Accidente ofídico como problema de salud pública serpientes en la ciudad / Ophidian accident as a public health problem snakes in the city

En todo el planeta ocurren mordeduras por serpiente tanto en humanos, como animales; sin embargo, muchos pueblos carecen de recursos para prestar atención sanitaria, administrar suero antiofídico o mantener seguimiento desde lo multidisciplinario al paciente que quedó con secuelas. Objetivo: Establecer alertas tempranas sobre migración o emigración de serpientes hacia la ciudad, respecto al accidente ofídico como problema de salud pública. Materiales y métodos: La investigación es monográfica de tipo documental y muestra pertinencia social. Resultados: Es indispensable abordar tempranamente a la víctima, así como, registrar causas coadyuvantes o desencadenantes del accidente, ya que, dejó de ser exclusivamente rural y se registra en zonas urbanizadas e incluso en la ciudad. El alcance y magnitud de la investigación, sobrepasa lo académico de fortalecer áreas de conocimiento en carreras científicas del pregrado y trasciende a carreras relacionadas, afines y de postgrado, relacionadas indirectamente al problema. Conclusión: Garantizar seguridad del humano y su entorno requiere disposición para la prevención; no obstante, la migración o emigración de ésta biodiversidad revela un problema socio-ambiental, dependiente de entender la gestión académica y alertas tempranas que anuncian que, las serpientes han llegado a la ciudad(AU)

All over the planet snake bites occur in both humans and animals; however, many towns lack the resources to provide health care, administer antivenom serum or maintain multidisciplinary follow-up of the patient with sequelae. Objective: To establish early alerts on the migration or emigration of snakes to the city, regarding the ophidian accident as a public health problem. Materials and methods: The research is monographic documentary type and shows social relevance. Results: It is essential to address the victim early, as well as to record contributing causes or triggers of the accident, since it is no longer exclusively rural and is recorded in urbanized areas and even in the city. The scope and magnitude of the research goes beyond the academic of strengthening areas of knowledge in undergraduate scientific careers and transcends related, related and postgraduate careers, indirectly related to the problem. Conclusion: Ensuring the safety of humans and their environment requires provision for prevention; however, the migration or emigration of this biodiversity reveals a socio-environmental problem, dependent on understanding the academic management and early warnings that announce that the snakes have arrived in the city(AU)

Comparison of two Anti Snake Venom protocols in hemotoxic snake bite: A randomized trial.

The dose of Anti Snake Venom (ASV) in hemotoxic snake bite depends on the amount of venom injected and species of snake. All trials in South East Asia have studied different doses of ASV, wherein the ASV in high dose group itself was lower than the dose that is recommended in Indian National protocol. These studies favored low dose protocol, as there was no difference in mortality and morbidity between the groups. So, this study intended to assess the efficacy of National protocol in reducing morbidity and mortality in hemotoxic snake bite in comparison to current protocol followed in institution. This was an open label randomized trial of 140 hemotoxic snakebite patients. Group A received national protocol: initial dose of 100 ml followed by 100 ml 6th hourly till 20-min Whole Blood Clotting Time (20WBCT) was negative or 300 ml of ASV was given, whichever was earlier. Group B received 70 ml followed by 30 ml every 6th hourly until two consecutive 20WBCT were negative. There was no statistical difference in the amount of ASV required in both the groups. Mortality and acute kidney injury were higher in group A (statistically not significant), probably due to sicker patients in that group. There was no relapse of clotting time abnormality in both the groups. In a significant number of patients (12%), clotting time was persistently prolonged till death. We found that the use of National ASV dosing protocol did not decrease the mortality and morbidity.

Ofidismo no Tocantins: análise ecológica de determinantes e áreas de risco, 2007-2015 / Ofidismo en Tocantins: análisis ecológico de determinantes y áreas de riesgo, 2007- 2015 / Snakebite in Tocantins: ecological analysis of determinants and risk areas, 2007- 2015

Objetivo: Investigar o perfil dos casos de acidentes ofídicos, seus determinantes e áreas de risco no estado do Tocantins. Métodos: Estudo ecológico, com dados do Sistema de Informação de Agravos de Notificação do período 2007-2015. Empregou-se regressão linear múltipla e os testes Mann-Whitney e Kruskal-Wallis. Resultados: Foram notificados 7.764 acidentes ofídicos (incidência de 62,1/100 mil habitantes; letalidade de 0,5%). As variáveis associadas ao ofidismo foram densidade demográfica (Coef.=1,36 - IC95% 0,72;1,99), trabalho agropecuário (Coef.=0,02 - IC95% 0,01;0,03), índice de desenvolvimento humano municipal (Coef.=2,99 - IC95% 0,60;5,38), área cultivada de mandioca (Coef.=8,49 - IC95% 1,66;15,32), população indígena (Coef.=0,02 - IC95% 0,00;0,04), proporção de população analfabeta (Coef.=4,70 - IC95% 0,61;8,79) e população empregada (Coef.=3,00 - IC95% 0,93;5,06), que explicaram 64,48% da variação. As áreas de alto risco foram as regiões de saúde Amor Perfeito, Cantão, Cerrado Tocantins Araguaia e Médio Norte Araguaia. Conclusão: Aspectos socioeconômicos e demográficos municipais associaram-se ao ofidismo.

