Snake Bite: Approach to a case in Endemic region

Major (Dr) Ashutosh Ojha & Colonel (Dr) Sharat Johri

Snake has been an object of worship since time immemorial. It was probably due to fear
or respect. In Hindu mythology, Lord Vishnu is shown as lying over many headed Cobra
called Sheshnag and Lord Shiva has Cobra coiled round his neck. Old Egyptian nobilities
are shown with cobrahood around their forehead. Jews and Central Americans also have
their ways to remember these species. Even many medieval emblems have snakes as an
essential symbol.
Many cultures have an auspicious day especially reserved for worshipping
snakes. Nagpanchami is celebrated worshipping cobra. Almost in all continents there are
pockets where snake bites are accepted ,as a curse from some unholy spirit and people go
for spiritual cure rather than seeking urgent medical attention.

Epidemiology: There is very little reliable information on incidence of snake bites in

many parts of the world.
In India available published literature suggests yearly 15000 to 20000 of deaths
due to snake bites. This data is based on the death registered in the states where snake
bite cases are common. As per WHO bullentien, there are 5.6 to 12.6 deaths per 10000
populations in the endemic region. [ 1]
Snake bite cases cluster around the time, when there is heavy rains, floods,
deforestation, and sudden movement of large population due to any reason. Myanmar has
probably highest mortality figure in Asia due to snake bite. In India, Maharashtra records
the highest number of snake bites followed by West Bengal, Tamilnadu, Uttar Pradesh
and Kerela. In Maharashtra 70 bites per 100000 populations occurs yearly with 2.4 per
lakh mortality .[2] In Rajasthan, Marwar and Mewar region and Jammu region of Jammu
and Kashmir have large number of viper bite and have significant mortality.
Most case report during rains and floods, there is high evidence of cases in mobile
population such as troop bodies going for exercise, newly established camps of laborers
of border roads, paramilitary forces which camp in previously unoccupied buildings.
Mostly bites occur between midnight and 0400 hrs, usual site of bite is lower limb
probably due to inadvertent trodden snake. In India, more than 2/3rd of bites are due to
viper and 1/4th due to Russel viper and still smaller number due to kraits and cobra .
There have been a number of publications, suggesting haemotoxic viperine bites
far out number neurotoxic snake bites though almost all refer to local epidemiology.
However ,in coastal areas, sea snake bite is usually on upper limbs with severe local
manifestation in fisherman.
For correct epidemiology studies. ELISA (Enzyme Linked Immunosorbent
Assay) to identify antigen and antibody is required; this technique can have reliable
identification and sensitive quantification of venom antigen and antibody.
Natural antibody is detectable in serum by one week of bite, which rises and
peaks over in one year and remains detectable for as long as 3 yrs. A few studies are
under way but the reports will take time to guide us.
In India 216 species of snakes are reported, out of which 56 are reported
poisonous.
Identification of poisonous snakes
1) Fangs; It is most distinctive feature of poisonous snakes this is hollow and
grooved modified teeth in upper jaw in communication with salivary glands. In elapidae
(cobra & kraits) and sea snakes they are short & immobile, while in viperadae, they are
large, curved and have large range of movements.
2) Scales on Belly: In poisonous snakes, belly scales are large and extend across
the belly.
3) Head: Vipers have heavy triangular head with small scales all over, There may
be a pit, located between nostril and eye, in case of pit viper.In elapidae, there are large
head scales. In cobra, upper third labial is largest and touches the eye and nasal shield. In
kraits, lower 4th labial scale is largest. In poisonous sea snakes, there are large head scales
and valved nostrils.
4) Pupil: Poisonous snake have generally elliptical; and vertical slit
pupil.Although mostly killed snakes have smashed head. Still, if we can get one side
undeformed eye in killed snake, it can aid in identification.
5) Body design: Kraits have central row of almost hexagonal scales. It also has
white and black stripes, across the bodies. Some cobras have spectacle like mark on their
hood.
6) Fang marks on the victim’s body: In non poisonous snake bite, bite marks is
stretched with multiple indentation.

