MANDALI VISHA.pptx
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Mandali visha is a type of visha that can be correlated with viper venom. Here are the ayurvedic and modern descriptions of the same.
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MANDALI VISHA.pptx
- 1. Anu Mariam Varghese 2nd MD Scholar Dept of Agadatantra G AVC, TVM
- 2. ⦿ Prevalence ⦿ Mandali-Viper ⦿ Types ⦿ Lakshana -Identifying feature ⦿ Viper venom- Action ⦿ Signs and symptoms of envenomation ⦿ Diagnosis ⦿ Prognostic signs ⦿ Treatment ⦿ Complications ⦿ Case –Viper envenomation ⦿ Research works
- 4. ⦿ An estimated 5.4 million people are bitten each year with up to 2.7 million envenomation. ⦿ Around 81 000 to 138 000 people die each year because of snake bites. ⦿ IIndia is the most heavily affected country in the world (at least 81,000 snake envenomings and 11,000 fatalities ). ⦿ India has witnessed an estimated 1.2 million deaths due to snakebites between 2001-2020.(a new study, published in the journal eLife, claims 17-Jul-2020 dated)
- 5. ⦿ Viper bite is responsible for majority of snakebite in India. ⦿The family of viperidae is the largest family of venemous snakes,and they are found in Africa, Europe, Asia and the America.
- 6. MANDALI ⦿ Mandali from the Sanskrit mandala meaning circle ⦿ AH, Susrutha included as Bilesaya ⦿ Caraka as Bhumisaya VIPER Latin word vipera, -ae , meaning ⦿ referring to the trait viviparity (giving live birth) ⦿ Named in honor of Patrik Russell • vivus (“living”) • parere (“to beget"),
- 7. ⦿ Mere correlation from identification features, signs and symptoms of envenomation etc.. ⦿From identifying feature python is also closely related and since it is non venomous we take it as viper.
- 8. ⦿ A/c Susrutha -22 types ⦿ Vishajyotsnika, Prayogasamuchayam, Kriyakoumudhi -16 types ⦿ May be the classification is based on what they see in the external features and symptoms they produce. Color – sweta, krishna .. Visha lakshana – sopha, brama .. ⦿ But the treatment and samanya lakshana are same for all.
- 9. ( വി ഷ Ф ൃൃോൃത്സി ക - 6 / 1 മ ണ്ഡ ലി വി ഷ ചി കി ത്സ) ( स. ु क. 4 /34 )
- 10. ( പ്ര ോയ ഗ സ മു ച്ച യം-പ്ര ഥ മ ര രി ോൃ ദംമൂ ർ ോ ദിവി ോ ഗം) ( പ്കി ോയ ൃോൄ കകൌ മു ദി-മ ണ്ഡ ലി വി ഷ പ്ര ക ര ണം)
- 11. ⦿Russell‟s viper ⦿Saw scaled viper ⦿ Hump nosed pit viper ⦿Levantine viper ⦿Bamboo pit viper ⦿Mountain pit viper ⦿ Horseshoe Pit Viper ⦿ Jerdon‟s Pit Viper ⦿Puff adder
- 12. ⦿ Russell‟s Viper SN - Daboia russelii ⦿ Saw Scaled Viper SN – Echis carinatus ⦿ Humpnosed PitViper SN - Hypnale hypnale ⦿ PitVipers Subfamily - Crotalinae TAXONOMY Kingdom Phylum Subphylum Class Order Suborder Family Subfamily : Animalia : Chordata : Vertebrata : Reptilia : Squamata : Serpentes :Viperidae :Viperinae
- 13. ⦿ Calloselasma rhodostoma - malayan pit viper ⦿Green pit vipers or bamboo vipers (genus trimeresurus) ⦿T albolabris white-lipped green pit viper ⦿T gramineus indian bamboo viper ⦿T mucrosquamatus chinese habu ⦿T purpureomaculatus mangrove pit viper ⦿T stejnegeri chinese bamboo viper
- 14. Russell’s Viper Hump nosed PitViper Saw Scaled Viper PitViper
- 15. Mountain pit viper Levantine Viper Bamboo Pit Viper Puff adder
- 16. Horseshoe Pit Viper Jerdon’s Pit Viper Malabar Rock Pit Viper Gaboon Viper
- 17. Abhoga – No hood Vividhamandala- have round patches of different kinds (size and shape) Pramsava- big size Mandagamana-moves slowly • No hood • Large triangular head • Tail is short and tapering • Robust and stout body • It has three rows of diamond shaped black or brown spots along the back, outer two rows consisting of spots ringed with white edges-R Viper • Upper surface of which is covered with a white mark resembling bird‟s foot print or an arrow- Saw scaled Viper • Body-short with narrow neck • Pupil vertical
- 20. ⦿ Movable folding fangs ⦿ Fixed to a rotating maxilla (jaw bone) ⦿ Kept folded backwards and upwards against the roof of the mouth ⦿ Canalised and long ⦿ Viper opens mouth very widely up to 180o and the fangs get erected ⦿ Discharge orifice is usually well above its tip.