Objetivo: Investigar el perfil de accidentes ofídicos, sus determinantes y áreas de riesgo, en el estado de Tocantins. Métodos: Estudio ecológico con datos del Sistema de Información de Enfermedades de Agravamiento de Notificación, 2007-2015. Se utilizaron pruebas de regresión lineal y pruebas de Mann-Whitney y Kruskal-Wallis. Resultados: Se reportaron 7.764 accidentes ofídicos (incidencia: 62,1/100.000 hab.; letalidad: 0,5%). Las variables relacionadas al ofidismo fueron densidad demográfica (Coef.=1,36 - IC95% 0,72;1,99), trabajo agrícola (Coef.=0,02 - IC95% 0,01;0,03), índice de desarrollo humano municipal (Coef.=2,99 - IC95% 0,60;5,38), área cultivada de yuca (Coef.=8,49 - IC95% 1,66;15,32), población indígena (Coef.=0,02 - IC95% 0,00;0,04), proporción de la población analfabeta (Coef.=4,70 - IC95% 0,61;8,79) y empleados (Coef.=3,00 - IC95% 0,93;5,06), explicando 64,48% de la variación. Las áreas de alto riesgo fueron las regiones de salud Amor Perfecto, Cantão, Cerrado Tocantins Araguaia y Medio Norte Araguaia. Conclusión: Aspectos socioeconómicos y demográficos municipales se asociaron con el ofidismo.

Objective: To investigate the epidemiological profile of snakebite accident cases, their determinants and risk areas in the state of Tocantins. Methods: This was an ecological study using data from the Notifiable Health Conditions Information System, from 2007 to 2015. Multiple linear regression and the Mann-Whitney and Kruskal-Wallis tests were used. Results: A total of 7,764 snakebite accidents were reported (incidence: 62.1/100,000 inhab.; lethality: 0.5%). The variables associated with snakebite were population density (Coeff.=1.36, 95%CI 0.72;1.99), farming work (Coeff.=0.02, 95%CI 0.01;0.03), municipal human development index (Coeff.=2.99 - 95%CI 0.60;5.38), area planted with cassava (Coeff.=8.49 - 95%CI 1.66;15.32), indigenous population (Coeff.=0,02 - 95%CI 0.00; 0.04), proportion of illiterate people (Coeff.=4.70 - 95%CI 0.61;8.79) and employed people (Coeff.=3.00 - 95%CI 0.93;5,06), which together accounted for 64.48% of the variation. The high-risk areas were Amor Perfect, Cantão, Cerrado Tocantins Araguaia and Mid-North Araguaia health regions. Conclusion: Municipal socioeconomic and demographic aspects were associated with snakebites.

Envenenamientos por mordedura de serpiente en Guatemala: revisión de literatura / Snakebite envenomings in Guatemala: literature review

El accidente ofídico es una enfermedad tropical desatendida que ocasiona un problema de salud pública en el mundo, siendo una de las principales causas de morbilidad y mortalidad en las áreas empobrecidas de América Latina. En Guatemala se distribuyen 23 especies de serpientes venenosas de importancia médica. La composición de los venenos es compleja y diversa, resultando en una variedad de manifestaciones clínicas. Los departamentos con mayor incidencia de ofidismo son Petén, Alta Verapaz, Quiché, Escuintla e Izabal. Estos accidentes afectan más a hombres que a mujeres, siendo la mayoría agricultores; el rango de edad más comprometido es de 10-19 años y principalmente ocurren en miembros inferiores. El tiempo medio que tarda la víctima en llegar al hospital es de 5.6 h, siendo el retraso en la atención médica, un factor de riesgo para severidad y mortalidad. Los servicios de salud en ocasiones no cuentan con recursos idóneos para atender a las víctimas, brindando tratamiento sintomático. Simultáneamente, el tratamiento empírico tiene gran aceptación, sin embargo, los resultados de investigaciones realizadas con algunas plantas de uso común en casos de ofidismo, concluyeron que no es recomendable su uso aislado en el tratamiento del envenenamiento. Dada la falta de información se debe promover más investigación sobre el ofidismo en el país, siendo indispensable la elaboración de una ficha de reporte obligatoria. Además, deben elaborarse guías de tratamiento e identificación de serpientes para uso del personal médico, incluyendo programas de educación a nivel comunitario.

