Snakebite is a major public health issue, causing over 100,000 deaths worldwide each year. India accounts for nearly half of snakebite deaths globally, with the highest numbers occurring in rural areas. The "Big Four" venomous snakes that cause the majority of bites in India are the common krait, Indian cobra, Russell's viper, and saw-scaled viper. Proper first aid and timely administration of antivenom are critical to reducing mortality. Symptoms of envenoming depend on the snake species and amount of venom injected, and may include local tissue damage, bleeding disorders, organ dysfunction and systemic effects. Diagnosis involves examining the bite site and signs/symptoms, and lab tests can

1. Snakebite
Dr JAMSHEER V.T
MCh SURGICAL ONCOLOGY

3. • Incidence 5 million each year world wide .
• An estimated 1.8–2.7 million people worldwide are
envenomed annually.
• 81,000 - 138,000 deaths occur each year
• A nationally representative study noted 45,900
annual deaths in India.

4. • 400,000 amputations and other permanent disabilities
'BIG FOUR‘ (90%)
• Common krait
• Indian cobra
• Russell's viper
• Saw-scaled viper.
• Snakebites in the South-East Asia Region contribute to
almost 70% of estimated global snakebite deaths.

7. India
• Death in 2005 was 46 000 (1 snakebite death
for every 2 HIV/AIDS deaths).
• Snakebites caused 0.5% of all deaths, 3% in 5-
14 year-olds.
• 97% died in rural areas, only 23% in health
facilities.
• The highest numbers of deaths were in UP
(8,700), Andhra (5,200), and Bihar (4,500).

8. INTRODUCTION AND EPIDEMIOLOGY
• In the past, it was estimated that mortality
from venomous snakebite approached 25%
• Because of the availability of antivenom and
advances in emergency and critical care,
mortality rates today are

9. PREVENTIVE STRATEGY
• Development of region-specific guidelines and
training protocols.
• Support materials for health-care providers at
all levels of the health service
• Efficient supply of ASV can reduce preventable
deaths from snakebite

10. PIT VIPER

11. CROTALINAE (PIT VIPER) BITES- PATHOPHYSIOLOGY
• Crotaline venom is a complex enzyme mixture
• Local tissue injury
• Systemic vascular damage
• Hemolysis
• Fibrinolysis
• Neuromuscular dysfunction

12. • Up to 25% of crotaline snakebites are dry bites
Manifestations depends on ....
• The species and size of the snake
• Age and size of the victim
• The time elapsed since the bite
• Characteristics of the bite or bites (location,
depth, and number; the amount of venom
injected)

13. Clinical Feature
• LocalPain
• Swelling
• Ecchymosis
• Bleeding
• Blistering
• Lymphangitis

14. Systemic Symptoms
• Hypotension
• Nausea
• Vomiting
• Dizziness
• weakness
• Severe hypotension
• Shock
• Neurological Symptoms such as confusion,
convulsions, and respiratory paralysis.

15. DIAGNOSIS
• Presence of fang marks
Clinically, the injury may be manifest in three ways:
• Local injury (swelling, pain, ecchymosis)
• Hematologic abnormality
• Systemic effects (e.G., Oral swelling or paresthesias, metallic
or rubbery taste in the mouth, hypotension, tachycardia)
The absence of any of these manifestations for a period of 8 to
12 hours following the bite indicates a dry bite.

16. TREATMENT
• •
Avoid first aid treatments such as suction and incision.
• The Sawyer Extractor® suction pump with Doubtful efficacy
• Electric shock treatment of the bite site is dangerous
• Ice water immersion worsens the venom injury.
• Do not use tourniquets
• Constriction bands may be useful, especially when immediate
medical care is not available
• Apply the band snugly but loose enough to avoid arterial
compromise
• It should be easy to insert one or two fingers under the band.

17. FIRST AID

18. FIRST AID
• Reassurance
• Immobilization of the whole patient especially
their bitten limb,
• Accelerated transport to medical care
• Clear airway
• Give oxygen
• Establish intravenous access
• Monitor vital signs.