- 21. • Venom is white or yellow
- 22. ⦿Venom –Induced Blood disturbances by paralearctic viperid snakes, and their relative neutralization by Antivenoms and enzyme-inhibitors.-Frontiers in immunology ⦿Transcriptomic and functional proteomics analyses to unveil the common and unique pathways(s)of neuritogenesis induced by Russell‟s viper venom nerve growth factor in rat pheochromocytoma neuronal cells.
- 23. ⦿ Cause aggrevation of pitta dosa -प ऩ त्तं म ण्ड ल ऱ न श्चा प ऩ( स ൃ.क 4/ 1 2 ) ⦿ Moves about in the remaining hours of night except for the last ൃ या म स ऩाा श्श्श्च त्रा श्य र श्न्िൃह हश ष ൃषक ् ൃ िൃ ൃा yama of night. -र ज न्या ऩ श्श्श्च म म ण्ड ल ऱ नो ....... (स ൃ.क4/31) ⦿ Potent in old age –Su ,Ca, Mni - व द् ൃ धा म ण्ड ल ऱ न स्िൃ था ( स . क ൃ 4/32) middle age as per AH,Vishajyotsnika िൃ ൃा रु ण्य मध्यव द् ൃ ध त्व ⦿ Poison is amla (sour) and ushna( hot) P ↑ अ म्ऱो ष्णं....
- 24. ⦿ ⦿ Theekshna Ushna ---- ---- Pitta ↑ Pitta↑ ⦿ Rooksha ⦿ Visada ⦿ Vyavayi ⦿ Asukaram ⦿ Laghu ---- Pitta ↑ ⦿ Vikasi ⦿ Sookshmam ⦿ Avyaktha rasam(A.H)/annirdesya rasam(C.S) ⦿ Apaki
- 25. ⦿The venom affecting the circulatory system and cytotoxic or cell destroying. ⦿Venom destroys the clotting mechanism leading to heavy bleeding externally and internally. ⦿ Venom inhibits platelets activity and increases vessel wall permeability there by increase bleeding from bite site. ⦿ Cause intravascular hemolysis and depression of coagulation mechanism.
- 26. ⦿ Phospholipase A2 (Lecithinase) – Damaging effect on mitochondria,Vascular endothelium and RBC , leucocytes and platelets. ⦿ Argintine ester hydrolases – Increase capillary permeability ⦿ Hininogenase – mediates hypotension by releasing bradykinin ⦿ Hyaluronidase – spreading the venom through tissue ⦿ S Haemorrhagin – causes bleeding by direct action on vascular endothelium
- 27. ⦿FATAL DOSE ⦿ Maximum yield in one bite 15 mg 130-250 mg ⦿ FATAL PERIOD 1 - 2 days
- 28. ऩी िൃ त्वं त्व गा दी नां Yellowish discoloration of skin and other parts शी िൃ ൃा िल ऱा ष Desires towards cold ऩररधऩൃ नं Local burning sensation दा हं Burning sensation िൃष्ൃ णा Excessive thirst म द Intoxication मर्चൃ ൃ ् ൃाൃा Fainting ज्व र fever शोणिणागमन ऊधचवा अधश्च Bleeding from upper and lower orifices मांसा नांव शा िൃ नं Falling off of muscles श्व य थ ൃ Swelling
- 29. दंश को थ Putrefaction of the site of bite ऩीिൃरूऩ दशनं Persons sees all things yellow आ श क ൃ ൃो ऩं Person becomes angry quickly प ऩ त्त वद ना Other symptoms of aggravation of pitta उ ष्मा Site has great heat locally स शो षं Site is dry ऩथൃ ൃ पवसऩा दाहं Muscle becomes thick with visarpa (herpes) ऒष क्ऱदं Like ulcer accompanied को थैप व स शी िय With burning sensation, heat, moistness(exudation),putrefaction and falls off ऩी िൃ िൃ ൃा Yellowishness of the face, teeth स्र म Fatigue भ्र मा Giddiness Other symptoms apart from above ,as mentioned in Ashtanga Sangraha