Snakebite envenoming is a neglected tropical disease that causes a public health problem in the world, being one of the main causes of morbidity and mortality in impoverished areas of Latin America. 23 species of poi-sonous snakes of medical importance are distributed in Guatemala. The composition of venoms is complex and diverse, resulting in a variety of clinical manifestations. The departments with the highest incidence of snakebites are Petén, Alta Verapaz, Quiché, Escuintla and Izabal. These accidents affect more men than women, the majo-rity being farmers; the most compromised age range is 10-19 years and they mainly occur in the lower limbs. The average time it takes for the victim to reach the hospital is 5.6 hours, with delay in medical care being a risk factor for severity and mortality. Health services sometimes do not have adequate resources to care for victims, providing symptomatic treatment. Simultaneously, empirical treatment is widely accepted, however, the results of research carried out with some plants commonly used in cases of envenoming concluded that their isolated use is not recommended in the treatment. Given the lack of information, more research on snakebite envenoming in the country should be promoted, making the preparation of a mandatory report form essential. In addition, snake identification and treatment guides should be developed for use by medical personnel, including education pro-grams at the community level.

Characteristics and relative numbers of lethal snake bite cases in medicolegal practice in central Myanmar - A five year study.

Clinical and pathological case files of lethal snakebites were reviewed from the Magway Region General Hospital, Magway, Myanmar, over a five-year period (January 2013 December 2017). A total of 2069 postmortem examinations were performed which included 84 cases of lethal snake bite (4.1%). The annual numbers ranged from 10 out of a total of 268 autopsies in 2013 (3.7%), to 31 out of a total of 501 autopsies in 2016 (6.2%). There were 54 males (64%) and 30 females (36%) (M:F = 1.9:1; age range 5-75yrs, mean 33yrs). The most common time for lethal envenomation was August (16/84-19%), the middle of the monsoon season. 45/84 (54%) had acute renal failure, 27/84 (32%) were shocked, and the remaining 12/84 (14%) had disseminated intravascular coagulation. Twenty cases (24%) died within 24 h after envenomation. Fang marks were identified on the legs (either right or left) in 73/84 cases (87%) and on the arms in five cases (6%). The predominant findings at autopsy were of acute renal injury (82/84-98%), pituitary haemorrhage/necrosis (36/84-43%), and adrenal gland haemorrhage (30/84-36%). Despite the reduction in fatalities over the years snakebite from Russell's viper in particular remains an important contributor to mortality in central Myanmar despite the availability of antivenom.

Antivenom use in bite and sting cases presenting to a public hospital.

BACKGROUND: To evaluate the distribution of bite and sting cases presenting to a district public hospital and the use of antivenom in scorpion sting and snake bite cases. METHODS: The demographic characteristics of patients with bites/stings reporting to a public hospital in 2014, the agent involved, the season of reporting, severity of clinical findings during presentation, and use of antivenom in scorpion sting and snake bite cases were evaluated retrospectively. χ2 test was used for statistical analysis. RESULTS: Bite and sting cases comprised 0.5% of all the patients reporting to the hospital's emergency department, with scorpion sting cases comprising almost half (54.2%) of these hospital presentations, followed by Hymenoptera (bee and wasp) sting (30.8%) and snake bite (5.5%) cases. Unnecessary antihistamine administration was found to be significantly high in asymptomatic patients (p=0.00006). Furthermore, antivenom use was found to be significantly high in patients with scorpion sting and snake bite despite the absence of systemic or local indications (p<0.0001, χ2=80.595). CONCLUSION: The study results showed that antivenom was used in scorpion sting and snake bite cases even when it was not indicated. Therefore, primary practitioners should be provided training for management of envenomation cases and should be made aware of the updated guidelines and references to raise their knowledge levels.

Epidemiology of snakebites in Kédougou region (eastern Senegal): comparison of various methods for assessment of incidence and mortality

Although considered a public health issue in Senegal, the actual incidence and mortality from snakebite are not known. In the present study, an epidemiological survey was carried out in Kédougou region, southeastern Senegal, where envenomations, particularly by Echisocellatus, are frequent and severe. Methods Three sources of data were used: records from health centers and reports by health professionals; traditional healers; and household surveys. Results The annual incidence and mortality provided by health centers were 24.4 envenomations and 0.24 deaths per 100,000 population, respectively. The annual incidence recorded by traditional healers was 250 bites per 100,000 inhabitants, but the number of deaths was unknown. Finally, the household surveys reported an annual incidence of 92.8 bites per 100,000 inhabitants and an annual mortality rate of 2.2 deaths per 100,000 inhabitants. The differences in incidence and mortality between the different methods were explained by significant bias, resulting in particular from the complex patient's healthcare-seeking behavior. The incidence provided by health records should be used to specify the immediate quantitative requirements of antivenoms and places where they should be available first. Conclusion Mandatory reporting of cases would improve the management of envenomation by simplifying epidemiological surveys. Patients' preference for traditional medicine should prompt health authorities to urge traditional healers to refer patients to health centers according to defined clinical criteria (mainly edema and bleeding or neurotoxic symptoms). Finally, household surveys were likely to reflect the actual epidemiological situation. Poison Control Center of Senegal should continue its work to sensitize stakeholders and train health staff.

