Dr.

DHIRUBHAI PATEL
VICE CHAIRMAN
SNAKE RESEARCH INSTITUTE
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 Learning Objectives:
• Epidemiology of Snakebite
• Syndromic approach for snakebite
• Management of different snakebite
• Investigation
• Discharge criteria
• Advice on follow up

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 Background
• The World Health Organization (WHO) estimates that about 5 million snakebites occur each year, resulting
in up to 2.7 million envenomings. Published reports suggest that between 81,000 and 138,000 deaths occur
each year. Snakebite envenoming causes as many as 400,000 amputations and other permanent disabilities.
Many snakebites go unreported, often because victims seek treatment from non-medical sources or do not
have access to health care. As a result it is believed that many cases of snakebite go unreported.

• Snake antivenoms are effective treatments to prevent or reverse most of the harmful effects of snakebite
envenoming. They are included in the WHO Essential Medicines List and should be part of any
primary health-care package where snake bites occur.

• Unfortunately many people either lack access to antivenom, or cannot afford to pay for them. Many families
sell possessions or go into debt in order to obtain antivenom after someone is bitten. Difficulties in ensuring
proper regulation and testing of antivenoms also affect the availability of good quality, effective products.

• WHO added snakebite envenoming to its priority list of neglected tropical diseases (NTDs) in June
2017.
• In India, around 90% of snakebites are caused by the 'big four' among the crawlers - common krait, Indian
cobra, Russell's viper and saw scaled viper. Effective interventions involving education and antivenom
provision would reduce snakebite deaths in India.

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• Snake bite is very serious health hazard only to poor, rural
farm workers people.

• More than 50,000 Death per year due to snake bite in India -
WHO

• 88,000 to 1,38,000 death per year in world wide due to

snake bite - WHO

• Tropical neglected disease- WHO

• No awareness about snake bite

• Wrong understanding of primary treatment after bite -

tourniquet

• Snake bite related to follow superstition faith healer belief.

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 Patient with the History of Snake Bite

Brought dead
Photograph in mobile Identify in photograph
snake

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 Medical
Emergency

History , signs and symptom must be obtained

rapidly so that urgent and life saving treatment
can be administered.

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 On examination

Access the Condition of

the patient Critical symptoms
○ Feeble
pulse or no pulse.
SEROUS ○ Gasping respiration or no respiration.
○ Heart sound present or absent.
STABLE ○ Swelling at bite site ,pain ,
tenderness.
○ Bleeding from bite site.

○ Ptosis (drooping of eyelids)

Non venomous Venomous ○ Hypotension

○ Cold body , sweating

○ Systemic bleeding

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 In Critical Condition
End point patient can be
saved

q RESUSCITATE

q RESUSCITATE FOR SOMETIME

q NO RESPONSE

q NO PULSE , HEART SOUND ABSENT

q PUPIL DILATED AND FIXED

q ECG- ASYSTOLE

q DECLARE DEATH

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 Non venomous

• Bite mark shaped /no bite mark

• No positive signs of snake bite

• Non venomous snake

• Observation for 24 hours because sudden

clinical deterioration can occur,
particularly in krait and cobra bite.

• Assure no harm to the patient.

• Give Discharge.

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NEUROTOXIC SIGN VENOMOUS NEUROTOXI
YES NO C SIGN
Marked Swelling at Bite Site
YES YES

20 WBCT - Not clotted status

Systemic bleeding BITE TIME : 10:00 PM TO 4:00
AM
SLEEPING ON GROUND
NO YES
YES

COMMON KRAIT
Blister and Necrosis Acute Renal Failure
at Bite site Thrombocytopenia YES
Haematuria
20 WBCT - Not clotted status
Spontaneous systemic bleeding
COBRA NO
RUSSELL’S VIPER Yes

BLISTER AT BITE SITE

BLISTER AT BITE SITE

BAMBOO PIT VIPER

SAW SCALED VIPER
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 Syndromic Approach

NEUROTOXIC
MILD:

Vomiting and anxiety, epigastric discomfort HAEMOTOXIC

MODERATE

Drooping of eye lids.

Slurred speech , Difficulty in swallowing.

SEVERE:

Difficulty in breathing.

Hypotension, bradycardia , hypoxic crisis, respiratory arrest.

Convulsion

MODERATE - Cardiac arrest. Bite mark mostly

SEVERE: not seen , Local
Swelling ,severe pain , swelling rarely
tenderness and found
bleeding at bite site
and bite mark seen. H/o sleeping on
Necrosis at bite site. ground,Bite Time
10:00pm - 4:00am
May be no effect (DRY

COBRA KRAIT
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BITE , no ASV). May be no effect
(DRY BITE ,no ASV)
 HAEMOTOXIC
MILD :Swelling ,Sever pain and
tenderness at bite site

MODERATE : Blister and necrosis

at bite site . BAMBOO PIT VIPER
MODERATE - SEVERE :Swelling MILD : Swelling , pain and
may extends up to half of body tenderness at bite site

Pain in abdomen, vomiting

MODERATE :Bleeding from
bite site
Hemoptysis, Hematuria ,
Hematemesis
Blister at bite site.

