This document provides information on snake envenomation and its management in India. It discusses that India has the highest snakebite mortality in the world, with an estimated 83,000 bites and 11,000 deaths annually. The four main venomous snakes in India are cobras, kraits, Russell's vipers, and saw-scaled vipers. Symptoms of envenomation depend on the snake species but can include local tissue damage, neurotoxicity, coagulopathy, renal toxicity, and myotoxicity. First aid involves reassuring the patient, immobilizing the bite area, and rapidly transporting to a hospital. At the hospital, investigations are carried out and antivenom is administered via intravenous route in

1. SNAKE ENVENOMATION
DR. HANUMAN PRASAD
GUIDE : DR. GAUTAM NAGORI SIR
DEPT. OF PAEDIATRICS
JHALAWAR MEDICAL COLLEGE,
JHALAWAR (RAJ.)

2. INTRODUCTION
More Than 2000Species Of Snakes In The World
216 Species In India – 52 AreVenomous
Atleast 421,000 Envenomings & 20,000 Deaths Occur Worldwide
From Snake Bite Each Year,
May Be As High As 18,41,000Envenomings And 94,000 Deaths.
Highest Burden - South Asia, Southeast Asia, And Sub Saharan
Africa.
Venomous Snakes And Non Venomous Snakes

3. EPIDEMIOLOGY
• The Annual Number Of Cases Of Snakebite Worldwide Is
About 5 Million, Among Which There Are Some 100000 To
200000 Deaths.
• In Addition To The Deaths, There Are An Estimated 400000
Snakebite - Related Amputations Each Year Around The World
.
• Children Have Both Higher Incidence Rates And Suffer More
Severe Effects Than Do Adults, As A Result Of Their Smaller
Body Mass.

4. INDIA
• India Is Estimated To Have The Highest Snake
bite Mortality In The World.
• World Health Organization (WHO) Estimates Place
The Number Of Bites To Be 83,000 Per Annum
With 11,000 Deaths
• Males: Female :: 2:1
• Majority Of The Bites Being On The Lower
Extremities
s.

5. SNAKES IN INDIA
• There Are About 236 Species Of Snakes In India, Most Of
Which Are Nonvenomous.
• Their Bites,Apart From Causing Panic Reaction And
Local Injury, Do Not Harm The Patient.
• 13 Known Species That Are Venomous And Of These Four,
Namely Common Cobra (Naja Naja), Russell’s Viper
(Dabiola Russelii), Saw-scaled Viper (Echis Carinatus) And
Common Krait (Bungarus Caeruleus) Are Highly Venomous
And Responsible For Most Of The Poisonous Bites In India.

6.  Snake Envenomation Is Known As OPHITOXEMIA.
 Almost 2/3 Deaths Due To Krait Bite.
 Mostly Snake Bite During Mansoon Months
[June To Sep]
 Krait Active During Night , Cobra And Vipers Bite
Occur During Day Or Early Darkness.

7. CLASSIFICATION :
 1. ELAPIDAE : Cobra , King Cobra , Krait .
 2. VIPERIDAE: Vipers, Pit Vipers .
 3. HYDROPHIDAE : Sea Snakes

8. COMMONEST INDIAN venomoussnakes
–
Cobra Krait
The Venom Is Synthesized By The Modified Salivary Glands And
Injected Through Special Channeled Or Grooved Teeth CalledFangs
Russel’s viper Saw-scaled viper

12. IDENTIFICATION FEATURES

13. SUSPECTED SNAKE BITE
 History Of Snake Bite
 Presence Of Fang Mark
 Local Symptoms – Pain & Swelling
 Systemic Manifestation – Spontaneous Bleeding
Neurotoxicity
 Dead Snake Is Brought

16. Common Krait- Key Identification Feature Is PAIRED White Bands.

18. Key Identification Feature-
Large Plate Scales On The Head
PIT VIPER
Haemotoxic Venom.Causes Renal
Failure Late Onset Envenoming