- 30. ििक ् िൃ वक्त्रत्वं Bitter taste in the mouth धमൃ क ं Feeling of smoke coming from the stomach आशൃ सवााड्ग पवस्रिൃ िൃ Accumulation and flow of fluids from the entire body
- 32. VEGA A.H/A.S SU P.S 1. Asrk dushtam Peethi bhavathi, peethangatha, daha A.H Yellowish discolouration of body 2. Svayathudbhava: Mamsa dushti Athyartham peethatha, Paridaha Sopham Raktadhatudusti, Paleness, shivering 3. Damsavikleda, Sveda, Trishna Medodushti Swedam Chakshugrahanam,Trs na ,Damsakleda Mamsadhatudusti, Sleepy thirst restlessness 4. Jvara Daha Reaches koshta Jvara Medodhatudusti, Body pain ,Sopha, Obstruction to words,Jvara VEGA LAKSHANAM
- 33. 5. Daha: sarvagathraga: Asthi dhatu Pranagni dushti A.H Asthidhatudusti, fainting,burning sensation,vision impairment 6. Hrit peeda Gaatra gauravam Moorcha, Avipakam Athisaram Majja dhatu Same Majjadhatudusti,Weaknesss of joints,Obstruction of nose 7. Reaches suklam skanda prishta kadee bhangam sarvacheshtanivartha nam Vyana dushti Uchwasa nirodham Sarvendriya rodha,Pranavayu lost
- 35. ⦿ Neeloshtam ⦿Dantha saithilyam ⦿Kesapatanam ⦿Angabhanga vikshepam ⦿Sisirai: na lomaharsham ⦿Na abhihate danda rajee ⦿ No formation of contusions ⦿ Absence of bleeding from ulcers(Cha.chi23/33) • Cyanosis • Loss of mucular and nervus functions
- 36. ⦿ Ophitoxaemia – Poisoning by snake venom. ⦿ Viperid snake merely strikes , discharging venom the moment fangs penetrate skin and then immediately leaves it. ⦿ As venom injected spot develops a severe pain within eight minutes. ⦿ Signs and symptoms usually manifest earliest
- 37. GENERAL SYMPTOMS • Local pain at bite site • Pain in regional lymph nodes • Vomiting • Bleeding from distant sites • Drowsiness • Epi gastric pain • Lower back pain • Dizziness/ impaired consciousness SYSTEMIC ENVENOMATION • Spontaneous systemic bleeding • Hypotension • Conjunctival edema • Bleeding from gums • Bleeding from venipuncture sites • Hematemesis • Melena • Bleeding from incisions • Subconjunctival hemorrhage • Epistaxis
- 38. Local • Local swelling • Tender, enlarged lymph nodes • Bleeding at bite site • Local blistering and necrosis Neurological and muscle signs • Bilateral ptosis, generalised muscle pain and tenderness • External ophthalmoplegia • Dysphagia • dysarthria Hematology • Shows both procoagulant (Factor V, IX & X activation )enzyme activity and direct fibrinolytic activity • Presents as DIC-type coagulopathy results in non coagulating blood and hemorrhage • Fibrinogen, platelet counts and hemoglobin levels are generally decreased • Fall in albumin may secondary to generalized increase in capillary permeability