RUSSELL’S VIPER SAW SCALED VIPER

SEVERE : Big bite marks with bleeding,
MODERATE - SEVERE : Bleeding
from bite site or from any orifies.
Diplopia, drooping of eyelids
Bite mark medium size .
Hypotension and circulatory shock
No sign an symptom (DRY BITE ,
Acute renal failure no ASV)

DIC ,VICC

Respiratory failure, ARDS , convulsion

Gangrene at bite site

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No sign and symptom (DRY BITE ,no ASV )
 I have
divided These stages
management depend on
part in two factors
STAGES

1. Amount of
2. Initiation
VENOM
of treatment
injected by
after bite
snake in
time.
human victim.

The patient arrived at mild stage or moderate stage could also get
severe stage at anytime.
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 Management in critical
condition
The immediate priorities in severe
envenomation after admission to the
emergency department of the hospital
• (1) CARDIO RESPIRATORYSUPPORT AND ALSO
SUPPORT TO OTHER ORGAN SYSTEM.

• (2) NEUTRALIZATION OF VENOM WITH ANTI

SNAKE VENOM (ASV).

• Both the priorities address simultaneously.

• A large peripheral venous line is promptly secured.

• Blood send for blood investigation.

• Close watch on urine output and color of urine.

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(1) NEUTRALIZATION OF
VENOM
The effective treatment against venom that has
entered in the circulation is, its neutralization by
the use of ASV.
• USE OF ASV
• In neurotoxic envenomation :
Cobra :10 vials in fast infusion and up to 40 vials if
necessary.
Common Krait : 10 vials in infusion and up to 5 vials
if necessary.
• In hemotoxic envenomation :
Russell’s viper : 10 vials or more up to 40 vials in 1 to
2 hours.
Saw scaled viper : 2 to 6 vials. (we can use more ASV
only if bleeding 15
 WHAT ASV CAN DO AND
IMPORTANTLY WHAT ASV CAN
NOT DO ?
• ASV CAN :

• Bind to a venom molecule that if is effective against

neutralized that venom molecule rendering it unable to
bind to target cell but only whilst the venom molecule is
circulating in the blood or lymph and is unbound.

• ASV can prevent the patient from worsening by

neutralizing venom.

• ASV CAN NOT:

• reverse renal failure

• Prevent local necrosis and swelling ;the damage is done

too quickly and the venom is in the tissue and therefore
not reachable by the ASV.
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 Anaphylactic Reaction

• Urticaria
• Itching, redness
• tachycardia
• Hypotension
• Bronchospasm
• Angioneurotic oedema
• Anaphylaxis
• Fever
• Chills
• Rigor
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 Management of anaphylactic
reaction
• Hold ASV for sometime

• Inj. Avil IM

• Inj. Hydrocortisone 100 mg iv

• Inj. Dexona iv

• Inj.adrenaline 1mg/1ml- give subcutaneous

undiluted(0.1 ml to maximum 0.5 ML ) repeat after 5
to 10 min if necessary.

• Inj.adrenaline(1mg/1ml)-( o.1 ml to maximum 0.5

ml) IM at anterolateral aspect of thigh if necessary .

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CARDIORESPIRATORY
SUPPORT
• In seriously ill patient.
• Suction throat.
• Immediate Endotracheal intubation.
• ventilator support if necessary .
• Oxygen
• Iv fluid to raise BP.
• Inj. atropine SOS.
• Inj.noradrenaline , Inj.Dobutamine , Inj. Dopamine to
raise BP.

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SUPPORT TO OTHER
SYSTEM
• INJ.DEXONA, INJ.MENNITOL , INJ.EPSOLIN in
Case of convulsion.
• Inj.Neostigmine and inj. Atropine
only in case of cobra bite. We can repeat up to 5
dose half hourly if no response after 1 or 2 dose ,
then in tapering dose after 1 hour ,2 hour , 6 hour ,
12 hour.
• Metabolic acidosis if present countered by increase
oxygen , improve tissue perfusion , intravenous
sodium bicarbonate to maintain Ph is not <7.3.
• metabolic acidosis is one of the indication for HD.

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 Must supported by care over fluid(according to CVC ) and electrolyte balance and
avoiding nephrotoxic drug
FAD (Forced Alkaline Diuresis ) : if patient has oliguria give a trial of FAD with in
first 24 hours of bite to avoid pigment nephropathy leading to acute tubular
necrosis (ATN). Delayed FAD has no role.