20. Key Identification Feature Is The Black Edged Almond Or Chain
Shape Marks On The Back.

22. SNAKEVENOM
•Complex Mixture Of Proteins Including Large
Enzymes - Local Tissue Destruction.
•Low Molecular Weight Polypeptides - Lethal
Systemic Effects
-Acidic.
-Sp Gravity: 1.030 -1.070
-On Drying Fine Needle Like Crystals.
-Water Soluble.
-Lethal Dose:
Cobra - 0.12gm, Krait 0.06gm, Russell’s V - 0.15gm

24. PATHOPHYSIOLOGY NEUROTOXIC

26. Mechanism Of Hemostatic Toxin
 Procoagulants [ Factor V, Factor X ]
 β Bungarotoxins [Phospholipase A2]
 Disintegrin And Metalloproteinase
 Hyluronidase
 Haemorrhagin Cause Direct Endothelial Damage

28. SIGN & SYMPTOMS
 Asymptomatic
 70% Nonvenomous BitE
 No Specific Symptoms
 Palpitations, Sweating, Tremoulessness, Tachycardia,
Tachypnoea, Elevated Blood Pressure, Cold Extremities And
Paraesthesia.
 Redness, Increased Temperature, Persistent Bleeding And
Tenderness Locally.

29. Dry Bite
 Venomous Species Are Not Always Accompanied By
The Injection Of Venom (Dry Bites).
 Dry Bite, Symptoms Due To Anxiety And Sympathetic
Over activity May Be Present.

31. SYMPTOMATIC
• Local symptoms
• Local Swelling, Bleeding, Blistering, And Necrosis.
• Progressive Painful Swelling Leadin To Compartment
Syndrome
• Regional Tender Enlarged Lymphadenopathy.
• More Prominent In Russel’s Viper Bite Followed By Saw
Scaled Viper And Least In Pit Viper Bite.

32. Fang marks Persistent Bleeding From Fang Marks
40min After Bite Of Pit Viper
Blistering at
site of bite

34. SYSTEMIC MANIFESTATION
Cardiotoxicity
 Seen With Cobra And Viper Bite
 Hypotension
 Bradycardia
 Arrhythmia – Due To Hyperkalamia
 Pulmonary Edema

35. Neurotoxicity
 Seen With Cobra & Krait Bite
 Symptoms Within 30 Min– 6 Hours In Cobra Bite And 6 – 24
Hours For Krait Bite.
 Symptoms
 Ptosis (Drooping Of Eyelids) Occurs First, Followed By
Diplopia (Double Vision), Then Dysarthria (Speech Difficulty),
Then Dysphonia (Pitch Of Voice Becomes Less) Followed By
Dyspnoea (Breathlessness) And Dysphagia (Inability To
Swallow) Occurs.
 Finally, Paralysis Of Intercostal And Skeletal Muscles Occurs.
 Signs Of Impending Respiratory Failure Are Diminished Or
Absent Dtr And Head Lag.

36. Bilateral Dilated, Poorly Or A Non-
reacting Pupil Is NOT The Sign Of
Brain Dead In Elapid Envenoming

37. HAEMOTOXIC
 Vasculotoxic Bites Are Due To Viper Species.
 Visible Systemic Bleeding - Gingival Bleeding, Epistaxis,
Ecchymotic Patches, Vomiting, Hematemesis, Hemoptysis,
Bleeding Per Rectum, Subconjunctival Hemorrhages.
 Continuous Bleeding From The Bite Site.
 Bleeding From Pre-existing Conditions E.G. Haemorrhoids,
Bleeding From Freshly Healed Wounds.
 Petechiae, Purpura, Ecchymoses, Blebs And Gangrene.
 Acute Abdominal Tenderness May Suggest Gastro-intestinal
Or Retroperitoneal Bleeding.
 Most Serious Is Intra-cranial Bleeding.

