MANDALI VISHA.pptx

Mandali visha is a type of visha that can be correlated with viper venom. Here are the ayurvedic and modern descriptions of the same.

1. A n u Mariam V a r ghese 2 nd MD Scholar Dept of Agadatantra G A V C , 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

3. ⦿ 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)

4. ⦿ 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.

5. MAN D ALI ⦿ Mandali from the Sanskrit mandala meaning circle ⦿ AH, Susrutha included as Bilesaya ⦿ Caraka as Bhumisaya VIPER Lat i n w o r d v i pe r a , - a e , me a n i ng ⦿ referring to the trait viviparity (giving live birth) ⦿ Named in honor of Patrik Russell vivus (“living”) parere (“to beget"),

6. ⦿ 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.

7. ⦿ 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. Co l o r – s w et a , k r ishna .. Visha la ksha n a – sop h a , b r ama .. ⦿ But the treatment and samanya lakshana are same for all.

8. ( വ ി ഷ ൅Фൃൃോത് സ ി ക - 6 / 1 മണ്ഡ ലി വ ി ഷ ച ി ക ിത് സ ) ( स . ु क . 4 / 34 )

9. ( പ്ര൅യൃോഗസമുച്ചയം - പ്രഥമരരി൅േദം മൂർഖൃോദി വിഭൃോഗം ) ( പ് ക ി യ ൃോൄക ൌ മ ു ദ ി - മണ്ഡല ി വ ി ഷപ്ര ക രണ ം )

10. ⦿ Russell‟s viper ⦿ Saw scaled viper ⦿ H u m p n o s e d pit v i per ⦿ Levantine viper ⦿ Bamboo pit viper ⦿ Mountain pit viper ⦿ H o rse s h o e Pi t Viper ⦿ J e r don ‟ s Pi t Viper ⦿ Puff adder

11. ⦿ Rus s e l l ‟ s Viper SN - Daboia russelii ⦿ S a w Sc a le d Viper SN – Echis carinatus ⦿ Hu m pnosed P i t Viper SN - Hypnale hypnale ⦿ P i t Vipers Subfamily - Crotalinae TAXONOMY Kingdom Phylum Subp h y lum Class Order Suborder Family Subfamily : Anima lia : Cho r d a ta : Vertebrata : Reptilia : Sq u am a ta : Se r pentes : Vipe r id ae : Vipe r in a e

12. ⦿ 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

13. Russell ’ s V iper Hu m p nosed P i t V iper S a w Scaled V iper P i t V iper

14. Mountain pit viper Le v a n t ine V iper Bam b o o Pit V iper Puff adder

15. Horseshoe Pit Viper Jerdon’s Pit Viper Malabar Rock Pit Viper Gaboo n V iper

16. 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

17. ⦿ 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 180 o and the fangs get erected ⦿ Discharge orifice is usually well above its tip.

18. Venom is white or yellow

19. ⦿ Venom –Induced Blood disturbances by paralearctic v i pe r id s n a k e s , and their r ela t i v e n e ut r al i zat i o n b y 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.

20. ⦿ Cause a g g r e v ation o f pi t ta do s a - पऩत् त ं मण ् डलऱ न श्च ा पऩ ( स ु . क 4 / 12 ) ⦿ Moves about in the remaining hours of night except for the last े या म े सऩााश ् श्चत्रा श्यरश ् न् ि हह श ष े े ष क् ू ि ा yama o f n i gh t . - रजन्या ऩश्श् च म मण ् डलऱ न ो .. ..... ( स ु . क 4 / 31 ) ⦿ Potent in old age –Su ,Ca, Mni - वद् ृ धा मण्डलऱनस्िथा ( स . क ु 4/32) mi d dle a g e as per AH , Vishaj y ot s n i ka िारुण् य मध् य व द् ृ ध त ् व े ⦿ Poison is amla (sour) and ushna( hot) P ↑ अम ् ऱोष ् ण ं . . ..

21. ⦿ ⦿ Theekshna Ushna ---- ---- Pitta ↑ Pitta ↑ ⦿ Rooksha ⦿ Visada ⦿ Vyavayi ⦿ Asukaram ⦿ Laghu ---- Pitta ↑ ⦿ Vikasi ⦿ Sookshmam ⦿ Avyaktha rasam(A.H)/annirdesya rasam(C.S) ⦿ Apaki

22. ⦿ 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.

