Snake bite is a common but under-reported medical emergency accounting for 0.5% of all deaths with greater risk of fatal envenomation in children. In India, four species of venomous snake are most common but better classification of medically significant species is warranted. Snake venom is a mixture of peptides with enzymatic & toxic properties which mediate activation of cytokine cascades along with organ specific toxicities, manifesting into local and systemic symptoms. The syndromic approach of attributing a constellation of signs & symptoms to a particular family of venomous snake has clinical acceptance but overlaps exist. Management of snake bite victim starts with a first aid measures of reassurance, immobilization and quick transfer to hospital. Measures such as application of tourniquet, incision and suction are harmful & should not be done. On arrival at hospital, triage and stabilization of Airway, Breathing & Circulation (ABC) is done followed by a focused assessment to ascertain the severity of envenomation. Antivenom treatment is the mainstay of snake bite management. ASV should be started only when specific indications such as signs of neurotoxicity, coagulopathy, hypotension, hematuria are present. Indiscriminate use of ASV is strongly condemned.Currently 8-10 vials of ASV as initial dose with a maximum of 25 vials is recommended. There is no role of test dose of ASV. Measures to treat any ASV induced anaphylaxis should be ready prior to start of ASV treatment. Supportive treatment is as important in determining the final outcome of envenomation as ASV

1. Vol. 5 - No.6 Nov-Dec 2018 34 JOURNAL OF PEDIATRIC CRITICAL CARE
Introduction
Snake bite is a common medical emergency but the
exact estimates of consequent morbidity and mortality
are not known due to lack of adequate reporting. This
has prompted World Health Organisation (WHO)
to include snake bite in the list of neglected tropical
diseases1
. There is paucity of uniform management
protocols for snake bite with controversies regarding
Anti Snake Venom (ASV) dose. The endemicity of
problem, lack of consensus in management, coupled
to the fact that risk of fatal envenomation is highest in
children; makes snake bite an area of special concern
and focus in acute pediatrics.
Epidemiology
Global annual estimates of snake bites range from 1.2
million to 5.5 million which lead to about 1,841,000
envenoming and 94,000 deaths per year2
. In 2005,
snake bite deaths in India constituted about 5% of all
injury related deaths and nearly 0.5% of all deaths.
The risk of dying from snake bite was greater in age
group of 5-14 years3
.
Snakes in India
Of the 236 types of snakes reported in India, only
15 varieties are venomous4
. The 4 most common
venomous snake in India or “The Big Four”5
are
Najanaja or Indian Cobra, Bungarus caeruleus or
Krait, Echiscarinatus or Saw scaled viper, Daboia
russelli or Russell’s viper. However, in view of
increasing reports of fatalities due to other species
like Hypnalehypnale (Hump Nosed Pit Viper),
Echiscarinatussochureki (Sochurek’s Saw Scaled
Viper), Trimeresurusmalabaricus; WHO has proposed
a new classification of medically significant species
of snakes6
.
Pathophysiology
Snake venom is a mixture of various enzymes, non-
enzymatic polypeptides and non-toxic proteins. The
enzymatic and toxic properties of these peptides are
responsible for pathogenesis of snake envenomation.
The pathogenesis is mediated primarily by activation
of cytokine networks of inflammation & coagulation
along with organ specific toxicities.
These pathophysiological mechanisms are operative
even in bites by snakes small in size; therefore, their
bitesshouldnotbeignored.Anotherimportantfactorto
Snake Bite -A review
Manish Kumar*, Lokesh Tiwari**
*Assistant Professor of Pediatrics, All India Institute of Medical Sciences Rishikesh, Uttaranchal, India,
**Associate Professor of Pediatrics, All India Institute of Medical Sciences Patna, Bihar, India
Received :31-Oct-18/ Accepted:29-Nov-18 / Published Online:31-Dec-18
Review Article
Correspondence:
Dr. Lokesh Tiwari, Associate Professor of Pediatrics,
All India Institute of Medical Sciences Patna, Bihar, India-
Phone-+919631638095, Email-lokeshdoc@yahoo.com
ABSTRACT
Snake bite is a common but under-reported medical emergency accounting for 0.5% of all deaths with greater risk of
fatal envenomation in children. In India, four species of venomous snake are most common but better classification of
medically significant species is warranted. Snake venom is a mixture of peptides with enzymatic & toxic properties
which mediate activation of cytokine cascades along with organ specific toxicities, manifesting into local and systemic
symptoms. The syndromic approach of attributing a constellation of signs & symptoms to a particular family of venomous
snake has clinical acceptance but overlaps exist. Management of snake bite victim starts with a first aid measures of
reassurance, immobilization and quick transfer to hospital. Measures such as application of tourniquet, incision and
suction are harmful & should not be done. On arrival at hospital, triage and stabilization of Airway, Breathing &
Circulation (ABC) is done followed by a focused assessment to ascertain the severity of envenomation. Antivenom
treatment is the mainstay of snake bite management. ASV should be started only when specific indications such as signs
of neurotoxicity, coagulopathy, hypotension, hematuria are present. Indiscriminate use of ASV is strongly condemned.