38. Broken Neck
Sign In A
Child
Envenomed
By Krait
Bleeding From
Gingival Sulci

39. Nephrotoxicity
 Seen With Viper And Sea Snake.
 Patient Presents With Hematuria, Hemoglobinuria,
Myoglobinuria Followed By Oliguria And Anuria With Acute
Kidney Injury (AKI).
 Hypotension Due To Hypovolaemia Or Direct Vasodilatation
Aggravates Acute Kidney Injury.

40. Myotoxic
 Seen With Sea Snakebite.
 Patient Presents With Muscle Aches, Muscle Swelling,
Involuntary Contractions Of Muscles.
 Passage Of Dark Brown Urine.
 Compartment Syndrome, Cardiac Arrhythmias Due To
Hyperkalaemia, Acute Kidney Injury Due To
Myoglobinuria, And Subtle Neuroparalytic Signs.

41. SPECIES: SIGNS AND SYMPTOMS
Signs/Symptoms
and Potential
Treatments
Cobra Krait
Russell’s
Viper Saw Scaled
Viper
Other
Vipers
Local pain/ Tissue
Damage
Yes No Yes Yes Yes
Ptosis/Neurotoxicity Yes Yes Yes! NO No
Coagulation No No Yes Yes Yes
Renal Problems No No Yes NO Yes
Neostigmine &
Atropine Yes No? No? NO No

42. SEVERITY OFENVENOMATION.

44. National snakebite management
protocol, India.

45. FIRSTAID
• The First Aid Recommended Is Based Around The Mnemonic:
• "Do It R.I.G.H.T."
• It Consists Of:
• R. = Reassure The Patient 70% Of All Snakebites Are From Non Venomous
Species.
• Only 50% Of Bites By Venomous Species Actually Enveno-mate The Patient
• I = Immobilize In The Same Way As A Fractured Limb. Children Can Be
Carried. Use Bandages Or Cloth To Hold The Splints, Not To Block The Blood
Supply Or Apply Pressure. Do Not Apply Any Compression In The Form Of
Tight Ligatures, They Do Not Work And Can Be Dangerous.
• G.H. = Get To Hospital Immediately. Traditional Remedies Have
NO PROVEN Benefit In Treating Snakebite.
• T = Tell The Doctor Of Any Systemic Symptoms Such As Ptosis, Progres Of
Swelling That Manifest On The Way To Hospital.
•

48. PRESSURE IMMOBILISATION
Its Purpose Is To Decrease
Absorption Of Venom
From Bite Site Into
Circulation.
Thus Buying Time For The
Patient To Reach Medical
Care.

49. Cont….
•Nil by mouth
•Remove shoes, rings, watches, jewellary and tight clothing
from the bitten area
•Leave the blisters undisturbed
•Traditional remedies have NO PROVEN benefit in
treating snakebite.
•Shift the victim to the nearest secondary or tertiary care
hospital where antivenom can be provided

50. DO NOTS IN FIRSTAID
• Do Not Apply A Tourniquet.
• Do Not Wash The Bite Site With Soap Or Any Other Solution
To Remove The Venom.
• Do Not Make Cuts Or Incisions On Or NearThe Bitten Area.
• Do Not Use Electrical Shock.
• Do Not Freeze Or Apply Extreme Cold To The Area Of Bite.
• Do Not Apply Any Kind Of Potentially Harmful Herbal Or
Folk Remedy.

51. Cont…
• Do Not Attempt To Suck Out Venom With Your
Mouth.
• Do Not Give The Victim Drink, Alcohol Or Other
Drugs.
• Do Not Attempt To Capture, Handle Or Kill The
SnakeAnd Patients Should Not Be Taken To Quacks.
• Do Not Apply Or Inject Antisnake Venom (ASV)
Locally.

