identification of snakes and clinical features of snakebite , envenomation and management of snake bite national snake bite treatment protocol

1. Management of snake bite
Dr. Prasenjit Gogoi
MBBS, MEM(SEMI), PGDHHM
Attending Consultant,
Emergency Dept., Apollo Hospitals Guwahati

2. Introduction
• India is estimated to have the highest snakebite
mortality in the world.
• 2.8 million cases of snakebite annually with 46,900
deaths annually in India (WHO)
• Snake bite is an occupational hazard in an agricultural
country like India.
• Snake bites are more common in rural areas especially
during monsoon season.

3. The Big 4
Common spectacled cobra(Naja naja) Common Krait(Bungarus caeruleus)
Saw-scaled viper(Echis carinatus) Russel’s viper(Daboia Russelii)
Hemotoxic
Neurotoxic

4. Composition of snake venom
• Procoagulant enzymes
(Viperidae)
• Haemorrhagins (zinc
metalloproteinases)
• Cytolytic or necrotic
toxins
• Haemolytic and myolytic
phospholipases A2
• Pre-synaptic neurotoxins
(Elapidae and some
viperidae)
• Post-synaptic
neurotoxins (Elapidae)

5. Clinical features
• General – fear and anxiety
• Local envenoming
– Local pain at bite site
– Local swelling
– Tenderness
– Painful swelling of regional lymph nodes
– Other signs : fang marks, persistent local bleeding,
bruising, lymphangitis, inflammation, blistering,
infection, abscess formation, necrosis

6. Signs of local envenomation

7. Clinical features (cont)
• Systemic envenoming : nausea, vomiting,
malaise, abdominal pain, weakness,
drowsiness, prostration.
1. Cardiovascular (Viperidae)
– Hypotension, syncope, collapse, shock
– Cardiac arrhythmias
– Myocardial damage

8. Clinical features (cont)
2. Generalized increase in capillary permeability
– Facial, periorbital, conjunctival edema
– Pleural and pericardial effusions, pulmonary edema
– Massive albuminuria
– Hemoconcentration
3. Bleeding and clotting disorders(Viperidae)
– Local bleeding
– Spontaneous systemic bleeding
(gums. epistaxis, hemoptysis,
subarachnoid hemorrhage etc)

9. Clinical features (cont)
4. Neurological (Elapidae, Viperidae)
– Bilateral ptosis
– External ophthalmoplegia
– Descending paralysis progressing
to generalized flaccid paralysis
5. Generalised rhabdomyolysis
– Muscular stiffness, tenderness
– Painful on passive stretching, trismus
– Dark brown urine

10. Clinical features (cont)
6. Acute kidney injury
– Low back pain
– Hematuria,
hemoglobinuria, myoglobinuria
– Oliguria/anuria
– Uremia
7. Pituitary insufficiency (Russell’s viper)
– Acute : shock, hypoglycemia
– Chronic : weakness, loss of sexual characters,
loss of libido, amenorrhea, testicular atrophy,
hypothyroidism etc

11. First aid (WHO guidelines)
“CARRY NO R.I.G.H.T.”

12. First aid (cont.)
• CARRY = Do not allow victim to walk.
• No = Tourniquet, No-electrotherapy, No-cutting, No-pressure
immobilization, No-sucking of venom
• R = Reassure the patient.
• I = Immobilize the limb.
• GH = Get to hospital immediately.
Traditional remedies - NO PROVEN benefit
• T = Tell the doctor of any systemic symptoms that manifest on the
way to hospital.

13. Pre - hospital management
• Manage airway/breathing/circulation
• Immobilization
• Identify neurological
symptoms
• Watch for paradoxical
respiration
• Secure IV line

14. Emergency hospital management
Initial management
• Access ABCDE
• CPR if needed
• Tetanus toxoid if skin is breached
• Antibiotic if cellulitis or local necrosis present
• Specific treatment after history and physical
examination

15. Diagnosing Envenomation
Pure clinical skill
No diagnostic kit available yet !!

16. Diagnosis phase

17. Investigations
• Blood investigations
• Urine examination
• Biochemistry –S.
Creat/Urea/K+/Na+
• ABG
• ECG/X-ray/CT/USG
• ELISA - to confirm snake
species.

18. Treatment phase
• Pain management – oral paracetamol/tramadol
~NO APRIRIN/NSAIDS~
• Handling tourniquets
– Sudden removal -> neurological paralysis and hypotension.
– Remove after ASV administration + doctor present
– Test for the presence of a pulse distal to the tourniquet. If
no distal pulse, apply blood pressure cuff & reduce the
pressure slowly.

19. Anti Snake Venom
• ASV is Ig (usually the enzyme refined F(ab)2
fragment of IgG) purified from the serum/plasma
of a horse/sheep immunised with the venoms of
one or more species of snake.
• It neutralises the free, unbound venom and to
some extent also dissociates bound toxin.
• WHO has included ASV in the list for Essential
Medicines and should be part of any primary
healthcare package where snakebites occur.

20. Anti Snake Venom
• In India, polyvalent ASV, effective against all the
four common species; Russell’s viper, common
cobra, common Krait and saw-scaled viper is
available.
• ASV is produced both in liquid and lyophilized
forms.
– Liquid ASV requires a reliable cold chain and has 2-
year shelf life.
– Lyophilized ASV, in powder form, has 5-year shelf life
and requires only to be kept cool.

