- Snake bite is a common occupational hazard in rural India, with approximately 2.5 lakh bites reported annually and 20% requiring anti-snake venom (ASV). - The document summarizes guidelines for snake bite management, including indications for ASV use such as systemic envenoming symptoms or local swelling over half the bitten limb. - It describes ASV as an immunoglobulin produced in horses or sheep to neutralize venoms from common Indian snakes, and outlines protocols for skin sensitivity testing, desensitization, and ASV administration via intravenous push or infusion to treat snake bite.

1. Snake bite
management
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- Dr Nikita Ingale
- Jr2
- Dept of Pharmacology
- GMCH, Nagpur
Guide
- Dr Vijay Motghare
- Professor and Head
- Dept of Pharmacology
- GMCH Nagpur

2. Introduction
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- Snake bite is common, neglected, occupational
disease specially in rural areas
- Major public health problem in India with incidence of
about 2,50,000, 20% bites require anti-snake venom
(ASV) administration
- Morbidity is 1.4-68/1 lakh population, mortality 1.1-
2.4/1 lakh and case fatality rate 1.7-20%

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Introduction
- In 2009, snake-bite was included in the World Health
Organization (WHO’s) list of neglected tropical diseases
- 35,000 and 50,000 people die of snakebite in India each
year
- Snake-bite is a common occupational hazard of farmers,
plantation workers who are generally from low socio-
economic status

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Anti snake venom
- Anti snake -venom is an immunoglobulin (Ig) usually
pepsin refined F(ab)2 fragments of IgG purified from the
serum or the plasma of a horse or sheep
- The anti-venins are produced against 4 most important
venomous snakes of India - Naja naja (Indian Cobra);
Bungarus caeruleus (Indian common krait); Daboia
russelii (Russell’s viper); and Echis carinatus (Saw-
scaled viper).

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- Each milliliter of polyvalent ASV produced in India
neutralizes-
0.6 mg dried Indian cobra venom
0.45 mg dried common krait venom
0.6 mg of dried Russell’s viper venom
0.45 mg of dried saw-scaled viper venom
Anti snake venom

11. Intradermal skin testing
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- Skin/conjunctival hypersensitivity testing does not reliably
predict early or late anti-venom reactions as they are
mediated by direct activation of complement system and not
mediated by IgE and is not recommended.
- It was found that in about 86% of cases the skin
hypersensitivity test was performed prior to initiation of ASV
therapy. Skin testing only delays the administration of ASV
and can itself be sensitizing

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Role of anti-venom
- Specific antidote to the toxins in snake venom is
hyperimmune globulin from an animal that has been
immunized with the appropriate venom
- The introduction of serum anti-venom by Albert Calmette
in 1895 for the treatment of envenoming was quickly
accepted without formal clinical trials
- More than a century later, anti-venoms are considered as
essential drugs.

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- .
- It is costly, due to constant shortage it should be used only
when there is a possibility of circulating venom in the body
and not to all snake bite cases.
- Early administration of ASV is essential to neutralize the
maximum circulating venom before it is fixed in the tissue.
should be given to cases with evidence of systemic
envenomation
- Development of enlarged tender lymph node draining the
bitten limb is an early manifestation of poisonous snake bite.
- ASV is prepared from horse serum and is
associated with allergic reactions which may
result in anaphylaxis and even death

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Adverse reactions to anti-venom and its
Prevention and treatment
Early anaphylactic reactions
- It usually occurs in 10-180 minutes of starting anti-venom.
- It includes urticaria, itching (often over the scalp), cough,
nausea, vomiting, abdominal colic, diarrhea, and tachycardia.
Minority of cases present with fatal anaphylaxis-hypotension,
bronchospasm, and angioneuritic edema.
- They occur due to direct activation of complement by IgG and
residual FC fragment or direct stimulation of mast cells and
basophils by antivenin proteins. They are not IgE mediated,
type I reactions.

