clear understanding of these variations is necessary in order to focus care attention particular on most lethal symptoms so as to prevent complications, morbidity and mortality from snakebites. According to Brutto and Brutto [32], serious neurological complications, including stroke and muscle paralysis, are related to the toxic effects of the venom, which contains a complex mixture of toxins affecting the coagulation cascade, the neuromuscular transmission, or both. These clinical findings are consistent with symptoms reported by several authors from various regions [33, 34]. Seizures were manifested in few patients due to neurotoxic involvement. These presentations have similarly been reported by several authors [35-37]. Paralysis which affected 10% cases of victims and limb numbness which affected 3.2% of victims in this study are considered to be associated with neurotoxic effect of snake venoms and are within the range of 3.2%-100% cases of similar symptoms reported by other researchers elsewhere in the world [24, 27-29, 31].
The proportions of patients who experienced complications as negative clinical outcomes vary from different snakebites. The number of patients who experienced one complications or the other are in nearly in equal proportion from those who do not. Half of the victims (50.2%) experienced one form of complication or the other from snakebites in a region. The snake venoms contain several toxins capable of affecting all organs when poorly managed or when there is delay in seeking for medical care. Many factors could account for these observed variations particularly those relating to early transfer to clinic, initial reliance on traditional herbal treatment, types of snake, medical facilities, trained and government policy support, medication factors, educational levels and a host of others. Most of the complications reported here are similarly reported in other parts of the world particularly bleeding, renal dysfunction and ulcer [33].
Carpet viper constitutes the major types of snakebite in the region and early hospital visit is important to survival of snakebite victims. The length of hospital stay is in part related to the level of complications developed. Pharmaceutical care is required in area of monitoring of ASV and other adjunct therapies in the area as well as in patients’ education.