21. Each ml of ASVS neutralizes
1. 0.60 mg of Indian Cobra venom
2. 0.45 mg of Common Krait venom
3. 0.60 mg of Russel’s Viper venom
4. 0.45 mg of Saw-scaled Viper venom

22. Prophylaxis of ASV reactions
• hydrocortisone (100 mg) + antihistamine
or
0.25–0.3 mg adrenaline subcutaneously
• In asthmatics inhaled adrenergic beta2 agonist
may prevent bronchospasm
Test dose of ASV is not recommended.

23. National Snakebite Treatment Protocol
• For neurotoxicity: 10 vials stat as infusion over 30 mins
followed by 2nd dose of 10 vials after 1 hour (if no
improvement within 1st hour)
• For hemotoxicity :
Low dose infusion therapy – 10 vials for russels viper or 6
vials for saw scaled viper as stat infusion over 30 mins
followed by 2 vials every 6 hours as infusion in 100 ml ns
till clotting time normalizes or 3 days whichever is earlier
High dose intermittent bolus therapy – 10 vials of asv over
30 mins as infusion followed by 6 vials 6 hourly as bolus
therapy till clotting time normalizes or local swelling
subsides

24. • For saving surgery - high initial dose of ASV is
justified (up to 25 vials)
Local administration of ASV – not recommended.
Criteria for repetition of ASV
Persistence/recurrence of blood incoagulopathy
after 6 hours or bleeding after 1-2 hours
Deteriorating neurotoxic or cardiovascular signs
after 1 hour

25. Victims presenting late
• Often after several days -> acute renal failure.
• Perform a 20WBCT. Positive -> ASV.
Negative -> ARF -> dialysis.
• Neurotoxic envenoming –
10 vials of ASV + respiratory support.

26. ASV reactions
• Early anaphylactic reactions – within minutes to
180 miutes.
• Pyrogenic reactions – within 1-2 hours after
treatment.
• Late reactions (serum sickness type) – within 1-12
days (mean 7) after treatment.

27. Treatment of early ASV reaction
Discontinue ASV
• Epinephrine: 0.5 mg for adults & 0.01 mg/kg
for children IM (1:1000)
• Antihistamine + Corticosteroids
*ASV can be restarted slowly after 10 to 15
minutes under observation

28. Role of neostigmine in neurotoxic
envenomation
• Anticholinesterase – prolongs life of
acetylcholine.
• Reverses respiratory failure and neurotoxic
symptoms.
• Effective against postsynaptic neurotoxins -
cobra

29. Neostigmine test
Step 1 : Administer atropine 0.6 mg IV
Step 2 : Administer neostigmine 1.5 to 2 mg IM
Step 3 : Observe for 1 hour for effectiveness
Responding Not responding
0.5 mg IM ½ hourly + 0.6 mg
atropine IV for 5 doses and then
2-12 hourly according to recovery.
Stop neostigmine

30. Additional supportive care
• Respiratory failure: Mechanical ventilation.
• Significant bleeding: FFP or cryoprecipitate.
• Shock: Inotropic support.
• Renal failure: Hemodialysis.
• Compartment syndrome: Fasciotomy.
• Wound necrosis: Surgical debridement.

31. Special situations
Same dosage of ASV

32. Follow up
Essential
Discharged within 24 hours -> return if any
worsening of symptoms
Serum Sickness

33. Snakebite prevention
• Use a torch.
• Avoid sleeping on the ground
• Use mosquito net.
• Away - animal feed and rubbish from your house.

34. References
• Jesudasan JE, Abhilash KP. Venomous snakebites: Management and anti-snake
venom. Curr Med Issues 2019;17:66-8
• Himmatrao Saluba Bawaskar, Pramodini Himmatrao Bawaskar. Snake bite:
prevention and management in rural Indian settings. The Lancet Glocal Health,
Vol.7, Issue9, sept2019; Page e1178
• Mohan G, Singh A, Singh T. Guidelines for the Management of Snakebites. Curr
Trends Diagn Treat 2018;2(2):102-108.
• Guidelines for the management of snakebite, 2nd edition; South east asia WHO
publication 2016. https://www.who.int/docs/default-source/searo/india/health-
topic-pdf/who-guidance-on-management-of-snakebites.pdf?sfvrsn=5528d0cf_2
• Shibendu Ghosh, Prabuddha Mukhopadhyay, Tanmoy Chatterjee: Management of
Snake Bite in India. https://www.japi.org/r2a48494/management-of-snake-bite-in-
india#.YPbjVzpSUO8.link
• Surjit Singh, Gagandip Singh. Snake Bite: Indian Guidelines and Protocol. Available
at http://www.apiindia.org/medicine_update_2013/chap94.pdf
• Ahmed SM, Ahmed M, Nadeem A, Mahajan J, Choudhary A, Pal J. Emergency
treatment of a snake bite: Pearls from literature. J Emerg Trauma Shock.
2008;1(2):97-105. doi:10.4103/0974-2700.43190

35. Thank You ..!!