Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
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Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case Series
Year : 2023 | Month : November | Volume : 17 | Issue : 11 | Page : OR01 - OR04 Full Version

Clinical Evaluation of Patients with Krait Bites in the Emergency Department: A Series of Three Cases

Published: November 1, 2023 | DOI:
Saurabh Jha, Rajiv Ratan Singh, Shiv Shanker Tripathi, Sachin Kumar Tripathi, Pradeep Kumar Yadav

1. Junior Resident, Department of Emergency Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 2. Professor Junior Grade, Department of Emergency Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 3. Professor (Jr), Department of Emergency Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 4. Research Scholer, Department of Forensic Medicine, Dr. Ram manohar Lohia Insitute of Medical Science, Lucknow, Uttar Pradesh, India. 5. Assistant Professor, Department of Forensic Medicine, Dr. Ram manohar Lohia Insitute of Medical Science, Lucknow, Uttar Pradesh, India.

Correspondence Address :
Dr. Pradeep Kumar Yadav,
Assistant Professor, Department of Forensic Medicine and Toxicology, Dr. Ram Manohar Lohia Insitute of Medical Sciences, Lucknow-226010, Uttar Pradesh, India.


Envenomation from snakebites continues to be a severe public health issue in many parts of the world, particularly in tropical and subtropical regions. The complex range of envenomation symptoms necessitates ongoing innovative approaches for the effective treatment of snakebite victims, especially those resulting from krait species. The present case series provides a comprehensive clinical assessment of krait bite patients ( three male patients) in the Emergency Department (ED), emphasising the distinct clinical implications, cutting-edge perspectives, and critical requirements for reporting such occurrences. To identify both shared traits and unique attributes among the cases, authors analysed clinical records, laboratory data, treatment methods, and outcomes. Within the case series, three patients exhibited diverse envenomation symptoms. Notably, discrepancies were observed in the timing and severity of conventional neurotoxic indicators. Additionally, some individuals showed unusual coagulopathic symptoms, which posed challenges in diagnosis and treatment decisions. It is noteworthy that one patient demonstrated resistance to traditional antivenom therapy, raising the possibility of the need for individualised treatment plans. The wide range of clinical manifestations emphasises the importance of individualised care strategies and thorough surveillance. By illustrating the diverse clinical course of krait envenomation and the challenges it presents to healthcare professionals, present case series contributes to the current body of knowledge. The need for reporting and further research is particularly urgent, given the emergence of antivenom resistance. Reporting such occurrences becomes crucial in establishing global treatment recommendations and enhancing scientific understanding in the field as snakebite management tactics continue to evolve.


Clinical assessment, Elapidae, Emergency medical services, Envenomation, Neurotoxicity, Snakebites

Snakes, being cold-blooded vertebrates, cannot regulate their body temperature and become active in cold conditions (1). Snakebites are a severe public health concern, causing numerous deaths in India annually. According to the World Health Organisation (WHO), upto 2.7 million envenomations are caused by an estimated 5 million snakebites each year. According to WHO reported data, there are 81,000 to 138,000 fatalities annually [2,3]. Venomous snakebites can result in a wide range of symptoms, from mild to life-threatening (3). The onset of neurotoxic symptoms can be rapid and subtle, and respiratory failure is a major concern. Prompt diagnosis depends on history, examination, and laboratory tests (4).

Krait snakebites can lead to descending paralysis due to venom-containing β-bungarotoxins. Local symptoms are usually minor, and fang marks may or may not be visible (5). In the ED, admission and antivenom therapy are crucial, while carefully monitoring for allergic reactions (6). Maintaining the patient in intensive care is advised until major symptoms subside. In managing krait snakebites, the patient should rest, be kept warm, and movements minimised (7). Neurotoxic symptoms should be regularly checked, and respiratory support provided if necessary. Fluid balance is important for hydration. Oropharyngeal paralysis or swallowing issues should prompt withholding oral intake and positioning the patient on their side with the head down (8). Morphine and alcohol are avoided due to potential respiratory suppression. In cases of circulatory shock unresponsive to antivenom, plasma volume expanders and vasopressor agents may be considered (9). Tetanus prophylaxis should be upto-date, and prophylactic antibiotics are not recommended. Special considerations may arise in cases of multiple bites or severe envenomation.