- 39. Urinary symptoms and Renal failure • Hematuria • BUN range • Proteinuria (>1 gm /liter) • RBC casts • Oliguria • Renal –angle tenderness Severe Envenomation • Hypotension and increased heart rate secondary to peripheral circulatory collapse • Acute renal failure secondary to acute tubular necrosis • Internal bleeding secondary to DIC • Neurological symptoms including ptosis, external ophthalm-oplegia and dysphagia
- 40. • Low platelets • Prolonged clotting time • Presence of band forms • Polimorph nuclear leucocytosis • Crenated RBCs • Low serum protein and albumin • Bilateral parotid swelling – viper head appearance • G iddiness, syncope immediately following snake bite • Profound thirst • Loin pain
- 41. Ref : Progasamuchayam 50-100 mg of lehya,spread on a betel leaf is given to the victim Venom detection according to taste ⦿Amla(Sour) – Mandali ⦿Katu (Punjent) – Darveekara ⦿Swad(Sweet) – Rajila ⦿Thiktha(Bitter) – Non venomous ⦿No taste – Very serious
- 42. LABORATORY INVESTIGATIONS A. HEMATOLOGICAL ⦿ Anaemia ⦿ Leucocytosis ⦿ Thrombocytopenia ⦿ High Haematocrit initially ;later it falls ⦿ Evidence of hemolysis: Fragmented RBC (Schistocytes or helmet cells) ⦿ Prolonged clotting time and prothrombin time ⦿ Prolonged partial thromboplastin time ⦿ Depressed fibrinogen levels ⦿ Elevated FDP (Fibrin degradation products)
- 43. ⦿ Braycardia with ST segment elevation or depression. ⦿ T wave inversion ⦿ QT prolongation ⦿ Changes due to hyperkalemia C.METABOLIC ⦿ Hyperkalemia ⦿ Hypoxaemia with respiartory acidosis ⦿ Metablic acidosis or lactic acidosis( increased anion gap) D. URINE ⦿ Haemeturia ⦿ Protenuria • Haemoglobinuria • Myoglbinuria
- 44. ⦿ Pulmonary edema ⦿ Intrapulmonary hemorrhages ⦿ Pleural effusion G. X-RAY OF BITTEN PART ⦿ Presence of embedded snake tooth or fang fragments H. IMMUNODIAGNOSIS ⦿ Venom antigens in body fluids can be accomplished by ELISA
- 45. ⦿ Atyayika Chikitsa ⦿ Samanya Chikitsa ⦿ Vegachikitsa ⦿ Dhatugata chikitsa ⦿ Doshagata chikitsa ⦿ Sthanagata chikitsa ⦿ Lakshanika chikitsa ⦿ Traditional chiktsa in visha granthas
- 46. ⦿Arishta bandam ⦿Achooshanam ⦿Nishpeetanam ⦿Chedanam ⦿Agnikarmam ⦿ Application of ear wax with saliva on bite site
- 49. • Mentioned in Charaka Chikitsa 23 rd chapter • Here 24 types of treatment modalities are described which should adopt in appropriate conditions .
- 50. VEGA A.H/A.S SU PS 1 Visravya sonitham Agadam+madhu+sarpi Rektha moksham Jaladhara, chandanapana 2 Vamanam Agada panam Agadam+madhu+sarpi,Va manam,Yavagu, poorvoktham Siravedam, Chandanoshira lepa and nasya 3 Vamanam Peya Sodana,Theekshna yavagu pana Ramacham+chandana m+Irattimaduram+Tag aram+Irippakkathal lepa 4 Vamanam Yavagu Same Thriphalapanam 5 Sprinkled and bathed in cold water Vamanam, Agadapanam Same Siravedam Chandanapana 6 Atheekshnam agadam Padmakadi agada Kakolyadi gana, peya with madhura agada Nasyam &Pana- Punarnava 7 Strong agada, nasya, anjana, kakapadam Avapeeda nasyam, anjanam , kakapadam Rooksha Nasyam,&anjanam VEGA CHIKITSA