Currently 8-10 vials of ASV as initial dose with a maximum of 25 vials is recommended. There is no role of test dose
of ASV. Measures to treat any ASV induced anaphylaxis should be ready prior to start of ASV treatment. Supportive
treatment is as important in determining the final outcome of envenomation as ASV.
Key words: snake bite, envenomation, anti snake venom
DOI-10.21304/2018.0506.00442

2. JOURNAL OF PEDIATRIC CRITICAL CARE
Review Article
35Vol. 5 - No.6 Nov-Dec 2018
be taken into account in pediatric snake envenomation
is accelerated physiological derangements due to
higher dose of antivenom per body surface area in
children.
Clinical features
Symptoms and signs of snake bite can be divided into
local and systemic symptoms.
Locked in syndrome:
In this condition, victims of snake bite may present
with quadriplegia, ophthalmoplegia and dilated
pupils. It is important to recognize this syndrome
and differentiate it from brain death. Continuation of
definitive and supportive management in such cases
can result in intact survival.
Figure 1: Pathophysiology of snake bites
Table 1: Classification of medically significant snakes in India
Category Species
Category
1
Highest Medical Importance:
Highly venomous snakes causing
numerous snakes bites resulting in
high levels of morbidity, disability
or mortality.
Elapidae:Bungarus caeruleus (Krait); Najakaouthia, Najanaja
(Indian Cobra)
Viperidae: Daboia russelii (Russell’s Viper), Echiscarinatus
(Saw Scaled Viper); Hypnalehypnale (Hump Nosed Pit
Viper)
Category
2
Secondary medical importance:
Highly venomous snakes capable
of causing morbidity or mortality
but are less implicated because of
their behavior or habitat preference
or for which epidemiological data
is lacking
Elapidae:Bungarusfasciatus, Bungarusniger,
Bungarussindanus, Bungaruswalli; Najaoxiana
,Najasagittifera Ophiophagushannah
Viperidae:Cryptelytrops albolabris, Cryptelytrops
purpureomaculatus,Trimeresurus malabaricus
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3. JOURNAL OF PEDIATRIC CRITICAL CARE
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36Vol. 5 - No.6 Nov-Dec 2018
Syndromic Approach based on signs & symptoms:
Figure 2 : Syndromic approach in snakes bite
“Syndromic” approach of attributing a constellation
of symptoms to a specific snake like neurotoxicity to
elapidae and coagulopathy to viperidae, has been in
clinical practice7
; however, there is significant overlap
of clinical symptoms.
Table 2 : Clinical features
Local Fang marks, pain, bruising, swelling, blis-
tering, abscess and necrosis
General Pain abdomen, nausea, vomiting, malaise,
prostration
Neurological Drowsiness, parasthesia, ptosis, external
ophthalmoplegia, bulbar palsy, general-
ized flaccid paralysis including respiratory
failure
Coagulopathy Skin bleeds, epistaxis, gum bleeds, hemop-
tysis, malaena, visceral bleeds, cerebral
hemorrhage
Cardiovascular Hypotension, shock, cardiac arrhythmia,
pulmonary edema
Renal Hematuria, oliguria, hemoglobinuria, myo-
globinuria, uremia
Endocrine Acute pituitary/adrenal insufficiency, hypo-
glycemia, shock, panhypopituitarism
Management
First Aid
The principle of “Primum non nocere” or “First Do
No Harm” guides first aid in cases of snake bite.
Potentially harmful practices such as, incision of
bite wounds and application of tight tourniquets
can lead to ischemic damage and are, therefore, not
recommended8
. The National Snake Bite Management
Protocol4
has proposed a creative mnemonic – “Do
It RIGHT” which summarizes all important &
recommended aspects of first aid care to a snake bite
victim.