52. INVESTIGATIONS
• Twenty Minute Whole Blood Clotting Test (20WBCT)
• Reliable Test Of Coagulation Which Can Be Carried Out By
Bedside And Is Considered To Be Superior To ‘Capillary Tube’
Method For Establishing Clotting Capability In Snake Bite.
• Fresh Venous Blood Should Be Placed InA Fresh, Clean And Dry
Test Tube And Left Undisturbed At Ambient Temperature For 20
Minutes.
• After That Tube Should Be Gently Tilted To Detect Whether Blood
Is Still Liquid And If So Then Blood Is Incoagulable.
• The Test Should Be Carried Out Every 30 Minutes From
Admission For 3 Hours And Then Hourly AfterThat.

53. OTHER INVESTIGATION
 CBC – Transient ↑ Hb, Thrombocytopenia
 PBF - Fragmented Red Cells (Helmet Cell , Schistocytes) -
Micro Angiopathic Haemolysis
 PT, aPTT – Rise In Viper Bite
 BT, CT
 Liver function test (LFT)
 Renal Function test (RFT) – Rise Due to AKI
 Serum Amylase
 Blood Sugar
 Urine Examination For Proteinuria / RBC / Hemoglobinuria
 Oxygen Saturation / Arterial Blood Gas (ABG)
 Ecg
 Abdominal Ultrasound
 2D Echo (If Available)

54.  ECG
 Bradycardia
 With ST Elevation Or Depression
 T Wave Inversion
 QT Prolongation
 Tall Tent T Wave
 Urine Analysis
Haemoglobin Or Myoglobin - Dipstick/ Immunoassays
Red Cell Casts - Glomerular Bleeding.
Massive Proteinuria - Generalized Increase In Capillary
Permeability In Russell’s ViperEnvenoming
Early Indicator Of Acute Kidney Injury

55. X RAY
Pulmonary Oedma
Intrapulmonary Haemorrhages
Pleural Effusion

56. Management of Snake Bite
STANDARD TREATMENT GUIDELINE
January 2016

57. SNAKE BITE TREATMENTPROTOCOL
• The Initial Management Includes Dealing With Airway, Breathing
And Treatment Of Shock.
• Administer Tetanus Toxoid 0.5 Ml Intramuscular.
• AllThe Patients Should Be Kept Under Observation ForA
Minimum Of 24 Hours.
Many Species, Particularly The Krait And The Hump-nosed Pit
Viper Are Known For Delayed Appearance Of SymptomsWhich
Can Develop After 6–12 Hours
• Pain Can Be Relieved With Oral Paracetamol OrTramadol.
• Aspirin Or Other NSAIDs Should Not Be Administered

58.  Try To Identify The Snake Responsible.
 Snake Colouration, Its Pupil Shape And Bitemarks
 Ask The Victim Relatives To Carefully Bring The Snake To
Hospital If It Has Been Killed And Then Use The Snake
Identification Material In Protocol To Identify It.
 Determine If Any Traditional Medicines Have Been Used As
They Can Sometimes Lead To Confusing Symptoms.
 Determine The Exact Time Of Bite Which Helps In
Determining Progression Of Signs And Symptoms.

59. Cont….
• IVAccess Established In Unaffected Extremity
• CBC,Coagulation Profile, Fibrinogen Concentration,
Should Be Assessed.
• Tourniquets Placed In Field Should Be Carefully
Removed.
• The Bitten Extremity Should Be Marked At 2 Or More
Sites Proximal To The Bite And The Circumference At
These Locations Should Be Assessed Every 15min To
Monitor For Progressive Edema-indicative Of Ongoing
Venom Effects.

60. ANTI SNAKE VENOM (ASV)
Anti snake Venom (ASV)Is Mainstay Of Treatment Antivenom Is
Immunoglobulin [Usually Pepsin refined Fab2 Fragment Of Whole
IgG ] Purified From The Plasma Of Horse.
• In India, Polyvalent ASV- Effective Against All The Four Common
Species; Russell’s Viper, Common Cobra, Common Krait And Saw-
scaled Viper
• No Monovalent AsvsAre Available
• ASV Is Produced Both In LiquidAnd Lyophilized Forms’
• LyophilizedASV Freeze Dried Powder [Heat Stable] 5-year Shelf
Life.
• LiquidAsv [Heat Labile] 2-year Shelf Life.