The main treatment for krait envenomation is antivenom therapy (10). The patient’s condition must be continuously monitored, and additional antivenom administered if needed. Patients are often kept in intensive care for 24 hours after significant symptom improvement. These actions can significantly enhance patient outcomes (11). The specific antivenom used is a polyvalent formulation containing antitoxin against the four most poisonous snakes in India: standard cobra venom (Naja naja), standard common krait venom (Bangarus caeruleus), standard Russell’s viper venom (Viperarusselli), and snake venom antiserum (polyvalent) (12). Each vial contains specific amounts of these venoms. The antivenom is vital in neutralising the snake’s venom and alleviating symptoms (13).

This research work offers fresh insights into the clinical range and dynamic nature of krait envenomation, in addition to literature findings. Due to the heterogeneity in symptom presentation, treatment response, and long-term results, ongoing monitoring and research are required. The discovery of treatment-resistant cases underscores the importance of sharing such experiences. They could indicate changes in venom composition, organism physiology, immune resistance, environmental shifts, treatment effectiveness, and recent advancements in treatment. Collaborative analysis can drive innovative solutions for better outcomes.

Case 1

A 12-year-old male child who had recently experienced a double krait snake bite on the right-side of his neck while playing in the garden during the evening, was presented to the ED. The patient was having fun in the garden when he suddenly began to experience severe neck discomfort. He informed his parents immediately, and they rushed him to the hospital. According to the youngster, the snake was long, thin, and light-coloured, with dark bands on its body. Since the incident, he has struggled with swallowing, slight disorientation, growing discomfort at the bite site, and generalised weakness. The patient had no noteworthy prior dental or medical history. He had no known sensitivities or previous snakebite injuries.

The youngster showed ecchymosis and oedema at the bite site on the right-side of the neck, and he appeared apprehensive during the examination. There were two definite fang markings about a centimeter apart. When the patient’s neck was palpated, it was sensitive. He had a normal oxygen saturation of 98% and respiratory rate, but he also exhibited tachycardia (heart rate of 110 beats per minute). According to a neurological assessment, upper and lower limb motor and sensory functions were both intact. A neck X-ray was taken to determine the location and depth of the fang markings. The X-ray showed no signs of bone damage or foreign objects.

Point-of-care ultrasound showed diaphragmatic paralysis on day one, two, three and four (Table/Fig 1). The Magnetic Resonance Imaging (MRI) confirmed the suspicion of hypoxemic encephalopathy.

Probable diagnosis: The provisional diagnosis of venomous snakebite by a krait species (Bungarus spp.) was made based on the history, clinical examination, and presentation of a krait snake bite with neurotoxic symptoms. The patient was intensively monitored in the critical care unit. Vital signs, respiratory health, and neurological state were routinely checked. Laboratory tests, including complete blood count and coagulation profile, were carried out to check for any systemic effects of envenomation.

Ten vials of Antisnake Venom (ASV) were given immediately after receiving the patient in the ED. The patient was intubated on the night of day one. The patient’s Glasgow Coma Scale (GCS) score was (E1V1M1) at the time of intubation. After intubation, the patient was kept on mechanical ventilation. Neostigmine and atropine were administered for 24 hours. Calcium gluconate was administered for six hours. Supportive care treatment with a focus on maintaining vital functions, monitoring neurological status, and managing complications was given for the next 2-6 days. An additional 10 vials of ASV were given on the 2nd day. On the 5th day of treatment, diaphragmatic paralysis was recovered (Table/Fig 2). The patient’s GCS score improved (E3VtM6) on the 6th day. The patient was extubated on the 8th day and kept on extubation. The patient had received supportive broad-spectrum antibiotic therapy during their hospital stay. No other significant findings were noted. The patient was discharged satisfactorily on the 10th day.