In poisonous snake bite easy identification of different snakes

Cobra- Hood may be present while alive, large scale on head, pupil is round ,upper 3rd
labial touches eye and nostril, large belly scales are across the width.
Krait -4th Lower labial in undersurface of mouth is largest, hexagonal scales in central
row on the belly, body may be banded.
Viper -Triangular heavy head with small scales all over, large belly scales extended
across the width.

Snake venom: brief chemistry

It is a complex mixture of enzymes, non enzymes peptide toxin and non toxin proteins,
including heavy metals. It is acidic as well as basic (pH-4.6 to 10). There are over 20
different types of enzymes viz. phospholipids A2, B, C, D, hydrolases, phosphatases
proteases, nucleotidases, ATPases, hyaluronidases and others. There are many species of
snake whose venoms is yet to be analyzed. Based upon the proportion of the toxins, the
venom is vasculotoxic neurotoxic or both. The molecular weight of venom varies from
1500 Dalton to 30 kilo Dalton. Light venom viz.of viper venom is easily absorbed in
blood and has more systemic effect while heavy venom viz. sea snake has more of local
effect. [4]
Constituents of venom
Enzymes :
Phospholipids A
Hyaluronidase
Exo-peptidases
L-amino-oxidases
Phosphatases
Exo-Nucleases
Acetyl choline esterases
Toxins: Nerve Growth Factor
Hemorrhagins
Neurotoxins
Cardiotoxin
Heavy metals: Lead
Mercury

A study done in Africa has shown that venom constituents vary with season, age of the
snake and periodicity of bite.
Lethal dose of venom
Cobra 120mg
Krait 60 mg
Viper saw scaled & Russell 150mg

Onset of pathophysiological effects takes place from 1 hr to 7 hrs.

Neurotoxic & local reaction precedes the coagulopathy.
Excreation: Venom is excreted by renal route.
Detection of venom & quantitative assessment of venom can be done by ELISA which is
mostly of academic interest
Pathophysiology of snakes envenomation
Local swelling: More common in viper and sea snakes, it starts within minutes and
massive swelling may take place in 48 – 72 hrs, mostly hemorrhagins and hydrolases
open endothelial pores resulting in leakage of plasma and whole blood. It may lead to
hypovolomic shock, compartment syndrome and its consequent long term sequaelae.
Local necrosis: Due to cytolytic enzymes present in venom, local necrosis of tissue
takes place. In cobra bite, necrosis appears early. It is associated with local swelling,
mimics wet gangrene
Early non specific symptoms: Vomiting, diarrhea, headache, abdominal pain may
occur. Some patients collapse. These symptoms are possibly kinin mediated and resolve
after an hour by activation of bradykinin system. In viper bite, the local necrosis occurs
late in due to ischemia around 2 to 3 weeks later and is like dry gangrene [9].
 Shock: It may occur due to anaphylaxis with the venom. It may take place due to
extensive volume leak from vessels in case of viper bite.
Pulmonary intravascular clotting, pulmonary edema and cardiac depression may be a
contributory factor.
Spontaneous Heamorhage: It is common amongst viper bite even days after the bite. It
may occur from any of the orifice viz. Epistaxsis, haematemesis, haemoptysis,
haematuria, malaena, haematochesia and even heavy periods.There may be some life
threatening complication such an intracranial hemorrhage. It can take place despite giving
adequate doses of ASV and may take place after as late as 3 weeks.
Effects on circulation: There is leukocytosis of polymorphonuclear type. In some
viperine bites, these is pocoagulant state due to activation of prothrombin to thrombin
and fibrinogen to fibrin. It must be understood that bleeding in viperine bite does not take
place due to coagulation dysturbance but due to haemorrhogins present in venom. In sea
snakes as well, the hemorrhagic manifestations are quite common [9]
Renal failure; Renal failure is common complication of viper bite. It is fairly common
common and due to varied renal pathology, It is most commonly implicated cause of
death[6]. It can take place within 6 hr of bite to as late as 4 to 5 years as chronic
glomerulonephritis, as per a report, the pathology demonstrated are as follows
microscopic.
Microscopic Pathology Percentage Onset
a) Acute Tubular 50- 70% 6 hrs to 72 hrs
Necrosis
b) Acute cortical 20-25% 12 to 72hrs
necrosis

