Treatment Protocol of Snake Bite

Kaushik.H.M
080201388

Rapid clinical assessment and resuscitation

Detailed clinical assessment and species

diagnosis
Investigations/laboratory tests
Specific treatment

Attend to AIRWAY , BREATHING,

CIRCULATION
Secure an IV line (wide bore).
Booster dose of tetanus toxoid is
recommended.
Identify the snake responsible

All patients should be kept under

observation for a minimum period of

24 hrs.
Determine the exact time of bite
Bacterial Infections- Prophylactic
course of penicillin (or erythromycin for
penicillin-hypersensitive patients)and a
single dose of gentamicin or a course of
chloramphenicol

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.
Pain-paracetamol/ 50 mg of tramadol maybe
given. NSAIDs and Aspirin are
contraindicated.

Investigations
20 minute whole blood clotting test -considered most

reliable test of coagulation.

Platelet count : may be decreased viper
WBC cell count : Early neutrophil leucocytosis in

systemic envenoming from any species.

Blood film : Fragmented RBC(helmet cell,

schistocytes) are seen in microangiopathic haemolysis.

Plasma/serum : may be pink or brownish if there is

gross haemoglobinaemia or myoglobinaemia.

Aminotransferases, creatine kinase, aldolase elevated if

there is severe local damage or, particularly generalised

muscle damage.
Bilirubin is elevated following massive extravasation of

blood.
Creatinine, urea or blood urea nitrogen levels are raised in

the renal failure

Early hyperkalaemia may be seen following extensive

rhabdomyolysis in sea snake bites. Bicarbonate will be low

in metabolic acidosis (eg renal failure).
Arterial blood gases and pH may show evidence of

respiratory failure (neurotoxic envenoming) and acidaemia

(respiratory or metabolic acidosis).

Urine for RBC Viper Bite Hematuria,

Proteinuria, Hemoglobinuria, Myoglobinuria

ECG Normal, Bradycardia with ST

elevation or depression, T inversion, QT

prolongation.

Chest X- ray Normal or may show

Pulmonary Oedema, Intrapulmonary

Hemorhages, Pleural Effusion.

Monitor vital signs

Observe every patient for minimum 24 hours. Monitor the

patient every 6 hours.

Pulse, BP, Respiration
Urine output
Blood urea, Creatinine
Bleeding tendency
Local swelling
Vomiting
Diplopia, Ptosis, Muscle Weakness, Breathlessness

Anti Snake Venom

Antivenom is immunoglobulin (usually the

enzyme refined F(ab)2 fragment of IgG) purified

from the serum or plasma of a horse or sheep
that has been immunised with the venoms of one
or more species of snake.
It neutralises 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(neutralizes venom of different
species of snakes.)

1 ml of ASV neutralises
Cobra 0.6 mg
Common krait 0.45mg
Russels viper 0.6 mg
Saw scaled viper 0.45 mg

Indications
As per W.H.O Guidelines ONLY if a

patient develops one / more of the

following signs/symptoms ASV should
be administered :
SYSTEMIC ENVENOMING
Evidence of coagulopathy: detected by
20WBCT or visible spontaneous
systemic bleeding
Evidence of neurotoxicity : ptosis,
ext.ophthalmoplegia

 CVS abnormalities : hypotension,

shock, arrhythmias

Acute renal failure

Hemoglobinuria / myoglobinuria
Persistent severe vomiting /

abdominal pain

LOCAL ENVENOMING
Local swelling > of involved limb
Rapid extension of swelling
Enlarged tender lymph nodes draining the

bitten limb

ASV administration
NO ASV TEST DOSE MUST BE ADMINISTERED .
Recommended initial dosages are 100 ml( 10

vials) of polyvalent ASV for adults & children

based on published research that
russells viper injects on an average of 63 mg
of venom.
Our initial dose must be calculated to

neutralize the average dose of venom

injected.

Range of venom injected = 5mg 147 mg

Suggested ASV dose = 100 -250 ml
Initial dose of 100 ml must be diluted in 100 ml

of NS & given over 1 hour.

Patient should be carefully monitored for 2 hrs.
Local administration of ASV, near the bite site

ineffective, painful, raises intracompartmental

pressure. SHOULD NOT BE DONE

Victim who arrives late ?

Often after several days , usually with acute

renal failure.
Are there any signs of current venom activity ?
Perform 20WBCT & determine if any

coagulopathy is +, if + administer ASV. If - ,

treat ARF dialysis
Neurotoxic envenoming look for ptosis,

respiratory failure , + administer 1 dose of ASV ,

respiratory support

ASV reactions
Patient should be monitored closely
First sign of any one of the following :

1. Utricaria
6. Vomiting
11.Bronchospasm
2. Itching
7. Diarrhoea 12.Angioedema
3. Fever
8. Abdominal cramps
4. Chills
9. Tachycardia
5. Nausea
10. Hypotension
Discontinue ASV & give 0.5 mg of 1 :1000

adrenaline IM/ IV

Repeat doses of ASV

HEMATOTOXIC POISONING :
20 WBCT abnormal initial dose given over 1 hr.
Repeat 20WBCT after 6 hrs
Abnormal another dose to be given. Repeat

same dose again.

20WBCT & Repeat doses of ASV to be continued
on 6 hourly manner until coagulation is restored.

NEUROTOXIC POISONING
Assess the patient 1-2 hrs after the initial

dose
If symptoms persist / worsen , 2 nd dose

which is same as 1st dose is to be given &

then ASV can be discontinued

Role of Neostigmine in
Neurotoxic poisoning
Anticholinestrase & prolongs life of Ach - which

can reverse resp.failure & neurotoxic symptoms

( post synaptic )
Neostigmine test : 1.5 -2.0 mg IM preceeded by
0.6 mg atropine IV
Observe for 1 hr
If victim responds , continue 0.5 mg Neostigmine
IM hrly with 0.6 mg Atropine IV over 8 hrs
If no improvement in symptoms after 1 hr , stop
Neostigmine

Supportive Therapy
RESPIRATORY FAILURE :
ABG
Intubate & Ventilate
Neostigmine & Atropine
HYPOTENSION :
Plasma expanders-crystalloids
Dopamine 2.5 5 micrograms/Kg/min

PERSISTANT / SEVERE BLEEDING :

Majority timely use of ASV will stop

systemic bleed
ASV + Blood Transfusion

RENAL FAILURE
Hemodialysis / peritoneal dialysis
COMPARTMENT SYNDROME :
Fasciotomy
SURGICAL DEBRIDEMENT OF WOUND:

Necrosis