Polyvalent antivenom was provided without any allergic responses. The patient’s symptoms gradually improved during the treatment. His neurological condition was stable, and the swelling and ecchymosis at the site of bite lessened at the time of discharge. There were no visible indicators of systemic envenomation at the time of discharge. The patient was given proper wound care instructions before being 2discharged, and a follow-up appointment was set for one week later to check for any complications due to polyvalent antivenom and envenomation-related late problems or sequelae. No significant complications or sequelae were noted during the follow-up.

Case 2

A 39-year-old male walking in the yard during the evening reported to the ED with agonising pain, swelling, and discoloration on his left hand as a result of a possible snakebite. The patient immediately noticed two small puncture wounds on his palm, which he suspected were caused by a snakebite. He experienced immediate pain, which quickly spread up his arm. Additionally, he reported slight vertigo, nausea, general weakness, ptosis, trouble swallowing, difficulty breathing, a low breath count (10 breaths/minute), and low single breath count (8 breaths/minute),. According to a relative, it was a krait snake. Upon assessment, the patient showed signs of worry and anxiety. The patient’s vital signs were as follows: oxygen saturation on room air was 97%, blood pressure was 140/90 mmHg, heart rate was 100 beats/minute, and respiratory rate was 20 beats/minute. The patient had a GCS score of E2V2M2. Local examination of the left hand revealed two obvious fang marks with surrounding oedema, ecchymosis, and tenderness. Although the arm had slight oedema, there were no indications of compartment syndrome. A neurological evaluation of the injured limb revealed no alterations in sensory and motor functions. The patient was referred to us from the district hospital where he had received 15 units of antivenom one hour after the bite. The patient had no other notable prior dental or medical history. He had no known sensitivities or previous snakebite injuries.

Probable diagnosis: The provisional diagnosis was venomous snakebite, likely from a krait species, based on the patient’s medical history, physical examination, and presentation of suspected snakebite symptoms combined with neurotoxic symptoms such as paralysis, ptosis, ophthalmoplegia, muscle weakness, blurred vision, and difficulty breathing. The patient was intubated and kept on mechanical ventilation. A 24 hour regimen of atropine and neostigmine was completed. Calcium gluconate was given for six hours. Point-of-care ultrasound showed diaphragmatic paralysis. On the next day, the patient had two episodes of a generalised tonic-clonic seizures, for which antiepileptic treatment (injection of midazolam and Levetiracetam) was started. On the 3rd day, the patient developed a fever and exhibited agitated behaviour. Secretions increased and the patient did not maintain SpO2 (below 94%). Suction, increased oxygen flow, ambubag resuscitation, and intubation were performed. The addition of a glycopyrrolate injection reduced the secretions. The patient remained stable after 12 hours of continuous suctioning and monitoring. On the morning of the 4th day, the GCS improved to E3VtM5. On the evening of the 4th day, the GCS was E4VtM6. The patient was extubated and kept off the ventilator. On the 5th day, the patient complained of haemoptysis. Chest X-ray showed infiltration in the left upper and middle zones. The patient received supportive broad-spectrum antibiotic therapy, and a sputum culture for antibiotic sensitivity was sent. After the treatment, the patient showed improvement. The patient was discharged satisfactorily on the 8th day of admission. After one week, the patient returned to the follow-up clinic and was normal without any major sequelae.

Case 3

A 48-year-old male who had been bitten by a snake arrived at the ED complaining of excruciating pain, swelling, and discolouration on his right foot. According to the patient’s relative, the patient experienced sudden, intense pain on the lateral aspect of his right foot while he was outside his house at night. They witnessed a snake slithering away, and the relative described it as long, slender, light-coloured, and banded in dark colours, which is consistent with the description of a krait. The patient felt intense pain at the bite site. Additionally, the patient expressed concerns about generalised weakness, respiratory distress, and slight vertigo. Upon presentation to the ED, patient had low GCS (E2V2T2) and was gasping. The patient arrived at the district hospital three hours after the bite and was given 10 vials of antisnake venom. The patient had no other notable prior dental or medical history. He had no known sensitivities or previous snakebite injuries. A 20-minute whole blood coagulation test was negative at the time of presentation to the ED.