63. Test Dose
No
 Has No Predictive Value In Detecting Anaphylactoid Or
Late Serum Reactions And Should Not Be Used.
 Not IgeMediated, But Complement Activated.
 May Also Pre-sensitise The Patient, And Create Greater
Risk.

64. 1 ml ASV Neutrialized
 0.6 mg Cobra Venom
 0.45 mg Krait Venom
 0.6 mg Russel Viper Venom
 0.45 mg Saw Scaled Viper Venom
 ASV Neutrialized Circulating Venom In Blood But Can
Not Unlock The Venom That Attach To Receptor.

65. ROUTE
Freeze-dried (Lyophilized) Antivenoms Are Reconstituted With 10ml
NS Or D5 %.
Two Methods Of Administration Are Recommended:
(1)Intravenous “Push” Injection: Reconstituted Freeze-dried
Antivenom Is Given By Slow Intravenous Injection (Not More Than
2 Ml/Min).
(2) Intravenous Infusion: Reconstituted Freeze-dried
Antivenom Is Diluted In Approximately 5-10 ml/kg Isotonic Fluid
And Infused Over One Hour
Patients Must Be Closely Observed For At Least One Hour After
Starting Intravenous Antivenom Administration, So That Early
Anaphylactic Antivenom Reactions Can Be Detected And Treated
Early With Epinephrine(adrenaline)

66. Cont….
• Local Administration Of ASV Is Not Recommended As It Is
Extremely Painful And Can Raise The Intracompartmental
Pressure.
• Intramuscular Inj Are Not Recommended Antivenoms Are
Large Molecules Fab2 Fragments Which, After Intramuscular
Injection, Are Absorbed Slowly Via Lymphatics.
• Bioavailability Is Poor, Especially After Intragluteal Injection.
• Large Volumes Of Antivenom Cause Pain at Injection Site And
The Risk Of Haematoma Formation.
• ASV Should Be Given Only IV Route.

67. ASVAdministration
INDICATIONS
• Evidence Of Systemic Toxicity.
• Hemodynamic Or Respiratory Instability
Hypotension, Respiratory Distress
• Hemotoxicity
1. Clinically Significant Bleeding Or Abnormal Coagulation Studies
• Neurotoxicity
Any Evidence Of Toxicity Usually Beginning With Ptosis And Progressing To
Descending Paralysis Including Diaphragm
• Evidence Of Local Toxicity
Progressive Soft Tissue Swelling

68. INITIAL DOSE
Each Vial Of ASV Is Reconstituted With10ml NS.
• Initial Dose Is 10 Vials For BothAdultsAnd Children.
 Dose Of Asv For Neuroparalytic Snakebite –
ASV 10 Vials Stat As Infusion Over 30 Minutes Followed By 2nd
Dose Of 10 Vials After 1 Hour If No Improvement Within 1st
Hour.
 Dose Of Asv For Vasculotoxic Snakebite –
 Two Regimens
 Low Dose Infusion Therapy And High Dose Intermittent Bolus
Therapy Can Be Used.

69.  Low Dose Infusion Therapy –
10 Vials For Russel’s Viper Or 6 Vials For Saw Scaled Viper As
Stat As Infusion Over 30 Minutes.
Followed By 2 Vials Every 6 Hours As Infusion In 100 Ml Of
Normal Saline.
Till Clotting Time Normalizes Or For 3 Days Whichever Is Earlier.
 High Dose Intermittent Bolus Therapy –
10 Vials Of Polyvalent ASV Stat Over 30 Minutes As Infusion,
Followed By 6 Vials 6 Hourly As Bolus Therapy
Till Clotting Time Normalizes And/Or Local Swelling Subsides.