Mesengsal proliferation and basement membrane thickening leading to nephrotic

syndrome and late renal failure are reported frequently in different case reports.
Chronic glomernlonephritis and delayed renal failure is reported in viper and sea snakes.
Renal complications are probably due to shock, myoglobinaemia, haemoglobinuria
haemolysis, sepsis and disseminated intravascular coagulopathy. Many authors have
suspected hypersensitivity to venom as a cuse to renal failure [5].
Neurotoxic effects: Elapidae(Cobra & Krait)and sea snake venom cause neurotoxic
effect due to nemomuscualar blockade commonly affected muscle groups are of eye,
tongue, throat, chest (respiratory muscle leading to respiratory paralyses).Neurotoxins are
small molecular weight compounds which are excretable through kidneys. They have less
antigenicity. Cobra toxin causes N.M. - blockade of postsynaptic type without decrease
of acetylcholine and responds well to Inj Neostigmine.Krait venom has neurotoxicity of
presynaptic type. It remains sensitive to Acetyl choline hence response to Inj
Neostigmine is less satisfactory.Besides acute, life threatening respiratory paralysis,
venom also causes sensory motor type of polyneuropathy, as delayed complication. It
rarely causes altered sensorium. Hence, if a snake bite case has alterred sensonium, an
alternative cause should be looked for.

Cardio toxic Effect: - Cobra venom is known to cause paralysis of cardiac muscle
causing asystole. Hyperkalaemia after massive haemolysis causes depressed cardiac
function.
Mytoxic effect: Sea snakes are known to cause myotoxic effect, cause rhabdomyolysis
and hyperkalaemia causing threat to life.

Clinical features: Snakes are timid creatures .The bite is usually defensive rather
offensive. Hence, usually, the patient is male of young age group, mobile, probably has
performed manual labor involving cultivation or any economic activity in which he has
caused displacement of habitat of snakes. Mostly site of bite is in lower limb. It may be
any part of body in contact with floor. However, sea snakes bite on the hands of the
fishermen.

Patient is usually in terror which may cause nausea, vomiting, dizziness diarrhea
syncope, tachycacardia, cold calm skin, sweating, numbness and difficulty in swallowing
and respiration.The hyper activity of autonomic nervous system maybe a manifestation of
envenomation . There is local pain at the site of bite, which is followed by swelling
cellulitis , ecchymosis, edema and lymphangitis.

Haemotoxic syndrome: Local pain, progressive swelling, bruising ,lymphangitis

bleeding from the wound are the usual manifestation. Patient may have blistering
,necrosis over the next few days. He may have compartment syndrome leading to neuro-
vascular compromise.

Earliest & almost diagnostic symptoms of haemotoxic syndrome are haemorrhagic blebs
with uncontrolled bleeding from the site. Epistaxis haematemesis, ecchymosis
haemoptysis, subconjuctival, retroperitoneal & intracranial bleeding is frequently seen.
Large echymosis, purpura, gangrene of lips, toes and fingers are also frequently seen.
Massive extravasations of intravascular fluid may lead to hypotension,
tachycardia, tachyopnoea, respiratory distress and shock. Renal failure may result from
hypotension and direct nephrotoxic effect of snake venom.

Direct myocardial depression is noted as reduced inotropic function. Electrocardiography

changes such as ST/T depression and elevation ,1st or 2nd degree heart blocks and
hyperkaleamia is frequently seen in complicated cases. Involvement of anterior pituitary
leading to Sheehan’s syndromes is reported.