The patient was intubated and kept on mechanical ventilation, and other supportive treatments were initiated. Blood and urine cultures were sent before starting antibiotic therapy. A 24-hour regimen of atropine and neostigmine was completed. Calcium gluconate was administered for six hours. A 20-unit antisnake venom was given during treatment. During the patient’s time on the ventilator, sepsis, bleeding from the nose and ET tube developed. Prothrombin Time (PT)/International Normalised Ratio (INR) (2.5) was elevated, and Procalcitonin Test (PCT) (5 μg/L) was elevated, leading to a revision of antibiotic treatment and repeat blood and urine cultures. The patient developed acute renal failure during treatment, for which Continuous Renal Replacement Therapy (CRRT) was performed. Eight units of Fresh Frozen Plasma (FFP) and other supportive treatments were administered. Non Contrast Computer Tomography (NCCT) showed a large infarct in the Middle Cranial Artery (MCA) territory. The patient expired after eight days of treatment due to septic shock.


Krait snake bites pose a serious medical emergency, and prompt and appropriate management, including antivenom therapy, is essential for improving patient outcomes. The severity of symptoms varies, and close monitoring is critical. By following specific treatment procedures and using polyvalent antivenom, medical professionals can effectively address krait envenomation and save lives. The results of current research are consistent with earlier publications in the literature regarding the clinical manifestations and symptoms of krait snakebite. The present research showed a consistent pattern of neurotoxic symptoms in patients, including ptosis, ophthalmoplegia, dysarthria, and muscle weakness, similar to the cases described by Sharma SK et al., (14). Warrell D et al., also mentioned abnormal symptoms like vomiting and stomach pain in some patients in their study, highlighting the possibility of variation in clinical manifestations (15). The present study emphasised the vital importance of early delivery of proper antivenom therapy in managing krait snakebite patients, which is consistent with observations made by Alirol E et al., (16). The mainstay of treatment, antivenom therapy aims to counteract the neurotoxic effects of the venom. However, the authors identified instances of antivenom resistance in the index patient cohort, similar to the incidents described by Silva A et al., (17). This worrisome finding highlights the need for investigation alternative treatment options and potential changes in venom composition.

The article contributes new insights into the dynamic nature of krait snakebite envenomation, adding to the body of previous knowledge. Similar to the findings of Halesha BR et al., the discovery of treatment-resistant cases in the present cohort study emphasised the importance of promptly reporting such cases to spread knowledge of potential changes in venom properties. The present study findings, along with those of other researchers, emphasise the need for ongoing research, surveillance, and interdisciplinary cooperation to successfully address the challenges posed by krait envenomation (18). Respiratory distress was the most common presenting symptom, and mechanical ventilation was required for all patients. ASV therapy was effective in reversing the symptoms of envenomation in all patients, but repeat doses were required in some cases. The use of vasopressin support and CRRT reflects the systemic complications associated with krait bites, including hypoxemic encephalopathy (19). The mortality rate in this case series was 33%, which is lower than the reported mortality rates in some previous studies. This may be attributed to the prompt administration of Adaptive Support Ventilation (ASV) and the supportive care provided in the Intensive Care Unit (ICU) (20). The mean length of ICU stay was nine days, highlighting the importance of close monitoring and aggressive management of complications in the ICU (20). In one study, the most frequent bites were to the foot or toes; however, in present investigation, authors reported one case of a foot bite, one case of a hand bite, and one case of a neck bite (21).


Krait bites are a medical emergency that requires prompt recognition and management in the ICU. Respiratory distress is the most common presenting symptom, and mechanical ventilation may be required in some cases. ASV therapy is effective in reversing the symptoms of envenomation, and supportive care is crucial in managing systemic complications. The mortality rate in present case series was lower than that reported in previous studies, emphasising the importance of early intervention and aggressive management in the ICU.


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DOI and Others

DOI: 10.7860/JCDR/2023/64937.18671

Date of Submission: Apr 22, 2023
Date of Peer Review: Aug 02, 2023
Date of Acceptance: Sep 25, 2023
Date of Publishing: Nov 01, 2023

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Apr 26, 2023
• Manual Googling: Aug 19, 2023
• iThenticate Software: Sep 22, 2023 (2%)

ETYMOLOGY: Author Origin


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