Evaluación de la capacidad neutralizante de extractos de plantas de uso popular en Guatemala como antídotos para el envenenamiento por la mordedura de Bothrops asper / Neutralizing activities of ethanolic extracts of six plants traditionally used in Guatemala as antidotes for the envenomation caused by the snake Bothrops asper

Se determinó la capacidad de los extractos de seis plantas de uso etnomédico (Acacia hindsii, Aristolochia maxima, Cissampelos pareira, Hamelia patens, Piper peltatum y Sansevieria hyacinthoides) para neutralizar los efectos proteolítico y fosfolipasa A2 (PLA2) del veneno de Bothrops asper, la principal especie causante de envenenamiento en el país. Estos efectos, indicadores de la capacidad miotóxica, hemorrágica e inflamatoria del veneno, se evaluaron en ensayos controlados in vitro. Las plantas fueroncolectadas, secadas y extraídas por percolación con etanol. Los resultados demuestran que ninguno de los extractos posee actividad PLA2 o proteo-lítica intrínseca a las dosis estudiadas. Se determinó que tres de los extractos neutralizaron pobremente (< 50%) los efectos estudiados: S. hyacinthoides neutralizó 13.90 ± 6.41% del efecto PLA2 y P. peltatum y C. pareira el 32.98 ± 5.51% y 24.52 ± 7.45%, respectivamente, del efecto proteolítico. Por ello, ningún extracto se evaluó en pruebas de neutralización de la letalidad en ratones. Se concluye que no es recomendable el uso aislado de estas plantas en el tratamiento del envenenamiento por mordedura de B. asper, aunque posiblemente las que demostraron alguna actividad puedan resultar potenciadas al usarse en combinación con otras plantas, como se hace en las recetas tradicionales. Dada la complejidad de los componentes del veneno y sus efectos fisiopatológicos, falta investigar la capacidad de las plantas estudiadas para neutralizar las coagulopatías, edema y miotoxicidad producidas durante el envenenamiento.

Many plants are reported to be used in Guatemalan traditional medicine as antidotes against various effects of the snakebite; however, very few attempts have been made to evaluate their neutralizing capacity in controlled experiments. Six plants (Acacia hindsii, Cissampelos pareira; Hamelia patens, Piper peltatum, Sansevieria hyacinthoides and Aristolochia maxima) were evaluated in vitro for their ability to neutralize phospholipase A2 (PLA2) and proteolytic effects of the venom of Bothrops asper, the snake responsible for approximately half of the snakebite envenomations in Central America. These effects are indicatives of the ability of B. asper venom to produce myotoxicity, hemorrhage and inflammation. Plants were collected, dried and extracted by maceration with ethanol. After pre-incubation of several amounts of each extract with a challenge dose of venom, S. hyacinthoides demonstrated a low neutralizing capacity (< DE 50) of the PLA2 effect (13.90 ± 6.41%); C. pareira (32.98 ± 5.51%) and P. peltatum (24.52 ± 7.45%) neutralized less than 50% of the proteolytic effect. The results suggest that neither of the tested plants should be used individually to treat the main effects of B. asperenvenomation. However, the three low-active extracts might be potentiated when used in mixtures composed of several plants, as prepared by traditional healers. Given the complexity of the venom components and the multiple pathologic effects produced by B. asper envenomation, more tests are required to fully investigate the ability of this plants to neutralize the coagulant, fibrin(ogen)olytic, edematizing and myotoxic effects of the venom.

Ética sobre el envenenamiento ofídico en el paisaje agrario de Guatemala / Ethics of snakebite envenoming in agrarian landscapes of Guatemala

El envenenamiento ofídico es una enfermedad accidental, no infecciosa o contagiosa, causada por los efectos de los venenos de serpientes de las familias Viperidae, Elapidae y Colubridae. Esta enfermedad representa un problema de salud pública a nivel mundial, afectando principalmente a los trabajadores agrícolas. A pesar de derivarse de una relación ecológica antagónica natural entre humanos y serpientes el accidente ofídico es moralmente juzgado como algo malo. En tal sentido, el examen de esta relación supone un componente ético. En el presente ensayo se discute cuál es el significado moral de las serpientes venenosas bajo las perspectivas antropocentrista y biocentrista. Se abordan los temas de riesgo ocupacional y vulnerabilidad del trabajador agrícola a la enfermedad, se elabora sobre las causas de la desatención de esta enfermedad y se reflexiona sobre cuál es la responsabilidad ética del estado, del empresario y del consumidor, en la existencia de ésta enfermedad. Finalmente se discute el papel de la epidemiología social, como una herramienta generadora de información útil para la comprensión de la realidad multidimensional del envenenamiento ofídico.