23. ⦿ 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

24. ⦿ FATAL DOSE ⦿ Maximum yield in one bite 15 mg 130-250 mg ⦿ FATAL PERIOD 1 - 2 days

25. ऩीित्वं त्वगादीनां Yellowish discoloration of skin and other parts शीिालिऱाष Desires towards cold ऩर र ध ऩ ू नं Local burning sensation दाहं Burning sensation ि ष् ृ ण ा Excessive thirst मद Intoxication म र्च ू ्ा ा Fainting ज्वर fever श ो णणिागमन ऊर्ध व ा अधश्च Bleeding from upper and lower orifices मांसानांवशािनं Falling off of muscles श्वयथ ू Swelling

26. दंशकोथ Putrefaction of the site of bite ऩीिरूऩ दश नं Persons sees all things yellow आशक ु ोऩं Person becomes angry quickly पऩत्तवेदना Other symptoms of aggravation of pitta उष्मा Site has great heat locally सशोषं Site is dry ऩ थ ृ ु पव स ऩ ा दा ह ं Muscle becomes thick with visarpa (herpes) ऒष क् ऱ े द ं Like ulcer accompanied कोथैपवसशीयिे With burning sensation, heat, moistness(exudation),putrefaction and falls off ऩीििा Y ell o w i shne s s o f t h e f ac e , tee t h स्रम Fatigue भ्रमा Giddiness Other symptoms apart from above ,as mentioned in Ashtanga Sangraha

27. तिक्ि वक्त्रत्वं Bitter taste in the mouth ध म ू क ं Feeling of smoke coming from the stomach आ श ु स व ा ा ड ् ग पवस् र त ृ ि Accumulation and flow of fluids from the entire body

28. VEGA A.H/A.S SU P.S 1. Asrk dushtam Peethi bhavathi, peethan g atha, d a ha A.H Yellowish discolouration of body 2. Svayathudbhava: Mamsa dushti Athyartham peethatha, Paridaha Sopham Raktadhatudusti, P a l e n e s s, s h i v e r ing 3. Dam s a vikled a , S v ed a , Trishna Medodushti Swedam Chak s hug r ah a na m ,T r s na ,Damsakleda Mamsadhatudusti, Sleepy thirst r e s tless n e s s 4. Jvara Daha Reaches koshta Jvara Medodhatudusti, Body pain ,Sopha, Obstruction to words,Jvara VEGA LAKSHANAM

29. 5. Daha: sarvagathraga: Asthi dhatu P r an a gni 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 s a r v ache s htan i v a r tha nam Vyana dushti Uchwasa nirodham S a r v end r i y a r odh a , P r an av a y u lost

30. ⦿ Neeloshtam ⦿ Dantha saithilyam ⦿ Kesapatanam ⦿ Angabhanga vikshepam ⦿ Sisirai: na lomaharsham ⦿ Na abhihate danda rajee ⦿ No formation of contusions ⦿ Absence of bleeding from ulcers(Cha.chi 23/33 ) Cyanosis Loss of mucular and nervus functions

31. ⦿ 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

32. 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

33. Loc a l Local swelling Tender, enlarged lymph nodes Bleeding at bite site Local blistering and necrosis Neurological and muscle signs B il a te r al ptosi s, g ene r a l is ed 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

34. 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 ptosi s, e xte r nal ophthalm-oplegia and dysphagia

35. 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 idd i ness , syn c ope immediately following snake bite Profound thirst Loin pain

36. Re f : P r o g asamuc h a y am 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

37. 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)

38. ⦿ 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 . U RI NE ⦿ Haemeturia ⦿ Protenuria Haemoglobinuria Myoglbinuria

39. ⦿ Pulmonary edema ⦿ Intrapulmonary hemorrhages ⦿ Pleural effusion G. X-RAY OF BITTEN PART ⦿ Presence of embedded snake tooth or fang fragments H. IM M UNODI A GNO S IS ⦿ Venom antigens in body fluids can be accomplished by ELISA

40. ⦿ Atyayika Chikitsa ⦿ Samanya Chikitsa ⦿ Vegachikitsa ⦿ Dhatugata chikitsa ⦿ Doshagata chikitsa ⦿ Sthanagata chikitsa ⦿ Lakshanika chikitsa ⦿ Traditional chiktsa in visha granthas

41. ⦿ Arishta bandam ⦿ Achooshanam ⦿ Nishpeetanam ⦿ Chedanam ⦿ Agnikarmam ⦿ Application of ear wax with saliva on bite site

42. പ്രയയോഗസമുച്ചയം

43. Mentioned in Charaka Chikitsa 23 rd chapter Here 24 types of treatment modalities are described which should adopt in appropriate conditions .