Table 3: Dos & Don’ts of First Aid in Snake bite victim
Do it Don’ts
R Reassurance Tight tourniquet
I Immobilisation Incision & suction of
wound
GH Get to Hospital
immedately
Washing the wound
T Telling the doctor about
emergence of symptoms
Electro/Cryotherapy
Immobilization is an important aspect of first aid as
movement leads to centripetal spread of venom by
action of “muscle-pump” and lymphatics. Pressure
Immobilisation Method (PIM) was first described
in Australia by Sutherland in1974. Its applicability
has been questioned in Indian context citing lack of
readily available resources and lack of proficiency of
lay rescuers4
. However, if meticulously used at First
Referral Units, PIM may be an extremely useful first
aid tool for immobilization specially in bites where
local tissue damage is minimal like in Elapidae
envenomation. PIM involves application of an elastic
bandage to apply pressure between 40-70 mmHg
for upper limb and 55-70 mmHg for lower limb.
Care should be taken to ensure that a finger can be
easily passed underneath the bandage. PIM is of great
utility when delay in definitive care is anticipated
although concerns regarding local tissue damage and
compartmental syndrome exist.
Hospital Management:
First steps- Maintaining ABC:
Situations warranting resuscitation are common
in snake bite victims; therefore, upon arrival in
emergency department, a quick triage followed by
optimization of Airway, Breathing & Circulation is of
utmost importance.
Assessment:
Stabilization is followed by focused assessment to
ascertain envenomation and its severity; thereby
establishing the need for ASV treatment. It is also
imperative that all cases of snake bite are kept under
close observation for 24 hours as delayed appearance
of signs and symptoms of envenoming may occur.
Envenomation due to certain species like Krait, Hump
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37Vol. 5 - No.6 Nov-Dec 2018
nosed pit viper may take 6-12 hours to manifest.
Table 4 : Clinical clues in snake envenomation
History:
• Confirmed vs
Assumed Bite
• Site
• Time elapsed
• First Aid
• Allergies
• Last meal
Symptoms:
• Local pain
• Pain abdomen
• Nausea, vomiting
• Blurring of vision
• Slurring of voice
• Muscle weakness,
• Respiratory distress
• Bleeding
• Dark urine
• Loss of
consciousness
Signs:
• Neurotoxic
• Coagulopathy
• Myotoxic
• Local
Identification of species of snake if the killed snake
has been brought to the emergency is important albeit
difficult; however, species identification through
pattern of fang bites is not recommended.
Investigations
Investigations are aimed at documenting the systemic
involvement in snake bite.
20 min whole blood clotting test (20WBCT) is a
simple test in which 2ml of freshly sampled venous
blood is collected in a new/heat treated glass vial
and is left undisturbed for 20 minutes. If, after 20
minutes the blood remains unclotted; it is suggestive
of hypofibrinogenemia. This method is a reliable
test of envenomation induced coagulopathy and by
virtue of its simplicity; it can be done bed-side even
in resource constraint settings. The test is repeated
every 30 minutes for 3 hours after admission and then
hourly. If the test is positive, it should be repeated
6 hours after ASV administration. It is important to
ensure that the glass vial has not been cleansed by a
detergent as it would hamper the surface activation
of factor XI, rendering the test invalid. If uncertainty
exists, the test needs to be repeated with a control in
form of sample from a healthy person.
Table 5 : Ancillary investigations
Investigation Pointer towards
CBC SIRS, Infection, Microangiopathy
Clot Screen Coagulopathy
Renal Function Test Uremia
Liver Function Test Liver failure
Blood Gas Respiratory failure, Shock
Urine Examination Myoglobinuria, Hemoglobinuria, Hematuria
Ancillary investigations
Ancillary investigations are important to document
systemicenvenomationandconsequentderangements.
Dealing with tourniquets:
Despite numerous advisories against use of
tourniquets, most patients are brought to emergency
with tourniquet tied adjacent to site of snake bite. In
these patients, it is imperative that the treating team
is prepared for catastrophe such as hypotension and
respiratory failure resulting from sudden release
of toxins after removal of the tourniquet. Sudden
removal of tourniquets should not be done and if the
distal pulse is occluded, then a blood pressure cuff
should be used to reduce pressure gradually before
complete removal of tourniquet.
Specific treatment: Anti-venom treatment
In spite of being the mainstay of treatment of snake
bite, Anti-venom treatment suffers from lack of
universally acceptable protocols regarding its usage.9
This lack of consensus regarding indications and
doses leads to inappropriate usage.
In India, polyvalent anti snake venom serum against
venoms of the so called “Big Four” i.e. Indian Cobra,
Indian Krait, Russell’s Viper and Saw-scaled Viper
is available. Therefore, in envenomation by species
such as Hypnalehypnale, Echiscarinatussochurek
antivenom treatment may not be as efficacious.