70. Response To Intial Dose of ASV
.
(a)General: The Patient Feels Better. Nausea, Headache And Generalised
Aches And Pains May Disappear Very Quickly. .
(b)Spontaneous Systemic Bleeding (eg. From The Gums) This Usually
Stops Within 15-30 Minutes.
(c) Blood Coagulability (As Measured By 20WBCT):This Is Usually
Restored In 3-9 Hours.
(d)InShocked Patients: Blood Pressure May Increase Within The First
30-60 Minutes And Arrhythmias Such As Sinus Bradycardia May
Resolve.
(e) Neurotoxic Envenoming(Cobra Bites)
May Begin To Improve As Early As 30 Minutes After Antivenom,
But Usually Takes Several Hours.
(f)Active Haemolysis May Cease Within A Few Hours And The
Urine Returns To Its Normal Colour

71. REPEAT DOSES
Criteria For Giving More Antivenom
• Persistence Or Recurrence Of Blood Incoagulability After 6
Hours (Measured By 20WBCT) Or Of Bleeding After 1-2
Hours.
• Deteriorating Neurotoxic Or Cardiovascular Signs After
1-2 Hours Of Administering Intial Dose OfASV.
• Maximum Dose Of ASV is Around 20 Vials In
Neurotoxic.
• Maximum Dose Of ASV is Around 30 Vials In
Vasculotoxic.

72. HEMOTOXIC ENVENOMATION
• Once Initial Dose Has Been Administered Over One Hour, No
Further ASV is Given For 6 Hours.
• 20WBCT Test Every 6 Hours Will Determine If Additional ASV
is Required.
• If The Blood Remains Incoagulable Six Hours After The Initial
Dose Of Antivenom, The Same Dose Should Be Repeated.
• This Reflects The Period The Liver Requires To Restore
Clotting Factors.

73. Neurotoxicenvenomation
• Antivenom Treatment Alone Cannot Be Relied Upon To
SaveThe Life Of A Patient With Bulbar And Respiratory
Paralysis.
• Death May Result From Aspiration, Airway Obstruction Or
Respiratory Failure.
• A Clear Airway Must Be Maintained.
• Once There Is Loss Of Gag Reflex And Pooling Of
Secretions In The Pharynx, Failure Of The Cough Reflex
Or Respiratory Distress, Cuffed Endotracheal Tube Or
Laryngeal MaskAirway Should Be Inserted.

74. ANTIVENOM REACTION
Early (Within A Few Hours) – 10-180 Minute
Pyrogenic (Endotoxin) Reactions: - 1-2 Hours
Late – 1-12 Days

75. EARLYREACTION
Itch (Often Over The Scalp) , Urticaria
Dry Cough , Fever
Nausea ,Vomiting , Abdominal Colic , Diarrhoea
Tachycardia
Severe Life-threatening Anaphylaxis:
Hypotension,
Bronchospasm
Angio-oedema.
Even Death

76. Mx Of Earliest Sign Of A Reaction
Antivenom Administration Must Be Temporarily
Suspended.
Epinephrine (Adrenaline) (0.1% Solution, 1: 1000,1mg/ml)
Adrenaline Is Given
Intramuscularly (Into Upper Lateral Thigh) In An Initial
Dose
Of 0.5Mg For AdultsAnd
0.01mg/Kg Body Weight For Children
Dose Can Be Repeated Every 5-10 Minutes

77. Cont…
Chlorphenamine Maleate
Adults 10 Mg,
Children 0.2mg/Kg By Intravenous Injection
Over A FewMinutes.
Intravenous Hydrocortisone
Adults 100 Mg,
Children 2 mg/Kg
Antipyretics

78. Prophylaxis in High Risk patients
Pre Treated Empirically With S/C Epinephrine
(Adrenaline)
IV Antihistamines Anti-H1 +Anti- H2 (Ranitidine)
IV Hydrocortisone 100 Mg

79. Pyrogenic (Endotoxin)Reactions
Shaking Chills (Rigors)
Fever, Vasodilatation And A Fall In Blood Pressure.
Febrile Convulsions - Children.
These Reactions Are Caused By Pyrogen
Contamination During TheManufacturing Process.