Snakebite envenoming is an accidental, non-infectious, non-contagious disease, caused by the effects of snake venoms. This disease is a relevant worldwide public health problem in tropical countries. Agricultural workers are highly exposed and therefore, commonly affected. The occurrence of snake envenoming involves some ethics concerns. In this assay, the moral significance of venomous snakes under anthropocentric and biocentric perspectives is discussed. Occupational risk and vulnerability of agricultural workers are also addressed. The ethical roles of government, agricultural enterprises and consumers in the occurrence of the disease are analyzed to try to explain why snakebite envenoming is a neglected disease. Finally, the role of the emerging social epidemiology as the contributor factor to gain involvement of stakeholders ‒which should be responsible for mitigation, prevention, treatment and control of snakebite envenoming‒ is discussed.

Complicaciones neurológicas relacionada con la mordedura de serpiente venenosa: reporte de un caso clínico / Neurological complications related to a venomous snake bites: A Case Report

La mordedura de serpiente venenosa es una condición de emergencia pediátrica, que predomina en países tropicales y subdesarrollados, afecta a millones de personas a nivel mundial, produciendo alta morbilidad y mortalidad. Las complicaciones neurológicas pueden ser producidas por efecto de neurotoxinas o por alteraciones en la cascada de coagulación. Se presenta caso de un adolescente mordido por una serpiente barba amarilla que no recibió tratamiento oportuno y manifestó desde las primeras 48 horas, alteraciones hematológicas y a partir del cuarto día de evolución presentó signos de encefalopatía. Posteriormente se analiza el mecanismo mediante el cual se produjeron estos eventos...(AU)

Overlooked issues of snakebite management: time for strategic approach.

Snakebite is a medical emergency in many parts of the world, particularly in the temperate regions. According to 2007 World Health Organization (WHO) report, there are about 5 million snakebite incidences resulting in 2.5 million envenoming, and 125,000 deaths occur annually. Most affected are the healthy individuals like children and farming populations with resource poor settings and away from health care centers in low-income countries of Africa, Asia and Latin America. In view of this, the WHO has declared snakebite as an ignored health crisis and a tropical disease. Although the death rate has reduced markedly due to anti-venom regiment, several limitations of it offer scope for better understanding of various ignored issues. Currently, snakebite therapeutics facing plethora of scientific, technological and public health challenges, including secondary/long term complications that have not been given importance so far. Because of dearth of knowledge, venom researchers and medical practitioners from affected countries worldwide should join together to accomplish this scenario. In view of this, the present review provides a broader perspective on the possible production and application of highly effective therapeutic master anti-venom, designing master diagnostic kit and also to deal with the inefficacy of anti-venom therapy against local manifestations and secondary complications of snakebite. The review demands thorough understanding of venom pharmacology, inculcating new strategies to handle and to enhance the efficacy of snakebite management and urge the governing systems of affected countries to take steps to curtail accidental debilitation and death rate of healthy individuals due to snakebite.

Therapeutic potential of peptides with neutralizing ability towards the venom and toxin (CaTx-I) of crotalus adamanteus.

The CaTx-I (PLA2) toxin of Crotalus adamanteus venom is responsible for most of the symptoms observed during envenomation. Synthetic peptides were designed and screened for venom (0.8 µg/ml) and CaTx-I (0.1 µM) inhibition at varying doses of the peptide (10000- 0.0001 µM) using a Cayman chemical human secretory phospholipase A2 (sPLA2, Type II) assay kit. Further, in vitro neutralization studies were evaluated by a fixed dose of peptide (1 µM) against venom (0.8 µg/ml) and toxin (0.1 µM). Among the linear peptides (PIP-18, cyclic C and PIP59-67) that showed potent neutralizing effects against the venom/toxin of C. adamanteus. PIP-18 [IC50, 1.23 µM] and cyclic C [IC50, 1.27 µM] peptides possessed the strongest inhibitory effect against CaTx-I. A fixed dose of CaTx-I (75 µg/kg) was administered intraperitoneally (i.p.) into mice followed by an i.p. injection of peptides PIP-18 and cyclic C at (6 µg/mouse), venom (150 µg/kg) and toxin CaTx-I alone served as references. Mice treated with PIP-18 and cyclic C showed a very strong neutralizing effect and markedly reduced mortality compared to the control after 24 h. The CA venom and CaTx-I injected mice showed severe toxicity after 24 h. Peptides PIP-18 and cyclic C were non-hemolytic at 100 µM. They produced a significant decrease in lipid peroxidase (LPx) and enhancement of superoxide dismutase (SOD), catalase (CAT) and Glutathione-s-transferase (GST) levels indicating their antioxidant property against venom-induced changes in mice. This study confirmed the potent snake venom neutralizing properties of peptides.