- 54. OOTHU CHIKITSA ⦿ 1. TWAK ⦿ 2. RAKTHA ⦿ 3. MAMSAM ⦿ 150 times moordha and two srotra ⦿ Drugs viswa, dusparsa, maricha, vishavegam(garudakodi)
- 55. ⦿ 4. MEDAS INTERNALLY + LEPANAM ⦿ 5. ASTHI ⦿ 6. MAJJA NASYAM + ANJANAM ⦿ 7. SUKRAM ⦿ Poison not eliminated from the body for years – use taila/ghee prepared from suitable medicine
- 56. പ്ര യ ോയഗ സ മു ച്ച യം , വിഷയ ോൃ ത്സി ര
- 57. VATA PITTA KAPHA - Bhojana with Swadu, snigdha, lavana ,amla added with ghee and also use of meat as food -Virechana, Seka ,Pradeha which is cold and bhojana which is kashaya, tikta , madhura added with ghee. - Vamana and lepana which is ushna, rookhsa, theekshna and food which is kashaya, katu a,tikta
- 58. 1. VATA STHANA • Swedam • Nata kushta kalka panam with dadhi 2. PITTA STHANAM • Drink ghee, honey, milk, water • Avagaham, sekam with cold water 3. KAPHA STHANAM • Kshara agada • Sweda • Siravedham 4.Dooshi visha / rektha sthite • Siravedham • Panchakarma
- 60. PRAYOGASAMUCHAYAM ⦿Yellowish urine – Karanja tvak in hot water ⦿Fever – Root of Amlika in milk ⦿Vomiting – triphala pana ⦿Hemorrhage – pana of kadamb twak ⦿Blotting –pana of tippali with saindava ⦿Hotness – Useera chandana lepana ⦿ Thirst – Rhizome of banana plant swarasa in milk
- 61. ⦿Urine obstruction – Kashaya of kushmanda stem with ela ⦿Blood vomiting – Nimba in milk ⦿ Epistaxis- Swarasa of patolapatra with navaneeta talam ⦿Bleeding from ear – karnaporanam with vilwa patra swarasa and navaneeta
- 62. VISHAJYOTSNIKA ⦿Mentioned Various oushada yogams ⦿ 7 Nasya yogams and 5 anjana yogams for visha supta ⦿ Mentioned Vishopadrava chikitsa in detail ⦿Lepanayogams for vishaveekam
- 65. ⦿Kottamthagaradi ⦿Kizhiprayogam ⦿Sidhayogams for vishaveekkam ⦿Sigrpunanavadi ⦿Dhara prayogangal ⦿Thookkudhara ⦿Lepaprayogangal- Nalpamaradi, Ekanayakamooladi, Karaskaravandakadi ⦿Tailayogal – Durvarasadi, Brahmarasadi, Njottanjedungadi ,Paranthyadi ⦿Ghritham- Ekanayakamooladi, Paktiprasoonadi ⦿Dasapushpam
- 66. PRAYOGASAMUCHAYAM ⦿ Sadhyodashta chikitsa ⦿ Vega chikitsa ⦿ Chikitsa for each type of mandali mentioned ⦿ Mandali samanya chikitsa – medicines for externally and internally . Panam, Nasyam, Lepanayogams, Dhoopayogams, Anjanayogams ⦿ Lakshanika chikitsa ⦿ Yogams for visha veekkam ⦿ Dharaprayogangal- thookk dhara ⦿ Mandali visha vrana chikitsa ⦿ Yogams – Kottam thagaradi, sigrupunanavadi, sudhadurvadi, paranthyadi
- 67. KRIYAKOUMUDI ⦿ Vishavega chikitsa and dhatugata chikitsa ⦿ Chikitsa for each type of mandali mentioned. ⦿ Mentioned Rx for types seen in Kerala like payyani mandali, kuzhi mandali … ⦿ Lakshanika Rx for raktasravam, ⦿ Mandali samanya Rx- Lepana yogams, Pana yogam, Dhoopa yogams, Anjana Yogam, Nasya yogams ⦿ Yogams- Paranthyadi Tailam,Bramhmi ghritham, Sugandhadi agada….