80. Late(Serum Sickness Type)Reactions
Fever, Nausea, Vomiting,
Diarrhoea,
Itching, Recurrent Urticaria, Arthralgia,
Myalgia,
Lymphadenopathy,
Periarticular Swellings, Mononeuritis Multiplex,
Proteinuria With Immune Complex NephritisAnd,
Rarely, Encephalopathy.

81. Treatment Of Serum Sickness
(Late Reactions)
5Days Course Of Oral Anti Histamine
Chlorphenamine –Adult 2 mg SixHourly
Children –0.25 mg/Kg/Day
Doesn’t Respond –5Day Dose Of Prednosolone.
Adult 5mgQ6h
Children 0.7 mg/Kg/Day

82. Contraindications
Prior H/O Allergic Reaction To Equine Serum
Severe Asthma.

83. Neostigmine test.
• A Trial Of Anticholinesterase (Eg “Tensilon Test”) Should Be
Performed In Every Patient With Neurotoxic Envenoming
• Atropine Sulphate (0.6 Mg For Adults; 50 mg/Kg For Children Is
Given By Intravenous Injection
• Followed By Neostigmine Bromide 0.02 mg/Kg For Adults, 0.04
mg/Kg ForChildren By Intramuscular Injection .
• The Patient Is Observed Over The Next 30-60 Minutes
(Neostigmine) For Signs Of Improved Neuromuscular
Transmission. Ptosis May Disappear And Ventilatory Capacity
(Peak Flow, FEV-1 Or Maximum Expiratory Pressure) May
Improve.

84. MANAGEMENT NEUROTOXIC
ENVENOMATION
 Inj. Atropine 0.05 Mg/Kg
 Followed By Inj. Neostigmine 0.04 Mg/Kg Intravenous
And Repeat Dose 0.01 Mg/Kg Every 30 Minutes For 5
Doses.
 Thereafter To Be Given As Tapering Dose At 1 Hour, 2
Hour, 6 Hours And 12 Hour.
 Observe The Patient Closely For 1 Hour To Determine
Neostigmine Effect.
 Improvement Should Be Visible By An Improvement In
Ptosis

85. Stop Atropine Neostigmine If
 Patient Has Complete Recovery From Neuroparalysis.
 Patient Shows Side Effects In The Form Of Fasciculations
Or Bradycardia.
 If There Is No Improvement After 3 Doses.

86.  If There Is No Improvement After 3 Doses Of Atropine
Neostigmine (Within 1 Hr).
 This Indicates Probable Krait Bite. Krait Affects Pre -
Synaptic Fibres Where Calcium Ion Acts As
Neurotransmitter.
 Give Inj. Calcium Gluconate 1-2 ml/Kg (1:1 Dilution)
Slowly Over 5-10 Min Every 6 Hourly And Continue Till
Neuroparalysis Recovers Which May Last For 5-7 Days.

87. MANAGEMENT OF
VASCULOTOXIC SNAKEBITE
 Strict Bed Rest To Avoid Even Minor Trauma.
 Screen For Hematuria, Hemoglobinuria, Myoglobinuria
By Dipstick Method.
 Closely Monitor Urine Output And Maintain 1 ml/Kg/Hr
Urine Output.
 Intravascular Volume Depletion Replace By Isotonic
Saline.