Envenenamento experimental por bothropoides jararaca e bothrops jararacussu em ovinos: aspectos clínico-patológicos e laboratoriais / Experimental poisoning by bothropoides jararaca and bothrops jararacussu in sheep: clinic-pathological and laboratory aspects

Esse estudo teve como objetivo determinar as alterações clínico-patológicas e laboratoriais em ovinos inoculados com a peçonha de Bothropoides jararaca e Bothrops jararacussu, no intuito de fornecer subsídios que possam facilitar o estabelecimento do diagnóstico e do diagnóstico diferencial dessa condição. Os venenos liofilizados foram diluídos em 1 ml de solução fisiológica e administrados a quatro ovinos por via subcutânea. Três ovinos foram a óbito e um que recebeu a dose de 0,5mg/kg (B. jararaca), recuperou-se. Os sinais clínicos tiveram início entre 7 minutos e 1 hora. O período de evolução variou de 7 horas 9 minutos a 21 horas 59 minutos. O quadro clínico, independentemente das doses, caracterizou-se por aumento de volume no local da inoculação, tempo de sangramento e de preenchimento capilar aumentados, taquicardia, dispnéia, mucosas hipocoradas e apatia. Os exames laboratoriais revelaram acentuada anemia normocítica normocrômica, trombocitopenia, acentuada redução de fibrinogênio e proteínas plasmáticas totais, hematócrito diminuído em dois animais, além de acentuado aumento de creatinaquinase e desidrogenase lática em todos os animais. À necropsia, os principais achados no local da inoculação e tecidos adjacentes eram extensas hemorragias no animal que recebeu o veneno de B. jararaca e edema e acentuado edema pulmonar agudo para os dois animais envenenados por B. jararacussu. Além de hemorragia e edema a principal alteração histopatológica verificada foi necrose das fibras musculares e de vasos, no local de inoculação e adjacências. A necrose tubular renal foi atribuída ao quadro de choque. Nos ovinos deste estudo, o aumento de volume observado no local de inoculação e adjacências era constituído predominantemente por sangue (B. jararaca) e por edema (B. jararacussu).

The purpose of this study was to establish the clinic-pathological and laboratory changes in sheep inoculated with Bothropoides jararaca and Bothrops jararacussu venom to provide subsidies for the differential diagnosis of snake bites. The liofilized venoms were diluted in 1 ml saline and administrated subcutaneously to four sheep. Three of the animals died, and the one that received 0.5mg/kg (B. jararaca venom) recovered. First symptoms were observed from 7 minutes to 1 hour after inoculation, and the clinical course varied from 7 hours and 9 minutes to 21 hours and 59 minutes. The symptoms, independent of the dosage, were swelling of the inoculation site, increased bleeding time and capillary filling, tachycardia, dyspnea, pale mucous membranes and diminished reaction to external stimuli. Laboratory tests revealed pronounced normocytic and normochromic anemia, trombocytopenia, slight reduction of fibrogen and total plasmatic protein, in two animals diminished hematocrit, besides pronounced increase of creatinaquinase and lactic dehydrogenase. At necropsy, the main findings at the inoculation site and adjacent tissues were extensive hemorrhages in the sheep inoculated with jararaca venom, and predominantly edema in the two animals inoculated with jararacussu venom. In two sheep which received jararacussu venom, acute pulmonary edema was observed. Hemorrhage and edema as the main histopathological changes, besides necrosis of muscle fibers and vessels at the inoculation site and adjacent tissue was observed. The renal tubular necrosis was attributed to shock. The volume increase at the inoculation site and surroundings was mainly due to hemorrhage (B. jararaca) or edema (B. jararacussu).

Mordeduras de serpientes / Snake bites

En Cuba no existen serpientes venenosas, por tanto los médicos no están familiarizados con el tratamiento de las mordeduras de este animal. No obstante, a pesar de no constituir un problema de salud nacional, se ha considerado la necesidad de abordar este tema, teniendo en cuenta el carácter solidario de nuestra medicina, que ha extendido su ayuda por todo el planeta. Se realizó una minuciosa revisión del tema teniendo en cuenta variables como: distribución geográfica de serpientes venenosas, especies peligrosas, cantidad y modo de identificación, comportamiento del reptil, comportamiento humano frente al reptil, cuadro clínico de la mordedura, complicaciones y tratamiento profiláctico y curativo. Se ofrecen conclusiones relacionadas con la importancia del estudio.

There are no venomous snakes in Cuba, so the physicians are not familiar with the treatment of snake bites. In spite of the fact that this is not a national health problem, it deems necessary to address this topic, taking into account the solidarity character of our medicine that has extended its assistance to the whole planet. A detailed literature review was made on this topic based on variables such as geographical distribution of venomous snakes, dangerous species, number, way of identification, snake behaviour, human behaviour to face the reptile, clinical picture of the bite, complications and prophylactic and curing treatment. Conclusions are provided in relation to the importance of this study.

