A.

DEFINITION A snake bite is an injury caused by a bite from a snake, often resulting in puncture wounds inflicted by the animals fangs and sometimes resulting in envenomation.

B. EPIDEMIOLOGY 1. > 5 million bites annually by venomous snakes world wide 2. With > 1,25,000 deaths 3. Age : 11 50 yrs 4. Sex : males 5. Mc site : lower limbs 40 %

C. CLASSIFICATION OF SNAKES 1. Colubridae snake). 2. Elapidae 3. Viperidae Russels viper, aders. 4. Hydrophidae : Sea Snake. : Cobras, krait, mambas, coral snake. : American rattlesnake, Asian pitviper, : Most non venomous snakes (eg : grass

D. POISONOUS SNAKES 1. Neurotoxic 2. Haemotoxic 3. Myotoxic : cobra,krait & coral : vipers : sea snake

E. COMMON INDIAN VENOMOUS SNAKE 1. ELAPIDAE Common Cobra Naja Naja, Indian Cobra Common Krait Bangarus Caeruleus

2. VIPERIDAE

Saw Scaled Viper Echis Carinatus Russells Viper Vipera Russelli King Cobra Naja Bangarus, Hamadryad Banded Krait Bangarus Fasciatus Sea Snakes

3. OTHER SNAKES

F. THE SNAKE FEATURES OF POISONOUS SNAKES 1. Usually dull colored (Brown, Black, Grey) 2. Stout body with abruptly compressed and tapering tail 3. Broad belly scales extending entire width of belly 4. Small scales on triangular head 5. Pit between eye and nostril 6. Presence of hood with or without markings 7. Presence of fangs

G. CLINICAL FEATURES 1. Flushing, palpitations, sweating, anxiety & fear : prominent features in any snake bite victim (even if snake is non-venomous). 2. Specific features of venomous snakes ; depend upon type of snake and consists of local & systemic features of envenomation.

H. GRADES OF ENVENOMATION Grade Non-envenomated (dry) bites Features Presence of fang marks without local / systemic reactions Mild envenomation Local swelling & pain without systemic reaction Moderate envenomation Extensive local effects with

min.sys.effects / mild local effects

with marked sys.effects , mild lab.abn Severe envenomation Extensive local effects & systemic effects & marked lab.abn

I. FIRST AID Do it : RIGHT 1. R Reassure the patient . 70 % snake bites nonvenomous species. Only 50 % of bites by venomous species actually envenomate the pt. 2. I Immobilize in the same way as # limb. Use bandages / cloth to hold splints, not to block blood supply / apply pressure. Do not apply any compression in the form of tight ligatures 3. GH Get to the hospital immediately 4. T- Tell the doctor of any systemic symptoms that manifest on way to the hosp

J. TRADITIONAL METHODS TO BE DISCARDED 1. Tourniquets traditionally used to stop venom flow. ( increased risk of ischemia , loss of limb, necrosis, massive neurotoxic blockade when tourniquet is released, embolism viper , false sense of security ) 2. Incision & Suction increases risk of severe bleeding as clotting mech is ineffective & infection . No venom is removed by this method 3. Washing the wound it increases the flow of venom into system by stimulating the lymphatic system.

K. TREATMENT PROTOCOL 1. Attend to AIRWAY , BREATHING, CIRCULATION

2. Tetanus toxoid 3. Routine antibiotic is not necessary 4. Identify the snake responsible 5. All patients should be kept under observation for a min period of 24 hrs. 6. Determine the exact time of bite 7. Ask the victim as to what he was doing at the time of bite 8. Pain give PARACETAMOL 9. Not Aspirin & NSAIDS 10. 5o mg TRAMADOL can also be used 11. Care must be taken when removing tight tourniquets tied by victim. Sudden removal can lead to massive surge of venom leading to neurological paralysis, hypotension d/t vasodilatation.

L. INVESTIGATIONS 1. 20 minutes whole blood clotting test ; considered most reliable test of coagulation. 2. Single breath count 3. Complete Blood Count Anemia, Leucocytosis, Thrombocytopenia, HCT 4. Evidence of Hemolysis Fragmented RBCs 5. Prolonged Clotting Time Ampoule method Prolonged APTT 6. Serum Electrolytes Hyperkalemia 7. Raised Urea, Creatinine 8. Urine for RBC Viper Bite Hematuria, Proteinuria, Hemoglobinuria, Myoglobinuria 9. ECG Normal, Bradycardia with ST elevation or depression, T inversion, QT prolongation 10. ABG Hypoxemia with Respiratory Acidosis, Metabolic / lactic Acidosis

11. Chest X- ray Normal, Pulmonary Oedema, Intrapulmonary Hemorhages, Pleural Effusion

M. MONITOR VITAL SIGNS Observe every patient for minimum 24 hours 1. Pulse, BP, Respiration 2. 3. 4. 5. 6. 7. Urine output Blood urea, Creatinine Bleeding tendency Local swelling Vomiting Diplopia, Ptosis, Muscle Weakness, Breathlessness

N. ANTI SNAKE VENOM ASV is prepared by hyperimmunising horses against venoms of snake It neutralizes the free, unbound venom & to some extent also dissociates the bound toxin ASV is manufactured in India by the Haffkine Central Research Institute, Kasauli & Serum Institute of India, Pune & both are polyvalent. ASV reactions : Pt should be monitored closely First sign of any one of the following : 1. Utricaria 2. Itching 3. Fever 4. Chills 5. Nausea 6. Vomiting 7. Diarrhoea 8. Abd.cramps 9. Tachycardia 10. Hypotension 11.Bronchospasm 12.Angioedema

Discontinue ASV & give 0.5 mg of 1 :1000 adrenaline IM

O. SUPPORTIVE THERAPY 1. RESPIRATORY FAILURE : ABG Intubate & Ventilate Neostigmine & Atropine

2. HYPOTENSION : Plasma expanders Dopamine 2.5 5 micrograms/Kg/min