Sequence in adult :
1) inj. Frusemide 40 mg iv stat
2) inj. normal saline 500 ml +20 ml of sodabicarb over 20 minutes
3) inj. Ringer lactate 500 ml + 20 ml sodabicarb over 20 minutes
4) inj. Dextrose 500 ml + 10 ml KCL over 90 minutes
5) inj. Mennitol 150 ml over 20 min.

○ Whole cycle completes in 2 hours and 30 minute and urine output of 3 ml/min is
expected. if patient respond to first cycle if necessary 2 cycle can be given.
○ FAD convert oliguria into polyuria and avoid ATN.

○ if patient no respond to FAD discontinue and plan for HAEMODIALYSIS .

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 INDICATION FOR
HAEMODIALYSIS

• HYPERKALEMIA
• ACIDOSIS
• FLUID OVERLOAD
ALTERED CONSCIOUSNESS WITH
INCREASING S.CREATININE LEVEL AND
•

DECREASED URINE OUTPUT <400 ML IN

24 HOURS.

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 BLEEDING DIATHESIS OF
RUSSELL’S VIPER
• PATTERN’S OF HAEMOTOXICITY

• VICC- Venom induced consumption coagulopathy.

• VICC WITH THROMBOTIC MICROANGIOPATHY

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 Care of wound and
inflamed area
• Incision, drainage and debridement of gangrenous
area .

• Dressing.

• Amputation of gangrenous part.

• Skin grafting.

• Secondary suturing.

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 INVESTIGATION : 20 WBCT
Simple Diagnostic Test : 20 minute whole blood clotted
status. (20 WBCT).
It is consider as the most reliable test of coagulation
and may be carried out at bed side without specialist.
PROCEDURE : A few ml of fresh venous blood is
placed in a new, clean and dry glass tube and left at
ambient temperature for 20 min. The glass tube should
be left undisturbed for 20 min then gently tiled, not
shaken.

INTERPR ITATION : if the blood is solid then test is

clotted – no ASV is require at this stage.
The patient is re-tested for every 1 hour for the first 3
hours and then 6 hourly for 24 hours until either test
result in not clotted or clinically evidence of
envenomation that time dose of ASV is indicated.

In case test is not clotted status ,repeat after admission

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 INVESTIGATION
○ CBC : HB – Anemia , Hemoconcentration
Snake Bite Profile
Blood Group – Require when blood transfusion . 20WBCT
CBC
WBC – initially neutrophil, leukocytosis in all RBS
type of envenomation by any species –indicate S.Creatinine
systemic envenomation. But more leukocytosis in Urine Routine & micro
R viper.

PLATELET – Thrombocytopenia - in case of viper

envenomation.

S.CREATININE – in case of Russell’s viper – ARF

Decision about HD- if more than 4 mg/dl.
PROTHROMBIN TIME – increase in case of viper

URINE: Routine and microgram – in case of viper

○ ELECTROLYTE: may imbalance in viper bite and in

cobra and krait when patient on ventilatory
support
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○ ABG –(Arterial blood gas analysis) Acidosis , indication for HD.

○ ECG – necessary to rule out any Heart disease and useful when cardiotoxic
envenomation occur.

○ X Ray chest – Routinely done. patient on ventilatory support in case of respiratory

paralysis (cobra, krait) – to rule out aspiration .
In viper – pulmonary oedema ( Russell’s viper bite.)

○ Ultra sound of abdomen – in case of viper – ARF

○ CT BRAIN – in case of convulsion.( Hypoxic injury)

○ ECHO – patient with hypertension , continue tachycardia , accelerated hypertension .

Only useful if cardiotoxicity present (Russell’s viper ) or patient with heart disease .

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 CRITERIA ON DISCHARGE
NEUROTOXIC

• Patient fully conscious, taking spontaneous

respiration, full movement of four limbs can be
extubated.

(no hurry in case of krait bite patient to extubate up

till motor power control fully achieved. Keep
endotracheal tube for 24 hour. may re-neuroparalytic
effect can be develop. )

• No drooping, clear speech, normal respiration full

movement of all four limbs , full conscious .

• Patient can be discharge.

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 CRITERIA ON DISCHARGE
HAEMOTOXIC

• No bleeding from anywhere ,20 WBCT –clotted

status, platelet count –normal.

• Normal urine out put , normal BP , even if swelling

at bite site.

• Normal respiration.

• If vitals normal and patient need more HD cycle can

discharge with DLC in situ .

• Patient can be discharge.

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 GENERAL ADVICE ON
DISCHARGE
ADVICE TO COME AS SOON AS POSSIBLE
If patient had complain of :
Ø Hematuria , Hematemesis , Hemoptysis

Ø Decrease U/O

Ø Increase swelling at bite site

Ø Bite site abscess , blister

Ø Slurred speech , ptosis.

Ø Difficulty in breathing

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