À Cuba, les serpents venimeux n'existent pas, c'est pourquoi les médecins ne sont pas familiarisés avec le traitement des morsures de ces animaux. Bien qu'il ne soit pas un problème de santé nationale, il est nécessaire d'aborder ce question, tenant compte du caractère solidaire de notre médecine dans le monde entier. Une revue minutieuse de ce sujet a été réalisée tenant compte des variables telles que: distribution géographique des serpents venimeux, spécimens dangereux, nombre et mode d'identification, comportement du reptile, comportement humain devant le reptile, signes cliniques de la morsure, complications et traitement prophylactique et curatif. Des conclusions par rapport à l'importance de l'étude sont présentées.

Mortalidad por contacto traumático con serpiente y lagarto venenosos: México, 1979-2003 / Mortality from contact with poisonous snakes and lizards in Mexico from 1979 to 2003

Objetivo: Describir la tendencia de mortalidad tanto a nivel nacional como estatal causada por la mordedura de víbora y de lagarto venenoso en México, durante los años 1979 a 2003. Material y métodos: Se describe la tendencia de la mortalidad estandarizada por mordedura de víbora y lagarto venenosos registrada en México durante el periodo 1979-2003, en todo el país y en cada uno de los estados de la federación. Las defunciones se obtuvieron de las bases de datos de mortalidad del Instituto Nacional de Estadística, Geografía e Informática (INEGI). Se determinaron frecuencias, porcentajes, tasas crudas, tasas estandarizadas de mortalidad y riesgos relativos de mortalidad con intervalos de confianza a 95%. Resultados: La tendencia de la mortalidad por mordedura de víbora y lagarto venenosos muestra un descenso significativo de 63.5%. La mayor mortalidad por mordedura de víbora y lagarto venenosos se presenta en el sureste del país. Los estados con la mayor mortalidad en el trienio 2001-2003 fueron: Quintana Roo (7.47/1’000,000 de habitantes), Oaxaca (4.01/1’000,000), Veracruz (1.56/1’000,000), Chiapas (1.48/1’000,000), Campeche (1.43/1’000,000) y Yucatán (1.29/1’000,000). Los grupos con mayor riesgo fueron los mayores de 60 años y los del sexo masculino. Conclusiones: Resulta conveniente brindar en México servicios de atención antiviperina médica de emergencia, para evitar la mortalidad causada por contacto traumático con estos reptiles, a pesar de la disminución en los decesos.

OBJECTIVE: To describe the trend of standardized mortality by contact with poisonous snakes and lizards in Mexico from 1979 to 2003. MATERIAL AND METHODS: We describe the standardized mortality trend by contact with poisonous snakes and lizards occurring in Mexico from 1979 to 2003, and report the mortality data bases from the INEGI (Instituto Nacional de Estadística, Geografía e Informática). We determined frequencies, percentages, mortality rates, standardized mortality rates and mortality relative risks with 95% confidence intervals. RESULTS: The general trend shows a statistically significant descent of 63.8%. The highest mortality rate within the 2000-2003 period was reported in Quintana Roo (7.47/1,000,000), Oaxaca (4.01/1,000,000), Veracruz (1.56/1,000,000), Chiapas (1.48/1,000,000), Campeche (1.43/1,000,000) and Yucatan (1.29/1,000,000). The groups with the highest risk are those older than 60 years and males. CONCLUSIONS: In spite of the detected decrease in mortality, the contact with poisonous snakes and lizards still is a public health problem in Mexico. As timely treatment saves lives, it is necessary to include and offer treatment in all emergency units of the country.

Impact of snake bites and determinants of fatal outcomes in southeastern Nepal.

Current available data on snake bites in Nepal are based solely on hospital statistics. This community-based study aimed at evaluating the impact of snake bites and determining the risk factors associated with a fatal outcome in southeastern Nepal. A total of 1,817 households, selected by a random proportionate sampling method, were visited by trained field workers in five villages. Extensive data from snake bite victims during the 14 previous months were recorded and analyzed. One hundred forty-three snake bites including 75 bites with signs of envenoming were reported (annual incidence = 1,162/100,000 and 604/100,000, respectively), resulting in 20 deaths (annual mortality rate = 162/100,000). Characteristics of krait bites such as bites occurring inside the house, while resting, and between midnight and 6:00 am were all factors associated with an increased risk of death, as were an initial consultation with a traditional healer, a long delay before transport, and a lack of available transport. An initial transfer to a specialized treatment center and transport by motorcycle were strong protective factors. Among the 123 survivors, wounds required dressing and surgery in 30 (24%) and 10 (8%) victims, respectively, the mean working incapacity period was 15 days, and the mean out-of-pocket expense was 69 U.S. dollars. Snake bite is a major but neglected public health problem in southeastern Nepal. Public health interventions should focus on improving victims' rapid access to anti-snake venom serum by promoting immediate and fast transport to adequate treatment centers, particularly for bites occurring at night.