44. VEGA A.H/A.S SU PS 1 Visravya sonitham A g ad a m+m adhu+sa r pi Rektha moksham Jaladhara, c h anda nap a na 2 Vamanam Agada panam Agadam+madhu+sarpi,Va manam,Yavagu, poorvoktham Siravedam, Chandanoshira lepa and nasya 3 Vamanam Peya Soda n a, T h e e k shna yavagu pana Ramacham+chandana m+I r attimadu r am+ T ag aram+Irippakkathal lepa 4 V am a nam Yavagu Same Thriphalapanam 5 Sprinkled and bathed in cold water V amana m , A g adapanam Same Siravedam Chandanap a na 6 Atheekshnam agadam Padmakadi agada Ka k o ly adi g an a , p e y a with madhura agada Nasyam &Pana- Punarnava 7 St r o n g a g ad a , nas y a , anj a n a, kakapadam Avapeeda nasyam, anj a na m , kakap adam Rooksha N a s y am , &anj a nam VEGA CHIKITSA

45. പ്രിയോകരൌമുദി

46. OOTHU CHIKITSA ⦿ 1. T W AK ⦿ 2. RAKT HA ⦿ 3. MAMSAM ⦿ 150 times moordha and two srotra ⦿ Drugs  v i s w a , du s pa r s a , ma r i c ha , vishavegam(garudakodi)

47. ⦿ 4 . ME D AS INTERNALLY + LEPANAM ⦿ 5 . A S THI ⦿ 6 . MA J J A NASYAM + ANJANAM ⦿ 7 . S U KR AM ⦿ Poison not eliminated from the body for years – use taila/ghee prepared from suitable medicine

48. പ ് ര യ യോഗസ മ ുച്ചയം , വിഷയ ോത്സിര

49. VA T A PIT T A 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 ka s h a y a , tikta , m a dhu r a a d ded wi th ghe e . - Vamana and lepana which is ushna, rookhsa, theekshna and food which is kashaya, katu a,tikta

50. VATA STHANA Swedam Nata kushta kalka panam with dadhi PITTA STHANAM D r ink ghe e , hon e y , mi l k, water A v a g ah a m, sek a m w i th cold water KAPHA STHANAM Kshara agada Sweda Siravedham Dooshi visha / rektha sthite Siravedham Panchakarma

51. 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

52. ⦿ 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

53. VISHAJYOTSNIKA ⦿ Mentioned Various oushada yogams ⦿ 7 Nasya yogams and 5 anjana yogams for visha supta ⦿ Mentioned Vishopadrava chikitsa in detail ⦿ Lepanayogams for vishaveekam

54. ⦿ Kottamthagaradi ⦿ Kizhiprayogam ⦿ Sidhayogams for vishaveekkam ⦿ Sigrpunanavadi ⦿ Dhara prayogangal ⦿ Thookkudhara ⦿ Lepaprayogangal- Nalpamaradi, Ekanayakamooladi, Karaskaravandakadi ⦿ Tailayogal – Durvarasadi, Brahmarasadi, Njottanjedungadi ,Paranthyadi ⦿ Ghritham- Ekanayakamooladi, Paktiprasoonadi ⦿ Dasapushpam

55. 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

56. KRIYAKOUMUDI ⦿ Vishavega chikitsa and dhatugata chikitsa ⦿ Chikitsa for each type of mandali mentioned. ⦿ Menti o ne d Rx f o r ty p e s seen in K e r al a li k e p a y y a n i mandal i , kuz h i mandali … ⦿ Lakshanika Rx for raktasravam, ⦿ Mandali samanya Rx- Lepana yogams, Pana yogam, Dhoopa y o g am s , An ja na Y o g am , Nas y a y o g ams ⦿ Yogams- Paranthyadi Tailam,Bramhmi ghritham, Sugandhadi agada….

57. ⦿ 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

58. ⦿ 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 🞄 Vi l w adi gulika

59. Vih a r am ⦿ 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

60. LO C A L S P ECIFIC SUPPORTIVE IN A NUT SHELL First Aid Patient assessment phase on hospital arrival Handling tourniquet Managing pain ASV Treatment of complications

61. ⦿ Do it “ R I G H T ” ⦿ Sutherland technique ⦿ St Jones technique 2. PATIENT ASSESSMENT PHASE ON ARRIVAL ⦿ A B C (Airway, Breathing and Circulation) ⦿ I f the r e i s e v i de n ce o f a b i t e , w he r e the s k in ha s bee n broken, give Tetanus toxoid. ⦿ Use of antibioti cs (if t he r e i s e vide n ce of c el l ul i tis or necrosis)

62. ⦿ 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 . MA N A GING P AIN ⦿ T hi s can b e t r eate d w i t h pa i n ki l l ers s u ch a s P a r ace tamol (Symptomatic management).

