Role of steroid on management of limb swelling and local pain in haematotoxic snake bite

ABSTRACT

Introduction:

Local Pain and swelling in the biting area of haematotoxic snake bite victims are very common symptoms. This study was conducted to retrospectively observe the effect of oral Tab Prednisolone on a short-term basis as an add-on therapy of haematotoxic snake bite management in respect of Local Pain and swelling recovery.

Materials and Methods:

This retrospective descriptive study was conducted in a tertiary care hospital in West Bengal among 36 haematotoxic snake bite victims, admitted from February 2020 to January 2021. After collection of the data from hospital records and screened by inclusion and exclusion criteria, 36 participants were included in two groups based on the treatment regimen. Group A (n: 24) received only conventional treatment and Group B (n: 12) received oral Tab Prednisolone on a short-term basis as an add-on therapy of conventional treatment. Swelling was measured as a distance from the site of the bite with measuring tape in centimeters and pain was measured by a numerical rating pain scale (NRS) between 0 and 10. Ethical permission has been waived from the Institutional Ethical Review Committee.

Result:

A total of 36 patients (32 male and 4 female) were included in the study. Age (Mean ± SD) of the snake victim persons in Group A and Group B were 35.79 ± 8.34 years and 31.33 ± 6.47 years, respectively. The local swelling length and pain score reduced significantly among group B patients on day 6 in comparison to day 2. However, in Group A, the pain score and local swelling increased significantly on day 6 in comparison to day 2.

Conclusion:

A short course of systemic steroids as an adjuvant with anti-venom serum (ASV) for the management of local pain and edema in case of haematotoxic snake bite may be beneficial if there is no contraindication.

Introduction

Death due to a snake bite is a major preventable public health burden in most parts of rural India even in the twenty-first century and it comes under priority on the neglected tropical disease list in 2017.[1] Among the most affected states in India, West Bengal comes in the first row.[2]

For snake bite case management, World Health Organization (WHO) published “Guidelines for the Clinical Management of Snake bites in the South-East Asia Region” in 2005.[3] Thereafter Government of India published Standard treatment Guidelines for Management of Snake Bite on January 2016.[4] These guidelines are still practiced in various parts of the South East Asian regions including India by primary health care providers and family physicians. One of the most important clinical features of haematotoxic snake bite survivors is local swelling and pain in the biting area. This local swelling and pain are sometimes difficult to treat with available recommended treatment guidelines. We observed during daily clinical practices, local swellings extending from the bite site towards the central part of the body are very disabling symptoms for the survivor of viper bite. Local swelling and pain started immediately and gradually progressed in most of the cases. The swelling and pain persist even after other signs, and symptoms of snake bite have improved and lab tests showed complete neutralization of envenomation. As per standard treatment guidelines (Government of India) for the Management of Snake Bite, only Paracetamol (acetaminophen) and Tramadol are recommended for pain management for snake bite cases. These guidelines also discourage to use of corticosteroids, antihistamines, non-steroidal anti-inflammatory drugs and heparin at Primary Health Centre level for snake bite management.[4] However few studies reported that the application of oral steroids has some positive effects on reducing local pain and swelling in the haematotoxic snake bite cases.[5,6] Therefore, few medical practitioners are still practicing oral steroids as an add-on therapy to conventional treatment for the management of snake bites with a special target to reduce local pain and swelling. But there is a gap in practice on choice of oral steroid as an add-on therapy to conventional treatment for management of snake bite victims regarding pain and swelling management.

The aim of this pilot study was designed to observe and document the outcomes of haematotoxic snakebite in respect of local swelling and local pain by administration of oral Tab Prednisolone on a short-term basis as an add-on therapy to conventional treatment.

Material and Methods

Study setting including study design and study duration

This retrospective descriptive study was conducted in a rural tertiary care hospital in Murshidabad district, West Bengal, India among 36 haematotoxic snake bite victims admitted during February 2020 to January 2021.