Envenenamiento por mordedura de víbora marina / Sea snake poisoning

Las víboras marinas se caracterizan por tener una fuerte cola aplanada en forma de remo. Su veneno es el mas potente conocido entre los reptiles. Se les localiza en aguas tranquilas tropicales. Comúnmente la muerte es por falla respiratoria, cardiaca o renal

Obitos por serpentes peçonhentas no Estado de Säo Paulo: avaliaçäo de 43 casos, 1988/93 / Obits by venomous snakes in the State of Säo Paulo: evaluation of 43 cases from 1988 to 1993

Sao ainda mal estabelecidos os fatores prognósticos para a ocorrência de óbito nos envenenamentos por serpentes e as causas que o determinam. Objetivo. Determinar, no envenenamento ofídico, os fatores prognósticos e as causas mais prováveis do óbito. Métodos. No período de 1988 a 1993 foram notificados 12.639 casos de acidentes por serpentes peçonhentas no Estado de Sao Paulo, com 43 óbitos (0,34 por cento). Foram comparadas as variáveis obtidas das fichas de notificaçao dos acidentes com aquelas dos prontuários e/ou dos relatórios médicos dos casos de óbito. Resultados. O diagnóstico quanto ao gênero da serpente foi realizado em 11.297 acidentes, sendo 9.828 (87 por cento) por Bothrops, 1.359 (12 por cento) por Crotalus e 110 (1 por cento) por Micrurus, e em 41 casos de óbito, sendo 28 (68,3 por cento) por Bothrops e 13 (31,7 por cento) por Crotalus (p<0,05). Informaçao quanto a sexo e idade dos pacientes foi fornecida em, respectivamente, 12.620 e 12.527 acidentes. Pertenciam ao sexo masculino 9.783 (77,5 por cento) pacientes picados e 35 (81,4 por cento) que faleceram (p>0,05). Tinham 50 anos ou mais 15,9 por cento dos pacientes picados e 41,8 por cento daqueles que faleceram (p<0,05). As regioes anatômicas mais freqüentemente picadas foram: pé (42,2 por cento), maos (20,6 por cento), perna (17,6 por cento) e tornozelo (13,1 por cento), nos acidentes, e pé (35,7 por cento) e perna (35,7 por cento), nos casos de óbito (p<0,05). A alteraçao da coagulaçao ocorreu em 34 (91,9 por cento) de 37 pacientes que evoluíram para o óbito. As manifestaçoes e complicaçoes mais referidas como possíveis causas de óbito foram: insuficiência renal (34-79,1 por cento), insuficiência respiratória (28- 65,1 por cento), choque (18- 41,9 por cento) e septicemia (18- 41,9 por cento). Dentre os pacientes que evoluíram para óbito, excluindo-se um caso sem informaçao, 29,4 por cento faleceram dentro dos primeiros dois dias após a picada. A insuficiência respiratória foi mais comum entre os que faleceram devido ao envenenamento crotálico e a septicemia só foi referida para o envenenamento botrópico. Conclusao. A maioria dos acidentes e dos óbitos é causada por Bothrops; sao mais freqüentemente letais os envenenamentos por Crotalus, as picadas na perna e em pessoas com mais de 50 anos; a complicaçao mais comum nos casos fatais é a insuficiência renal.

Snake bites by the jararacuçu (Bothrops jararacussu): clinicopathological studies of 29 proven cases in São Paulo State, Brazil.

The jararacuçu, one of the most dreaded snakes of Brazil, southern Bolivia, Paraguay and northeastern Argentina, is a heavily-built pit viper which may grow to a length of 2.2 m. Up to 1000 mg (dry weight) of highly-lethal venom may be milked from its venom glands on a single occasion. It has accounted for 0.8% to 10% of series of snake bites in São Paulo State, Brazil. We examined 29 cases of proven jararacuçu bites recruited over a 20-year period in two São Paulo hospitals. Severe signs of local and systemic envenoming, (local necrosis, shock, spontaneous systemic bleeding, renal failure) were seen only in patients bitten by snakes longer than 50 cm; bites by shorter specimens were more likely to cause incoagulable blood. Fourteen patients developed coagulopathy, six local necrosis (requiring amputation in one) and five local abscesses. Two became shocked and four developed renal failure. Three patients, aged 3, 11 and 65 years, died 18.75, 27.75 and 83 h after being bitten, with respiratory and circulatory failure despite large doses of specific antivenom and intensive-care-unit management. In two patients, autopsies revealed acute renal tubular necrosis, cerebral oedema, haemorrhagic rhabdomyolysis at the site of the bite and disseminated intravascular coagulation. In one survivor with chronic renal failure, renal biopsy showed bilateral cortical necrosis; the patient remains dependent on haemodialysis. Effects of polyspecific Bothrops antivenom were not impressive, and it has been suggested that anti-Bothrops and anti-Crotalus antivenoms should be given in combination.