63. ⦿ 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

64. ⦿ 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

65. ⦿ 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

66. ⦿ 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

67. ⦿ 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

68. ⦿ 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

69. ⦿ Kidneys – inflammed and show tubular, cortical necrosis and interstital nephritis and marked congestion. ⦿ Subcapsular pinpoint hemorrhages ⦿ Regional lymph nodes swollen and hemorrhagic

70. 03/06/2016 ………7.00AM ⦿ Male patient 41yrs ⦿ While cleaning the surrounding ⦿ S n a k e bite in r t. f o r e 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

71. 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 ⦿ P atie n t w as co n scious, co h e r e n t a n d o r ie nted ⦿ No h/o abdominal pain ⦿ No passing of urine from morning ⦿ Diplopia ⦿ Vomiting

72. V I T ALS ⦿ 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 . sh i f ted to M I CU

73. DI A GNOSIS Unknown snake bite with envenomation Patient identified the snake as Russell‟s viper by seeing the pictures

74. ⦿ 10 vials of ASV in 100ml NS iv ⦿ Inj. Periset 400mg iv SOS ⦿ Inj. T r a m edo l 1 a m p in 100 m l NS ⦿ T . dol o 65 m g SOS ⦿ Limb elevated ⦿ Monitor urine output ⦿ Inj. Las ix 4 mg iv ⦿ Again no urine output was noticed ⦿ Increased the dose of lasix ⦿ No urine output ⦿ Dialysis option was made on 04.06.2016

75. 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

76. 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

77. Paramete Day 1 Day 2 Day 3 r ⦿ ⦿ ⦿ ⦿ ⦿ ⦿ ⦿ Jaundice Generalised weakness Parotid swelling Chemosis P/A - soft di s tended Chest – Crepitus ++ T . Udil i v 3 0mg 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

78. 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 - - - ++

79. 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 P r otein u re a - - ++ +++ +++

80. ⦿ Condition worsened – 40% mortality Parotid swelling Chemosis A b d di s tentio n , shifting dulln e ss Dyspnoea Scrotal oedema Echymosis on both hands Pitting pedal oedema Sleepy Hypertensive – 200/100 mm hg

81. DIALYSIS 7 SLED ( 4/6 - 11/6) 5 dialysis without heparin ???? (12/6 – 16/6) from 17 th 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 ⦿ Ch e mo sis R e y e lat. Ca n thus ⦿ Parotid swelling considerably reduced ⦿ Recovered from drowsiness

82. ⦿ 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

83. ⦿ 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

84. Prevention, Community Education & Pre-hospital Care Low cost per capita interventions Surveillance & Reporting, Clinical & Lab. Research Informing debate & resource allocation and deploying technology Education & Training, Improved Medical Management Getting maximum value from therapeutic care Immuno therapeutics Establishing simple, cheap methods of diagnosis Optimising ASV production, ensuring safety & efficacy Rehabilitation from Disability Repairing shattered lives, advocating basic human rights, restoring human dignity and independence

85. ⦿ 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 Hemoprotective effect of Drakshadi Agada on Cyclophosphamide induced Hemotoxicity in female wistar rats-Dr K Sangeetha, Govt Ayurveda college Trivandrum. Efficacy of Nimbapatra Agada in Cisplatin induced haemotoxicity ,nephrotoxicity and oxidative stress in male swiss albino rats- Dr Anjana M, VPSV Ayurveda College , Kottakkal

86. CLINICAL STUDIES ⦿ Clinical study to evaluate the efficacy of sigru sireeshadi yogaas lepa along with lodraseethadi kashayapana in pit v i per e n v e n omat i o n - Dr G S S r e e k u ma r , Al v a ‟ s A y u r v edic 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

87. ⦿ Venom-induced blood disturbances by Palearctic v i pe r id s n a k e s , and their r ela t i v e n e ut r al i zat i o n b y 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.

88. ⦿ Ashtangahridaya Uttarasthana ⦿ Ashtanagasangraha Uttarasthana ⦿ Charaka Chiktsa 23 rd chapter ⦿ Susrutha Kalpasthana ⦿ Vishajyotsnika ⦿ Prayogasamuchayam ⦿ Kriyakoumudhi ⦿ A textbook of Agadatatra, Dr Sobha Bhat K, Page no 216-226 ⦿ Comphrehensive toxicology –VV Pillay 3 rd edition ⦿ The essentials of Forensic medicine & Toxicology- Dr.K.S.Narayan Reddy , Dr.O.P.Murty 34 th Edition, Page no 519-526

89. T H A N K Y O U “THE A R T OF K N O WING IS KN O WING WH A T T O IGNORE “