Inclusion criteria

1. All patients suffering from local swelling and pain in limbs due to haematotoxic snake bite;

2. Patients received AVS and standard treatments as per standard guidelines;

3. Patients admitted in the hospital due to haematotoxic snakebite during February 2020 to January 2021.

Exclusion criteria

1. All patients with neurotoxic snake bite and suspected snake bite;

2. All patients on “Renal Replacement Therapy” and diabetes;

3. Long delay on admission of haematotoxic snake bite patients (more than 12 hours after snake bite);

4. Haematotoxic snake bite patients, who suffered by bite other than limbs (trunk, forehead etc.);

5. Haematotoxic snake bite patients, who used pressure tourniquets to prevent the spread of venom.

Data collection procedure

Data were collected from hospital records. After collecting the data from hospital records and screening by inclusion and exclusion criteria, a total 36 patients were included in two groups as per history of treatment received. In Group A, 24 haematotoxic snake bite victims were included who were treated in conventional treatment without any systematic steroids. In Group B, 12 haematotoxic snake bite victims were included who were treated with systematic steroids along with conventional treatment.

Data collection tools

Data were collected in a structured questionnaire. In the hospital records of the patients, the local swelling was measured as distance from site of bite with measuring tape in centimeter and local pain was assessed by Numerical Rating Pain Scale (NRS) between 0 and 10.[7]

Treatment received

All Haematotoxic snake bite patients suffering from local swelling and pain were undergone through ultra-sonography and color-doppler study to exclude any vascular compromised and compartment syndrome. Standard wound care protocols were applied to the patients. All patients also received amoxicillin or erythromycin as antibiotic support.

Sample size

36 (all Haemato-toxic snake bite cases admitted to the hospital during the study period were considered after filtering the inclusion and exclusion criteria).

Sampling procedure

A purposive sampling procedure was applied.

Statistical analysis

After collecting the data from hospital records, all data were checked thoroughly for consistency and completeness. Data were analyzed by SPSS-IBM software. Information was presented as the mean, SD, frequency, and percentage as appropriate. The student’s t-test was used to compare continuous variables. A P value less than 0.001 is the level of significant.

Ethical issues

Ethical Permission has been waived from the Institutional Ethical Review Committee as retrospectively the data were collected from the hospital records. The permission for the collection of information from hospital records was obtained from the hospital authority.

Result

A total of 36 patients were included in the study. The number of male and female participants were 32 and 4, respectively. Maximum snake bite victims were in the 26–50 years age group. Age (Mean ± SD) of the snake victim persons in Group A and Group B were 35.79 ± 8.34 years and 31.33 ± 6.47 years, respectively [Table 1]. There is no statistically significant difference in age group and gender group between Group A and Group B.

Table 1.

Demographic information of two interventions groups

Variables	Group: A Without Steroid (n: 24)	Group: B With steroid (n: 12)	P
Gender			0.407
Male	22	10
Female	02	02
Age	35.79±8.34	31.33±6.47	0.11
Age <25 years	02	01	0.773
Age 26-50 years	21	11
Age >50 years	01	00

P<0.001 is the level of significant

In Table 2, it was observed that the length of swelling increased significantly in respect of length on day 2 (14.79 ± 5.82 cm) to day 6 (20.79 ± 8.21 cm) in Group-A, who were treated in conventional treatment (without any steroids). In contrast, the length of swelling decreased significantly in respect of length on day 2 (25.42 ± 8.44 cm) to day 6 (8.08 ± 5.73 cm) in Group-B, who were treated in conventional treatment with steroids.

Table 2.

Distribution of swelling size in two interventions groups

Group	Days	Size of Swelling (cm)	P
Group: A Without Steroid (n: 24)	Day 2	14.79±5.82	<0.001
	Day 6	20.79±8.21
Group: B With steroid (n: 12)	Day 2	25.42±8.44	<0.001
	Day 6	8.08±5.73

P<0.001 is the level of significant

The Pain score also shows significantly improved from day 2 (8.50 ± 0.52) to day 6 (2.25 ± 1.14) in Group-B, who were treated in conventional treatment with steroids. In Group A, the pain score significantly increased from day 2 (6.46 ± 0.93) to day 6 (7.58 ± 0.88), who were treated in conventional treatment (without any steroids) [Table 3].