- 68. ⦿ Unconscious -make conscious • Nasya with vilwadi gulika + tulasi swarasa • Anjana with visha vilwadi + tulasi swarasa • Maricha is added if patient not responding to conventional treatment • Talam with amalaki+musta+chandanam+tulasi swarasa • Oothu chikitsa
- 69. ⦿ After gaining consciousness • Jeevaraksha + milk repeatedly given (5-6) • Vilwadi gulika + spl vilwadi (karalakom+nannari+adapathiyan+amalpori) • Local inflammation -eritailam • After vegas under control 🞄Patola katurohinyadi kashayam 6 hourly 🞄 Vilwadi gulika
- 70. Viharam ⦿ severe poisoning – not allowed to sleep for ⦿ ⦿ 24 hrs - mild poisoning to avoid sleep - sleep at evening - eye drops with ⦿ tulasi swarasa and small onion - sleeping on the next night is compulsory
- 71. LOCAL SPECIFIC SUPPORTIVE IN A NUT SHELL First Aid Patient assessment phase on hospital arrival Handling tourniquet Managing pain ASV Treatment of complications
- 72. ⦿ Do it “ R I GH T ” ⦿ Sutherland technique ⦿ St Jones technique 2. PATIENT ASSESSMENT PHASE ON ARRIVAL ⦿ A B C (Airway, Breathing and Circulation) ⦿ If there is evidence of a bite, where the skin has been broken, give Tetanus toxoid. ⦿ Use of antibiotics (if there is evidence of cellulitis or necrosis)
- 73. ⦿ Before removal of the tourniquet, check for the presence of pulse distal to the tourniquet. ⦿If the tourniquet has occluded the distal pulse, then a blood pressure cuff can be applied to reduce the pressure slowly. 4. MANAGING PAIN ⦿ This can be treated with pain killers such as Paracetamol (Symptomatic management).
- 74. ⦿ Viper inject an average of 63mg of venom(5-147mg) ⦿ 1ml ASV neutralises 0.6mg of viper venom ⦿ 1 vial – 10ml of ASV neutralizes 6mg of venom ⦿Total required dose will be between 100ml to 250mg i.e.10- 25 vials ⦿ 10 vials of ASV in 100 ml. of Normal Saline with 10-15 drops per minutes ⦿ Watch for reactions for 15 minutes ⦿ Total 1 hr period
- 75. ⦿Conservative ⦿Maintain effective blood volume ⦿Broad spectrum non nephrotoxic antibiotics ⦿Maintain BP above 90mm ⦿ Diet plenty of calories ;protein & potassium restrictions ⦿Fluid status be maintained –input to match output ⦿Dialysis
- 76. ⦿ Hypopituitarism- Russells viper causes acute pituitary insufficiency.Bleeding in the anterior pituitary leads to hypopituitarism (Sheehan „s syndrome) ⦿ Extensive suppuration and sloughiing followed by malignant edema ⦿Extensive necrosis ⦿Hemorrhagic syndrome ⦿Venous ulcer ⦿Renal failure
- 77. ⦿Mentioned deatiled in Visha jyosnika ⦿ In Kriyakoumudi and prayogasamuchayam though mentioned not specically quoted as upadrava Rx ⦿ For each upadrava lakshana special Rx mentioned. ⦿Chittabramam- Pana with Chandana and Usheera ⦿Yellowish discoloration of urine-Karnja twak in hot water. ⦿Fever – Puliver with milk
- 78. ⦿Vomiting- Triphala panam ⦿Hotness – Usheera, Hribera and chandana lepa ⦿Hemetemesis – nimba with milk ⦿ Fatigue to all joints- punarnava with hot water. ⦿ Abdominal distention –Saindavam with trikatu ⦿Trishna –Kadalikanda toyam with milk ⦿Obstruction to urine and faeces- Pippali and ela in narikerodakam ⦿ Epistaxis - Tailam in malathipatratoyam
- 81. ⦿Clothing shows amber-coloured fluid becomes yellowish needles on drying ⦿Venom on skin will pesent as yellowish crystals ⦿Two or occassinally one fang mark. ⦿Puntures two and half cm deep in viperine bites ⦿Discoloration, swelling and cellulitis about the mark ⦿Hemorrhages occur from puncture and mucous membrane. ⦿ Hemorrhages into bowel, purpuric spots o pericardium