Table 6: Indications of Antivenom treatment4
CLINICAL LAB
Hemopo-
etic
Spontaneous systemic
bleeding
Deranged 20WBCT,
abnormal clot screen
CNS Ptosis, ophthalmoplegia,
paresis
CVS Hypotension, shock,
arrhythmia
Abnormal ECG
Renal Oliguria, hematuria Rising creatinine,
dipstick test positive
for hematuria`
Local Site Local swelling involving
more than half of bitten limb
within 48 hours
Antivenom treatment is indicated in presence of
specific signs of envenomation. Given the high cost of
anti snake venom serum, its limited supply and risk of
anaphylaxis; its indiscriminate usage is discouraged.
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38Vol. 5 - No.6 Nov-Dec 2018
Dose of Antivenom:
The ideal initial dose of ASV has been subject of much
controversy. Some experts classify envenomation
as mild, moderate and severe on basis of clinical
manifestation and the initial dose is decided on the
basis of this classification10,11
.
Table 7: Dose of ASV based on severity of envenomation
SEVERITY CLINICAL FEATURES ANTIVEN-
OM DOSE
Mild Local swelling, purpura,
ecchymosis
5 vials
Moderate Mild systemic manifesta-
tions, cogulopathy, brady-
cardia
10 vials
Severe Rapid progression of
systemic features,DIC, en-
cephalopathy, paresis
15 vials
There is a contrary view that symptoms cannot be
used to classify envenomation as they are constantly
evolving and hence initial dose should be such that
it neutralizes average dose of venom injected. The
National Snake Bite Management Protocol has
recommended this initial dose as 8-10 vials. This
dose has been suggested based on research that
Russel’s Viper injects 63mg (Range 5-147 mg; SD
7mg) of venom on an average and each vial of ASV
neutralizes about 6 mg of venom. This recommended
dose is independent of age and weight of child as
snake injects the same dose whether the victim is
child or adult.
Indications for repeating the dose of antivenom:
a. Deteriorating neurotoxic or cardiovascular signs
after 1-2 hours of the initial dose
b. Deranged clot screen after 6 hours or clinically
evident bleeding after 1-2 hours of the initial dose.
20-30 vials of ASV is usually sufficient to neutralize
all unattached toxins in envenomation from Indian
snakes Further usage of ASV may not expedite the
recovery time in respiratory failure and therefore, in
such situations, emphasis should be on supportive
measures like mechanical ventilation
Administering the antivenom:
Antivenom can be administered either as slow IV
infusion or injection.
a) Freeze dried antivenom is reconstituted in 10 ml
of sterile water for injection per ampoule. This
reconstituted antivenom is then diluted in 5-10 ml/
kg of isotonic fluid and is infused at a constant rate
over 1 hour.
b) Freeze-dried antivenom after reconstitution or neat
liquid antivenom is given by slow intravenous
injection at a rate not more than 2 ml/minute
Intramuscular injection of antivenom suffers from
drawbacks such as poor bioavailability, pain and
risk of hematoma. IM injections might be considered
in situations such as where delay in hospital care is
anticipated and if an intravenous access cannot be
established even after repeated attempts.
Instillation of ASV at the site of bite is not efficacious
and therefore not recommended.
Response to antivenom:
After administering antivenom, patient should be
monitored for adequacy of response. Pointers towards
favorable response are:
• Improvement in nausea, headache, myalgia by 15
minutes
• Improvement in hypotension by 1 hour
• Resolution of coagulopathy by 3 hours
• Signs of neurotoxic envenomation like
ophthalmoplegia by 30 – 60 minutes
Role of skin hypersensitivity testing:
Anaphylactic or serum sickness type antivenom
reactionsaremediatedbydirectcomplementactivation
rather than IgE. Skin hypersensitivity tests predict
IgE mediated hypersensitivity; hence such testing
cannot predict antivenom reactions12
. Therefore skin
hypersensitivity testing is not recommended prior to
administration of snake antivenom.
Antivenom reactions13
• Early reactions
o Anaphylactic reactions range from urticaria,
coughing, vomiting, abdominal colic to life
threatening emergencies like hypotension,
bronchospasm and angioedema.
o Pyrogenic reactions result due to contaminants
present in antivenom and manifest as fever
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39Vol. 5 - No.6 Nov-Dec 2018
with rigor.
• Late reactions
o Serumsicknesstypecharacterizedbyarthralgia,
myalgia, mononeuritis multiplexa and rarely
encephalopathy.
Treatment of antivenom reactions:
• ASV infusion should be stopped immediately
and standard anaphylaxis management should be
started
• National Snake Bite Management Protocol
insists on IM epinephrine being tried prior to IV
epinephrine in view of potential risk of arrhythmia.