88. Management of AKI
 Give A Trial Of Forced Alkaline Diuresis (FAD) Within First 24
Hours Of The Bite.
 Delayed Fad Has No Role.
 Sequence Of Fad In Adults Is As Follows:
 • Inj. Frusemide 40 Mg IV Stat
 • Inj. Normal Saline 500 Ml + 20 Ml Of Nahco3 Over 20 Minutes
 • Inj. Ringer’s Lactate 500 Ml + 20 Ml Of Nahco3 Over 20 Minutes
 • Inj. 5% Dextrose 500 Ml + 10 Ml Of Potassium Chloride Over 90
Minutes
 • Inj. Mannitol 150 Ml Over 20 Min
 Whole Cycle Completes In 2 H 30 Min And Urine Output Of 3
Ml/Min Is Expected.

89.  If Patient Responds To First Cycle Continue For 3 Cycles
 If There Is No Response To Furosemide Discontinue FAD And
Refer Patient Immediately To A Higher Center For Dialysis.
 Indications For Dialysis Are:
1. Blood Urea >130 mg/dl (27 Mmol/L) (BUN 100 mg/dl), Sr.
Creatinine > 4 mg/dl (500 Μmol/L)
2. Fluid Overload Leading To Pulmonary Oedema
3. Hyperkalaemia (>7 Mmol/L Or Hyperkalaemic ECG Changes)
4. Unresponsive To Conservative Management.
5. Uremic Complications – Encephalopathy, Pericarditis.

90. MANAGEMENT OF SHOCK
 Infusion Of IV Boluses 10-20 Ml/Kg For Hypovolaemia.
 Initiate Inotropic Support With Dopamine Or Dobutamine.
 In Sepsis, Noadrenaline Is The Inotropic Agent Of Choice.
 Atients With Hypotension Associated With Bradycardia
Give Atropine.

91. For Coagulopathy
 Prolonged CT, PT, Aptt Administer Fresh Frozen Plasma (FFP)
Infusion.
 FFP Administration After ASV Administration Results In More
Rapid Restoration Of Clotting Function.
 Administer 10-15 ml/Kg Of FFP Within Over 30–60 Min Within 4
Hours Of ASV Administration.
 Antifibrinolytic Agents Are Not Effective And Should Not Be
Used In Snake Bite.
 Avoid Intramuscular Injections.
 Bleeding Leads To Anaemia, Pcv Is Lower Than 30 Needs Blood
Transfusion.

92. MANAGEMENT OF SEVERE
LOCAL ENVENOMING
 Give Prophylactic Broad-spectrum Antimicrobial Treatment For
Cellulitis
 Inj. Amoxiciilin+ Clavulanic Acid IV For First 7 Days Then Switch To
Oral Therapy
 Alternatively Inj Ceftriaxone If Amoxiciilin+clavulanic Acid Is Not
Available.
 Inj. Metronidazole IV Infusion For 7 Days
 Administer Booster Dose Of Tetanus Toxoid Injection.
 For Mild Pain Give Paracetamol But Not Use Aspirin Or Other Nsaids
[In Children Ibuprofen Cautiously 5-10 Mg/Kg/Dose Every 8 Hourly
May Use]
 In Case Of Severe Pain Inj. Tramadol

93. SURGICAL PROCEDURES IN
SNAKEBITE
 Debridement of necrotic tissue
 For Compartmental syndrome fasciotomy if require.
 fasciotomy should not be contemplated until haemostatic
abnormalities have been corrected.
 The limb can be raised in the initial stages
 Persistent moderate swelling of the limb after viper bite
can be successfully managed by systemic broad spectrum
antibiotics and repeated Magnesium Sulphate compresses.

94. FOLLOW-UP
• After Discharge From Hospital, Victim Should Be Followed.
• If Discharged Within 24 Hours, Patient Should Be Advised
To Return If There Is Any Worsening Of Symptoms Such As
Bleeding, Pain Or Swelling At The Site Of Bite, Difficulty In
Breathing, Altered Sensorium, Etc.
• The Patients Should Also Be Explained About Serum
Sickness Which May Manifest After 5–10 Days

95. THANK
YOU