Neurotoxic Syndrome: Elapid venom is more neurotoxic, symptoms may appear within
20 minutes of bite & may be as delayed as 24 hours. In acute stage, cranial nerve
involvement, respiratory muscle involvment takes place. Delayed complication such as
sensorymotor neuropathy is seen.

Investigation
In haemotoxic syndrome-Hemoglobin may rise due to extravasations of plasma
thereafter anaemia due to bleeding and heamolysis.Polymorphonuclear type of
leukocytosis associated with thrombocytopenia is common. Peripheral blood smear
shows broken RBC. Clotting time is often prolonged. It is performed as bedside test
showing severity of envenomation and response to therapy . Rhabdomyolysis is
associated with rise in creatinine kinase, myoglobins, potassium and transaminases.
Blood urea and serum creatinine may rise.
Plasma may be pink suggestive of gross haemoglobinaemia. Arterial blood gases, though
not done routinely, but may show low bicarbonate level, showing associated metabolic
acidosis. Urine is examined for RBCs, hemoglobin, myoglobin and proteins.

ECG is done to look for tachycardia - bradycradia, ST/T changes, AV-blocks, and
hyperkalaemia. Chest X-Ray is done to look for pulmonary oedema. Clotting time,
Hemoglobin and urine microscopy is done frequently for therapeutic assessment.. It is
learnt from experience that clotting time on day one should be done 4 hrly, next day 6
hrly and then after 12 hrly.

Commercial kits for detection of specific snake venom are available, but are costly.
ELISA and Radio immune assay can be done but are impractical in our setting.

Though for epidemiological purpose, some studies are underway .

MANAGEMENT OF SNAKE BITE

First aid

After a bite from any reptile, the patient should be immediately removed from the
striking distance to avoid repeated bite. Handling of a live snake for the sake of
identification should be avoided. Patient should be reassured to treat fight reaction. The
site of bite should be wiped, cleaned with water and antiseptic without much handling of
the part. Wound should not be incised, excised & sucked and manipulated as it may aid in
absorption of venom, introduce infection and damage tissue muscle nerve and vessel.
Immobilized the injured part in functional position. Tourniquets may be applied loosely,
as these prevent early absorption of venom. It should be removed after giving the initial
dose of ASV at the medical centre.

TRANSFER TO NEAREST MEDICAL CENTRE.

Patient should be transferred to a medical centre in outmost comfort without frequent,

undue handling. Patient should not be allowed to move unnecessarily as muscle
contraction causes absorption of venom early. During transit, hypovolumic shock should
be looked for and enough IV fluid should be infused enroute. Syncope and other
autonomic symptoms should be treated with 0.5ml of Inj Adrenallin 1:1000 injections
with an antihistaminic viz. Chlophenaramin and Promethazin. Clean airway and proper
ventilation, enroute helps in early recovery.

AT MEDICAL CENTRE

A large number of bites are dry bite. The patients must be reassured .Quick clinical
assessment and early institution of Antisnake venom is the mainstay of the therapy.All
the patient of unknown bite must be admitted and observed as on following lines.

(1) Pulse, BP and Respiratory rate.

(2) Size, surface & circumference of local swelling.

 (3) Abnormal bleeding from the site of bite, mucosal membranes viz
subconjunctival, mucosal surface & injection site.

(4) Base line investigation as advised above.

(5) Naked eye examination of urine.

(6) Single breath count, pulses, pharyngeal muscle function assessment.

Snake bite severity score to evaluate haemotoxic envenomation as suggested by Dart

and Hurlburt is basically for African snakes. It is time consuming and is grossly
laboratory dependent.

Antisnake Venom (ASV) : It is only specific antidote available for envenomation.

Though it is often reported to have sides effects as anaphylaxis, but benefits of ASV
far outweigh the risk. It can be given anytime when signs of envenomation come up.
In neurotoxic bite cases has been proved beneficial unto 2 days while in haemotoxic it
can be given even three weeks after viperine bite.