Table 3.

Distribution of pain score in two interventions groups

Group	Days	Pain score	P
Group: A	Day 2	6.46±0.93	<0.001
Without Steroid (n: 24)	Day 6	7.58±0.88
Group: B	Day 2	8.50±0.52	<0.001
With steroid (n: 12)	Day 6	2.25±1.14

P<0.001 is the level of significant

Regarding the stages of pain score, it was observed in Group A, all snake bite victims were moderate and severe pain score on day 2 and day 6. However, the number of patients with severe pain increased in Group A in comparison to day 2 to day 6. In group B, all the snake bite victims were in severe pain on day 2. On day 6, the pain score decreased among the Group B snake bite victims. About 75% of the patient’s pain score was reduced to mild pain in Group B on day 6 [Table 4].

Table 4.

Distribution of group wise pain score in two interventions groups

Group	Days	Mild pain	Moderate pain	Severe pain
Group: A	Day 2	00	12 (50%)	12 (50%)
Without Steroid (n: 24)	Day 6	00	04 (17%)	20 (83%)
Group: B	Day 2	00	0	12 (100%)
With steroid (n: 12)	Day 6	09 (75%)	03 (25%)	0

P<0.001 is the level of significant

Discussion

Studies over decades show male are predominant victims of snake bite,[8] our interpretation concluded with the same views. This study finding may be due to the presence of more outdoor activities of male population in comparison of female counterpart. One epidemiological study was conducted in Karnataka, India among 180 snake bite patients found that 60.5% of victims were male between the age of 20 to 40 years.[8] The mean ages of our study participants in groups are 35.9 ± 8.34 years and 31.33 ± 6.47 years, respectively.

This study observed positive outcomes of administration of oral Tab Prednisolone on a short-term basis as an add-on therapy of conventional treatment for the management of snake bite in respect of local pain and swelling management. It is well known that, Snake venom consist of enzyme (Phospholipase A2, L-amino acid oxidase, etc.), polypeptide (crotamine, crotoxin), glycoprotein and compound of low molecular weight, as foreign elements to human body cause several systemic and local complications.[9] In addition, it is also established that, Hyaluronidase facilitate spread of venom through tissue and proteolytic enzymes causes local oedema, blister and necrosis.[10] Increased vascular permeability by venous protein also contributes to local edema.[11] Severe local swelling, hemorrhagic blisters and local signs of inflammation are regular findings in viper bite. This swelling can persist even a long time after discharge.[12]

In clinical practice, it is observed that the swelling and inflammatory pains due to snake bites are very disabling during hospital stay. Standard treatment could not reduce this pain and swelling significantly. In this regard, Systemic Corticosteroid was first applied by Trishnanand et al.[5] in 1979. They found significant improvement in local swelling. Lekagul and his co-researcher also found improvement in local symptoms using steroids.[6] Both these previous mention studies systemic steroid was used in short course as adjuvant with antivenom. On animal study reported combined effect of steroid and antivenom reduced swelling and hemorrhage in dogs.[13] However, one randomized control (RCT) study conducted among children (under 3–15 years of age) did not find any benefit in short term use of systemic steroids in case of green pit viper bite when used without antivenom.[14] But in our study, we observed significant improvement in local swelling and pain score within 6^th day when systemic steroids were used as an add-on therapy to conventional treatment of snake bite.

Therefore, our current study may push for further research on application of systematic steroids on snake bite management. Hence, large sample size randomized control trials are needed to provide any significant conclusion.

Conclusion

With current study findings we may recommend using a short-term course of systemic steroid as adjuvant with antivenom serum for management of local pain and edema in case of haematotoxic snake bite if there is no contraindication. Further research on this topics will be the way forward.

Limitation

There are various limitations of this study. Like this is a retrospective study with limited sample size. This finding may not provide rigor scientific evidence, and this finding may not validate in other population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.