- 82. ⦿Kidneys – inflammed and show tubular, cortical necrosis and interstital nephritis and marked congestion. ⦿Subcapsular pinpoint hemorrhages ⦿ Regional lymph nodes swollen and hemorrhagic
- 83. 03/06/2016 ………7.00AM ⦿ Male patient 41yrs ⦿ While cleaning the surrounding ⦿ Snakebite in rt. fore arm ⦿ Snake was seen on the broomstick ⦿ Pain on the bite site ⦿ 2 tourniquets were tied on the Rt. UL ⦿ Taken to nearby hospital ⦿ No signs of envenomation seen ⦿ Kept him under observation till 4 pm
- 84. 4.30PM…………03/06/2016 ⦿ Oedema and redness on the BS ⦿ CT done – 14 mt 40 sec ⦿ Gave 4 vial ASV ⦿ Referred to LFH 6.30 PM…………03/06/2016 ⦿ Patient was conscious, coherent and oriented ⦿ No h/o abdominal pain ⦿ No passing of urine from morning ⦿ Diplopia ⦿ Vomiting
- 85. VITALS ⦿ PR – 72/mt ⦿ BP – 140/80 mm of Hg ⦿ CVS – S1S2 + ⦿ RS – clear bite site ⦿ O/E • Swelling + • Tenderness + • Multiple scratch marks + • Discoloration + • Severe pain + • CT > 20 min • Psoriatic lesion on both LL, occasionally alcoholic • Pt. shifted to MICU
- 86. DIAGNOSIS • Unknown snake bite with envenomation • Patient identified the snake as Russell‟s viper by seeing the pictures
- 87. ⦿ 10 vials of ASV in 100ml NS iv ⦿ Inj. Periset 400mg iv SOS ⦿ Inj. Tramedol 1 amp in 100ml NS ⦿ T . dolo 650 mg SOS ⦿ Limb elevated ⦿ Monitor urine output ⦿ Inj. Lasix 40 mg iv ⦿ Again no urine output was noticed ⦿ Increased the dose of lasix ⦿ No urine output ⦿ Dialysis option was made on 04.06.2016
- 88. 3.30AM ……….04/06/2016 ⦿CT done at 3.30 am ⦿Partial lysis seen ⦿Again CT done at 4.30 am – lysis seen ⦿10 vials of ASV given – 4.30 am – 5.30 am ⦿After 6 hrs CT done – no lysis seen ⦿Total 24 vials of ASV given ⦿ 5.00 am - R jugular catheterisation was made ⦿5 hr SLED done
- 89. Parameter Day 1 Day 2 Hb 15.6 10.4 TC 16700 22300 Platelet 1,24,000 64000 35000 20000 Urea 38 64 37 S.Creat 2.55 3.84 B (T) 2.6 B(D) 0.28 SGOT 84 SGPT 38 Alb 4 2.6 Input - 2400ml Output - 425ml ⦿Parotid swelling ⦿Chemosis ⦿Oedema on the bite site
- 90. Paramete Day 1 Day 2 Day 3 r ⦿ ⦿ ⦿ ⦿ ⦿ ⦿ ⦿ Jaundice Generalised weakness Parotid swelling Chemosis P/A - soft distended Chest – Crepitus ++ T. Udiliv 300mg • 1-0-1 Hb 15.6 10.4 9.6 TC 16700 22300 17000 64000 Platelet 1,24,000 35000 42000 20000 Urea 38 64 77 37 S.Creat 2.55 3.84 4.16 B (T) 2.6 16.65 B(D) 0.28 10.41 SGOT 84 152 SGPT 38 61 Alb 4 2.6 2.6 Input - 2400 1950 Output - 425 ml 20 ml
- 91. Parameter Day 1 Day 2 Day 3 Day 10 Parotid swelling Chemosis Hb 15.6 10.4 9.6 9.2 TC 16700 22300 17000 16600 Pedal oedema Abdominal distension Hematuria Pleural effusuion Platelet 1,24,000 64000 35000 20000 42000 230000 Urea 38 64 37 77 73 S.Creat 2.55 3.84 4.16 5.20 B (T) 2.6 16.65 B(D) 0.28 10.41 SGOT 84 152 SGPT 38 61 Alb 4 2.6 2.6 2.6 Input - 2400 1950 1000 Output - 425 ml 20 ml 100 Proteinurea - - - ++
- 92. PARAMET ER DAY 1 DAY 2 DAY 3 DAY 10 DAY 13 DAY 15 Hb 15.6 10.4 9.6 9.2 8.5 8.9 TC 16700 22300 17000 16600 23600 12900 Platelet 1,24,000 64000 35000 20000 42000 230000 361000 397000 Urea 38 64 37 77 73 40 37 S.Creat 2.55 3.84 4.16 5.20 4.45 4.16 B (T) 2.6 16.65 2.52 1.90 B(D) 0.28 10.41 1.34 0.92 SGOT 84 152 15 18 SGPT 38 61 18 16 Alb 4 2.6 2.6 2.6 2.7 2.9 Input - 2400 1950 1000 1000 750 Output - 425 ml 20 ml 100 150 175 Proteinure a - - ++ +++ +++