Availability- From Haffkine Biopharmaceuticals and Serum institute is available

usually at 10 ml vial. It is available in Lyophilized form requiring reconstitution. It
has potency of 5 years.

Reconstitution: This dry powder requires dissolving in distil water or normal saline.
This should be dissolved by side to side shaking and rolling on a hard surface. During
vigorous shaking, it may form froth in which ASV powder may get trapped and
patient may be given a low potency drug as ASV is trapped in froth, which is left in
the bottle.

Indication of ASV

As ASV carries risk of adverse reaction, it should be started when specifically

indicated commonly accepted indication are follows.

• Haemostatic abnormalities a high coagulation time, rising CT,

Thromlaocytopenia, overt bleeding.

• Neurotoxicity -Ptosis: Pharyngeal muscle weakness respiratoy muscle

involvement.

• Hypotension, shock, clinical and radiological evidence of CVS dysfunction.

• Acute Renal failure, rising urea, creatinine

• Rhabdomyolysis

• Lab investigations viz. EISA/RIA positivity

 • Indication of ASV (Contd)

• In suspected cases of snake bite

• Rapidly progressive, local swelling with enlayed tender lymphnodes in endemic

region.

The above indication may be seen exhaustive but not complete. Bhatt et al have used
ASV in unconscious patients brought to causality with statistically significant
recovery, proving hypothesis of painless krait bite in Jammu region.

Sensitivity testing: It is done by 0.1 ml of reconstituted ASV injected intradermal

and local instillation of diluted ASV in conjunctival sac. Sensitivity testing does not
reliably exclude the possibility of early or late reaction. But in severe sensitivity
reaction, ASV therapy should be given slowly and under cover of steroid and
antihistamine drugs.

Dose of ASV

Dose varies, usually published articles have suggested doses of ASV to start with
.The total requirement of ASV, depends upon amount of venom instilled in bite, age
of snake and species of the snake bitten. It may vary anything between 100ml to 1500
ml as reported in case reports.However to start with the dose is to be considered as
follows.

(a) Progressive local swelling – 50ml

(b) Mild to Moderate – 100 – 150ml

(c) Severe - 150- 200ml

Published studies on dose and protocol

YEAR STUDY PROTOCOL AVERAGE ASV REQD.

1974 BHATT (JAMMU) INTERMITTENT BOLUS 80-270 ML

1985 THOMAS & JACOB (KERALA) CONTINUOUS INFUSION 160ML

1999 TARIANG (VELLORE) CONTINUOUS IV. INFUSION 47-89ML

2000 VIJETH (PONDICHERY) INTERMITTENT BOLUS 179.2ML

2004 SRIMANNARAYAN CONTINUOUS IV 179ML

It is noted that continuous infusion is safer, requirement of ASV is lower and can be
monitored more effectively. ASV starts neutralizing the venom immediately and takes
care of all circulating venom in 3-4 hrs, but the systemic envenomation may recur hours
or days after an initial response. Hence, it is advisable to give last dose of ASV 24 hrs
after normalization to prevent recurrence.

Indesprate situations, where IV access in not there, it can be given intramuscular. This
route has multiple disadvantages such as erratic absorption, multiple injection and large
doses of ASV is required and risk of haematoma formation. It is worth mention that
pediatric cases are given in same doses ASV as adult. There is a case report of chronic
osteomylitis following administration of ASV intraosseous.

Our Experience

We are presently posted to two large army hospitals around Jammu region ,have managed
more than 60 cases of poisonous snake bite, 27 cases were having neurotoxic variety
brought to hospital in respiratory paralysis state. They were having bite marks without
much of local reaction, we believe that mostly were of krait bite. They required
mechanical ventilation for average 18 hrs. Average ASV requirement in our cases was
240ml. None of the case was exhibited with Inj Neostigmine and Atropine.32 cases were
having essentially haemotoxic type of presentation, the average ASV requirement was
370 ml over 3 days of ASV therapy.