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Pyrogenic reactions
- It usually develops 1-2 hrs after starting ASV therapy.
Fever, rigors, chills, hypotension are the presenting
features.
- They are due to the pyrogenic contamination of ASV and
diluting fluid.
Late serum sickness type reactions
- It develops in 1-12 days after antivenin therapy (mean 7
days).
- Clinical features include fever, nausea, arthralgia, myalgia,
arthritis, mononeuritic multiplex, recurrent urticaria,
lymphadenopathy, neuritis, and even encephalopathy.
- They usually respond to oral antihistamine.

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- Study showed a higher incidence of reaction to
ASV as compared to WHO literature, most of
which were of early anaphylactic type.
- The anti-venom reactions were treated with
adrenaline, anti-histaminics, and systemic
steroids.

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20 minutes WBCT (20 WBCT)
- Bedside test  clean, dry glass vessel. If the blood is still liquid (un-
clotted) after 20 minutes and runs out, the patient has hypofibrinogenemia
as a result of venom-induced consumption coagulopathy.
- This test is an important parameter for initiation and repetition of ASV in
snake bite cases.
- In India, whole blood clotting time of more than 20 minutes is virtually
diagnostic of viper bite and rules out elapid bite.
- study has shown that in about 26% cases of vasculotoxic snake bites, 20
WBCT was not done, and it was done only in 18% cases of undiagnosed
snake bites, indicating a poor management protocol.

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More about Snake
bite management

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2016
WHO
guidelines for
management
of snake bite

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- Known poisonous snake bite
Systemic envenoming- -
- hemostatic abnormalities
- Neurotoxic signs
- Cardiovascular
abnormalities
- Acute kidney injury
- Haemoglobinuria
Local envenoming-
- Local swelling more
than half bitten limb
- Rapid extension of
swelling
- Enlarged lymph nodes
Indications

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Guidelines
0.03 ml of 1:10 diluted ASV in normal saline intradermally
Urticarial wheal with erythema in 30 mins
Test positive
SKIN HYPERSENSITIVITY TEST

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Guidelines
DESENSITIZATION
Subcut 0.1 ml of 1:100 ASV dilution
Increase the dose every 15 mins as 0.2 ml, 0.5 ml
Repeat regimen with 1:10  1 and finally undiluted ASV

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Methods
IV PUSH
- Reconstituted freeze
dried or liquid ASV is
given by slow
infusion
- not more than
2ml/min
IV INFUSION
- Reconstituted freeze
dried or liquid ASV is
diluted in 5-10 ml of
isotonic fluid / kg body
wt
- Infused at constant rate
in 1 hr

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Response to ASV
- General  pt feels better, no pain, no nausea
- Spontaneous bleeding stops
- Blood coagulability restored in 3 hrs
- BP increases in an hr
- Neurotoxic envenoming improves in 30 mins
- Urine colour comes to normal

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When to repeat ASV?
- Blood is incoagulable after 6 hrs of 1st dose
- Pt bleeds briskly, repeat within an hr
- Deteriorating neurotoxicity or CVS signs

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How Not to Treat a Snakebite
• Application of a tight tourniquet which occludes arterial supply
• Cauterisation of bitesite
• Multiple, deep incisions through bitesite
• Suction by mouth, vacuum pump, or syringe
• Application of injurious substances such as potassium
permanganate, phenol, etc.
• Application of electric shock
• Application of ice (cryotherapy)
• Use of herbal, folk, or Ayurvedic medicines or remedies

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References
- Warrell DA, editor. WHO/SEARO guidelines for the clinical management
of snake bite in south east asia region. New delhi: WHO regional office for
south east asia; 2016. P. 1-67.
- Vinod s deshmukh, vijay m motghare, dharmendra gajbhiye, birajdar sv,
rushikesh deshpande, harshal pise, swapnil jaykare, study on acute
adverse drug reactions of antisnake venom in a rural tertiary care hospital,
asian journal of pharmacuetical and clinical research, vol 7, issue 5, 2014

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