- 93. ⦿ Condition worsened – 40% mortality • Parotid swelling • Chemosis • Abd distention, shifting dullness • Dyspnoea • Scrotal oedema • Echymosis on both hands • Pitting pedal oedema • Sleepy • Hypertensive – 200/100 mm hg
- 95. DIALYSIS • 7 SLED ( 4/6 - 11/6) • 5 dialysis without heparin ???? (12/6 – 16/6) • from 17th afternoon onwards NHD with heparin was used • Next day onwards oedema on all sites reduced • Symptoms of capillary leak syndrome were absent • Patient slowly recovering ⦿ Pedal oedema reduced ⦿ Chemosis R eye lat. Canthus ⦿ Parotid swelling considerably reduced ⦿ Recovered from drowsiness
- 96. ⦿Shifted to ward on 21.06.2016 ⦿Daily dialysis will be changed to alternate ⦿ NHD will continue till S.creatine becomes <3 ⦿ Continued with symptomatic management
- 97. ⦿ Persistent coagulation abnormality after 30 vials of ASV ⦿Possible Hump nosed pit viper bite (does not respond to ASV) ⦿Effectiveness of polyvalent ASV may be questionable in Sochurek‟s saw scaled viper (Rajasthan). ⦿Coagulation Abnormality can continue up to 3 weeks
- 98. 1. Prevention, Community Education & Pre-hospital Care – Low cost per capita interventions 2. Surveillance & Reporting, Clinical & Lab. Research – Informing debate & resource allocation and deploying technology 3. Education & Training, Improved Medical Management – Getting maximum value from therapeutic care 4. Immuno therapeutics – Establishing simple, cheap methods of diagnosis – Optimising ASV production, ensuring safety & efficacy 5. Rehabilitation from Disability – Repairing shattered lives, advocating basic human rights, restoring human dignity and independence
- 99. ⦿ TOXICITY STUDIES To find efficacy of the formulations mentioned under mandali visha prakarana in induced toxicity conditions to find out their hemo,nephro,hepato protective effects 1.Hemoprotective effect of Drakshadi Agada on Cyclophosphamide induced Hemotoxicity in female wistar rats-Dr K Sangeetha, Govt Ayurveda college Trivandrum. 2. Efficacy of Nimbapatra Agada in Cisplatin induced haemotoxicity ,nephrotoxicity and oxidative stress in male swiss albino rats- Dr Anjana M, VPSV Ayurveda College , Kottakkal
- 100. CLINICAL STUDIES ⦿Clinical study to evaluate the efficacy of sigru sireeshadi yogaas lepa along with lodraseethadi kashayapana in pit viper envenomation - Dr G S Sreekumar, Alva‟ s Ayurvedic medical college ,Moodbidgri ⦿A comparative clinical study on efficacy of kottamthgaradi yoga with sigrupunarnavadi yoga in Trimeresurus gramineus bite- Dr Sirosha M .VPSV Ayurveda college Kottakkal
- 101. ⦿Venom-induced blood disturbances by Palearctic viperid snakes, and their relative neutralization by antivenoms and enzyme-inhibitors-Frontiers in immunology ⦿ Transcriptomic and functional proteomics to unveil the common and unique pathways(s) of neuritogeneis induced by Russell‟s viper venom nerve growth factor in rat pheochromocytoma neuronal cells.
- 102. ⦿ Ashtangahridaya Uttarasthana ⦿ Ashtanagasangraha Uttarasthana ⦿ Charaka Chiktsa 23rd chapter ⦿ Susrutha Kalpasthana ⦿ Vishajyotsnika ⦿ Prayogasamuchayam ⦿ Kriyakoumudhi ⦿ A textbook of Agadatatra, Dr Sobha Bhat K, Page no 216-226 ⦿ Comphrehensive toxicology –VV Pillay 3rd edition ⦿ The essentials of Forensic medicine & Toxicology- Dr.K.S.Narayan Reddy , Dr.O.P.Murty 34th Edition, Page no 519-526
- 103. T H A N K Y O U “THE ART OF K NOWING IS KNOWING WHAT TO IGNORE “