One case had both neurotoxic and haemotoxic both types of derangements. The total
ASV given was 250 ml over 4 days.

Supportive care

Hydration: All the cases were given liberal IV infusing, normal saline was given at @
150ml/hr and renal output was maintained at 50 ml / hr. After adequate urine output is
noted potassium containing fluids may be started.

NEUROTOXIC ENVENOMATION

A clear airway is must during transport from accident site. If respiratory distress occurs,
immediately endotracheal entubation and mechanical ventilation be provided. In our
experience, most of the victims have been young average age – 36 yrs, required
ventilatory support on average for 20 hrs. There are reports that patients required
ventilator support for as long as 3 weeks. Incases of cobra bite, Inj Neostigmine
0.5mg along with inj Atropine 0.6 mg IV every half hour for five doses and then after
4 hrly till full recovery is seen should be given. In cases of cobra bite, usually there
are local reaction along with neuroparalytic effect while in Kraits usually ,there is no
local reaction . It may be a clinical clue for the use Inj Neostigmin . Cobra bite is
more common in western region and north east.
GASTO INTESTINAL PROTECTION

Snake bite patients are in inflammatory and in catabolic state. They require early
alimentation as it protects gastric mucosa. Ryle’s tube feeding in entubated patients
should be given with high calorie liquid meals. Soft bland frequent diets should be
provided to the patients who can take orally. Inj Ranitidine should be given to all
envenomated patients. Stress ulcers due to hypotension, hyperacidity due to steroid
can be prevented.

Renal protection: Frequent urine examination and urine output hourly monitoring
can detect early renal dysfunction. Fluid, Inj Frusemide; Inj Dopamine should be
given as acute renal dysfunction noted. Usually accepted indications for
haemodialysis and peritoneal dialysis hold good for snake bite cases. In viperine
bites, the renal dys function is more common, heparin free dialysis is advocated by
some as bleeding is common complication .

In our series, 04 cases had renal dysfunction, which required management by

nephrologists. Three cases responded to conservative management with intravenous
fluid, Inj Dopamine & Inj Furosemide ,one case required haemodialysis and also
progressed to chronic renal failure over one year, renal biopsy showed
chronicglomerulonephritis.

Treatment of local complications

Snake saliva is a rich source of both aerobic and anaerobic organism; hence broad
spectrum antibiotics covering Gram positive, negative and anaerobic organism were
given to all our patients. Inj Cefotoxime, Amikacin & Metronidazol were given to the
all patients. Dose modification of antibiotics was done as per creatinine clearance.

Local necrosis, compartmental syndrome and local infection at bite site should be
managed surgically. In our series, 02 cases had local necrosis, dibribement was done
which progressed to non healing ulcer and plastic surgery was done after 6 months. In
case of spat of venom in eyes, it should be irrigated thoroughly with water, topical
instillation of Atropine, and antibiotics is advisable. Myoglobinuria and
haemoglobinuria require correction of hypovolumia, acidosis and mannitol infusion.

Ovine and avian antivenoms are undertrial. Anti snake vaccine also is in experimental
stage.

Conclusion;

Snake bite is commonly encountered medical emergency in our clinical practice. It is

often incompletely treated. Ancillary management is not done properly. Hence, there
is often poor outcome . In our experience, ancillary management along with ASV
therapy improves the outcome.
 Profile of snake bite cases in our series

Total : 60 cases

Haemotoxic – 32

Neurotoxic without local reaction – 27

Both manifestation – 01

Age Min.-13 years Average 34 years

Max- 56 year

Gender Male 51

Female 09

Hospital Stay Min. 6 days

Max 28 days Average 12 days

Average Total Venom Required -240ml in Neurotoxic cases

-370ml in Haemotoxic cases

Average requirement of ventilator Support- 20 hours

Complications

Local

Necrosis – 02 patients

Severe Oedema with compartmentSyndrome : 04

Systemic

Renal dysfunction: 04[Conservative therapy – 03; Heamodialysis: 01 with progress to

chronic glomerular disease.]
References

1. Chapeaux J.P. snake bites: appraisal of global situation,Bull WHO 1998; 76(5);
515-524.

2. Gaitonde BB, Bhattacharya S. An epidemiological survey of snake bite cases in

India ;Snake 1980; 12; 129-33

3. Bhatt R.N. Viperine snake bite poisoning in Jammu – J. India Medical

Association 1974; 63; 383-392.