The guidelines insists that IV epinephrine be used
only in ICU settings.
• For late serum sickness type reactions,
chlorpheniramine maleate 0.25mg/kg/day for 5
days is given. If there is no response in 48 hours,
a 5 day course of oral prednisolone in a dose of
0.7mg/kg/day is recommended.
Box 1: Management of Anaphylaxis
• IM epinephrine (1:1000) in a dose of 0.01 ml/kg or by auto
injectors should be given.
• A second dose or IV epinephrine infusion may be needed
after 10 minutes in severe anaphylaxis.
• If needed isotonic fluid boluses to ensure adequacy of pe-
ripheral perfusion should be administered.
• Anti histamincs Chlorpheniramine maleate (0.2mg/kg) IV
along with Ranitidine should be given
Contraindication to anti-venom:
There are no absolute contraindications to use of
antivenom; special precaution needs to be taken in
case of patients with history of reaction to equine
serum and those with history of atopic diseases like
asthma.
Role of ASV in victims arriving late at a healthcare
facility:
Delayed arrival at a healthcare facility is common
in countries like India where a large population,
especially those with higher incidence of snake bite,
live in remote inaccessible areas. Although there is
no time limit for administration of ASV, but it should
be remembered that antivenom only acts against the
unbound venom. Also, patients who arrive late after
snakebite (in particular viperine) are often in acute
renal failure; further complicating the decision to
administer ASV.
In such patients, 20WBCT should be performed and if
coagulopathy is present, ASV should be administered.
If isolated derangement of renal function is present,
with no evidence of coagulopathy, dialysis should be
arranged.
In case of neurotoxic envenomation arriving late at
a health care facility, presence of symptoms such as
ptosis or central respiratory failure, administration of
8-10 vials of ASV is indicated along with institution
of supportive measures.
Role of anti-cholinesterases in neurotoxicity:
Anti-cholinesterase drugs have been documented to
have a useful albeit variable response. Atropine in a
dose of 0.05mg/kg followed by neostigmine is given
in a dose of 0.04mg/kg. Patient is observed for next
60 minutes for resolution of neurotoxicity. If there is
convincing response, neostigmine can be instituted
along with atropine every 2-4 hours.
Pain management:
For pain management, paracetamol or tramadol is
recommended. NSAIDS or aspirin may exacerbate
coagulopathy.
Role of antibiotics:
The clinical benefits of prophylactic antibiotics are
questionable & therefore, routine use of antibiotics in
snake bite is not recommended except for cases with
signs of infection or necrosis/abscess14
.
Role of tetanus toxoid:
Tetanus toxoid is considered in patients with local
tissue necrosis after taking into account previous
immunization status.
Supportive treatment:
Antivenom treatment neutralizes the free circulating
venom; thereby halting further deterioration.
However, complete recovery takes time and till
then patient requires supportive therapy to maintain
homeostasis in form of treatment of shock, renal
dialysis or assisted ventilation. In fact, this supportive
management along with antivenom treatment
determines the final outcome.
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40Vol. 5 - No.6 Nov-Dec 2018
Table 8 : Supportive treatment in a snake bite victim
Respiratory paralysis Assisted ventilation
Coagulopathy ASV along with FFP, Cryoprecipi-
tate, Platelets as indicated
Shock Fluid boluses, Inotropes
AKI Fluid restriction, Electrolytes man-
agement, Dialysis
Myoglobinuria Correction of acidosis, Diuresis
Surgical considerations:
• In victims with coagulopathy and need for surgical
intervention for intracranial bleeds, high dose i.e.
upto 25 vials of ASV should be given empirically
before neurosurgical intervention.
• Compartment syndrome should be considered
in victims with severe local tissue damage with
features such as pallor, parasthesia& pulselessness
of the limb, pain on passive stretch of the
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41Vol. 5 - No.6 Nov-Dec 2018
extremity or disproportionate pain. In such cases
fasciotomy should be considered after correction
of coagulopathy.
Prognosis:
Hospital based studies report mortality rates ranging
from 3 – 20%15,16
. The major predictors of mortality17
in snake bite are:
• Bite to hospital time
• Bite to hospital distance
• Neurotoxicity
• Vomiting
• Uremia
• Respiratory failure
Delay in definitive treatment i.e. institution of
antivenom treatment and supportive measures for
organ dysfunction has been implicated as the prime
reason for adverse outcomes.
Source of funding: None
Conflict of Interest: None
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How to cite this article:
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Snake Bite -A review