4. Anurbach P.S.,Norris R.L. Disorder caused by reptile bite, In Harrison’s

principles of Internal Medicine – Eds Kasper, Braunwald Fauci, Hauser, Longo,
Jameson 16th Ed. Mc Grow Hills New York 2005, 2593-94

5. Sakhuja V, Chugh K.S., Editorial, J. Assoc Physicians India 1989;37;423-24

6. Merchant MR, Khanna UB, Almedia AF, Acharya V.N., Mittal

BV:Clinicopathological study of acute renal failure after viperine bite

7. Kalra SP, Verma P.P, Chatterjee RS. Experience with viperine envenomation
MJAFI; 1998 54:204-207.

8. Swaminarayan J; Dutta T.K., Sahai A; Rational use of Anti snake venom; Trail of
various resinous in haenotoxic snake envenomtion;J.Ass. Physician India
2004;52;788-793.

9 .Mehta S.R;hashindra V.K. chemical features and management of snake bite,

MJAFI; 2002 & 58; 247-249.

10. Virmavi S.K. Dutt O.P. Snake bites in Jammu region :J. India Med Assoc 1987; 85;
132-135.
 Brief biodata of authors

Major (Dr) Ashutosh Ojha

MBBS,MD(Medicine)

Presently working as Medical Specialist in Indian Army near Jammu

Interests – Tropical Medicine,

Diabetic Autonomic Neuropathy,

High Altitude Medical Problems(,Dyslipidemia& Hypertension)

Publication s- Pancreatitis; physician perspective-Apr2006

Probiotics in clinical practice-Apr 2006

Drowning –API Textbook of Medicine (Co Author) submitted for 7 th edition

Colonel (Dr) Sharat Johri

MBBS,MD(Medicine),DM(Neurology)

Presently senior adviser in medicine and neurology near Jammu

Previously Professor of Medicine &Neurology AFMC, PUNE

Special interest- Stroke in Young

Tropical Medicine

High altitude medical problems

Address for communication –

Major (DR) Ashutosh Ojha Colonel (Dr) Sharat Johri

Graded specialist in medicine Senior Advier (Med & Neurology)

170 Military Hospital command Hospital (NC)

PIN-930170 C/O 56 APO

C/O 56 APO

Mobile-09419210649

Note- Due to operational reasons, the exact location of hospitals and other asked for
details cannot be provided. Since it is accepted in cases of service doctors, we
request you to kindly accept for publication.
 170 Military Hospital

C/O 56 APO

May 2007

To

Hon. Editor,
Journal of Association of Physicians of India,
Turf Estate, #6 & 7, Ground Floor,
Opp. Shakti Mills Compound,
Dr. E. Moses Road, Opp. Mahalaxmi Station (West),
Mumbai 400 011.
Tel. : (022) 66663224, 24912218
Tel./Fax : 2492 0263

Sub – submission of article

Sir,

We wish to submit the article “Snakebite – Approach to a case in endemic

area” for publication.

Copyright statement

We herby submit the copyright of the article to JAPI as preexisting

guidelines.

Further we state to confirm that we have read and approved the contents
and also confirm that the manuscript is not submitted or published
elsewhere.

We confirm that we have Ethics Committee Approval of our hospital and

informed consent from subjects

Colonel (Dr) Sharat Johri Maj (Dr) Ashutosh ojha

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Report, GP Forum and Current Topics: Maximum 2000-2200 words, 2-3 figures, and/or
2-4 tables, for Case Notes: Maximum 800 words, 2 figures, 1 table, for Letter to the
Editor: 300-500 words.

Tables— Tables should be simple, self-explanatory and should supplement and not
duplicate the information given in the text.
Illustrations— Graphs, charts, diagrams or pen drawings must be drawn by professional
hands in Indian ink (black) on white drawing paper. In case of x-ray, miniature
photoprints should be supplied. Photographs should be supplied in high quality glossy
paper not larger than 203 mm x 254 mm (8"x 10"). In case of microphotograph, stains
used and magnification should be mentioned. Each illustration should bear on its back the
figure number and an arrow indicating the top. All illustrations should be black and white
and should be submitted in triplicate with suitable legends.
References— References should be numbered in the order in which they are first
mentioned in the text. The full list of references at the end of the communication should
be arranged in the order mentioned below (names and initials of all authors and/or editors
up to 6; if more than 6, list the first 6 followed by et al):
Reference from journal :
1Cogo A, Lensing AWA, Koopman MMW, Piovella F, Sivagusa S, Wells PS, et al —
Compression ultrasonography for diagnostic management of patients with clinically
suspected deep vein thrombosis: prospective cohort study. BMJ 1998; 316: 17-20.
Reference from book :
2Handin RI— Bleeding and thrombosis. In: Wilson JD, Braunwald E, Isselbacher KJ,
Petersdorf RG, Martin JB, Fauci AS, et al editors—Harrison's Principles of Internal
Medicine. Vol 1. 12th ed. New York: Mc Graw Hill Inc, 1991: 348-53.
Reference from electronic media :
3National Statistics Online—Trends in suicide by method in England and Wales, 1979-
2001. www.statistics.gov.uk/downloads/theme_health/HSQ 20.pdf (accessed Jan 24,
2005): 7-18.
Only verified references against the original documents should be cited. Authors are
responsible for the accuracy and completeness of their references and for correct text
citation. The number of reference should be kept limited to 20 in case of major
communications and 10 for short communications.
Dual publication : If material in a submitted article has been published previously or is
to appear in part or whole in another publication, the Editor must be informed.
Forwarding letter : The covering letter accompanying the article should contain the name
and complete postal address of one author as correspondent and must be signed by all
authors. The correspondent author should notify change of address, if any, in time.
Declaration : A declaration should be submitted stating that the manuscript represents
valid work and that neither this manuscript nor one with substantially similar content
under the present authorship has been published or is being considered for publication
elsewhere and the authorship of this article will not be contested by any one whose name
(s) is/are not listed here, and that the order of authorship as placed in the manuscript is
final and accepted by the co-authors. Declarations should be signed by all the authors in
the order in which they are mentioned in the original manuscript.
Matters appearing in the Journal are covered by copyright but no objection will be made
to their reproduction provided permission is obtained from the Editor prior to publication
and due acknowledgment of the source is made..

1 International Committee of Medical Journal Editors—Uniform Requirements for

Manuscripts Submitted to Biomedical Journals. JAMA 1997; 277: 927-34.

- Hony. Editor
JIMA, 53, Creek Row, Calcutta 700014,
Fax : (033) 2236-6437, E-mail l : jima@cal2.vsnl.net.in
Maj Ashutosh Ojha
Graded specialist (Med) 170 Mil Hosp C/O 56APO
(On MOJCC-153,AFMC,Pune)

To
Commanding officer
170 Mil Hosp
C/O 56 APO
Sub- request permission for submission of article

Sir ,
1. I wish to submit my article titled “Snakebite –Approach to a case in Endemic area” co-
authered by senior adviser comprising of our experience in this area for publication to
Journal of Association of Physicians of India. Being a common medical emergency
encountered in medical practice, our experience will be beneficial to other colleagues
managing this emergency medical condition.
2. I further state that the article does contain any classified information and I am not
claiming any financial benefit from this publication.
3. I request you to kindly grant me your permission to publish this article.

Date May 2007 (Maj Ashutosh Ojha)