19. PREHOSPITAL MANAGEMENT
• Immobilize the limb
• Establish IV access in another limb
• Administer oxygen
• Hypotension --rapidly administer IV isotonic fluids.

20. ED MANAGEMENT

21. • India Polyvalent antivenoms raised in equines
against venoms of Bungarus caeruleus, Naja
naja, Daboia russelii
• Antivenoms are lyophilised (reconstituted to
10ml per vial) or liquid.
Snake Species Recommended Initial Dosage
Bungarus caeruleus 10-20 vials
Naja naja 10-20 vials
Daboia/Vipera russelli 10 vials
Echis carinatus 5 vials

24. AT HOSPITAL - Key questions:
• “Where (in which part of your body) were you bitten?
• “When were you bitten and what were you doing then?”
• “Where is the snake that bit you?”
• “What did it look like; did anyone take a picture?”
• “How are you feeling now?”
Examination of the bitten part:
• Extent of tenderness/swelling
• Lymph nodes draining bitten limb
• Signs of necrosis blistering, demarcated altered
pigmentation, putrefaction odour.

25. General Examination
• Blood pressure (postural drop indicates hypovolaemia)
• Gingival sulci, skin and mucosae for evidence of bleeding,
chemosis
• Abdominal tenderness
• Loin pain and tenderness
• Lateralising neurological signs (asymmetrical pupils),
• Impaired consciousness
• Bilateral ptosis, diplopia
• External ophthalmoplegia
• Trismus, tongue protrusion, facial muscles, gag reflex neck
flexors
• Fasciculations
• Painful muscles and dark brown urine suggest rhabdomyolysis

26. Species diagnosis
• expert identification of dead snake or a mobile
‘phone photo image is useful
• circumstances of bite (e.g. nocturnal bite
while sleeping on ground suggests krait)
• clinical syndrome.

27. Clinical Spectrum Of Syndromes

28. 20 minute whole blood clotting test
• A simple, informative bedside test requiring
only a new, clean, dry, ordinary glass tube,
bottle, vial or syringe.

30. • PT- INR (> or =1.2 is abnormal)
• aPPT
• fibrin(ogen) related antigens (fibrin degradation
products -FDP) or D-dimer.
• Hematocrit
• Thrombocytopenia
• Neutrophil - Leukocytosis
• Microangiopathic Hemolysis (Fragmented red cells
"helmet cells", schistocytes)

31. Biochemical Abnormalities Snake Envenoming Elevated Concentrations
Plasma Creatinine
Russell's viper/Hump-nosed
pit viper
Yes
Urea/Blood Urea Nitrogen
Russell's viper/Hump-nosed
pit viper
Yes
Potassium
Russell's viper/Hump-nosed
pit viper
Yes
Aminotransferases
Russell's viper/Hump-nosed
pit viper
Elevated
Sea-snake Elevated
Hyponatremia Common krait Yes
Muscle enzymes
Russell's viper/Hump-nosed
pit viper
Elevated
Sea-snake Elevated
Some kraits Elevated

32. Urine examination
• Dipsticks test for blood
• Haemoglobin or myoglobin and proteinuria.
• Microscopy to detect red cell casts, indicating
glomerular bleeding

33. Other Investigations Findings
ECG Arrhythmias ,evidence of hyperkalemia
Chest Radiography Pulmonary edema, hemorrhages, infarcts,
Ultrasound
Local envenoming, deep vein thrombosis,
pleural and pericardial effusion
Echocardiography Myocardial dysfunction
CT and MRI Imaging
Intracranial and spinal hemorrhages and
infarcts, osteomyelitis at the bite site

34. Antivenom treatment is indicated if/when patients with proven/
suspected snakebite develop one or more of the following signs.
• Systemic envenoming:
– Haemostatic abnormalities
– Neurotoxicity
– Cardiovascular abnormalities (
– Acute kidney injury
– Haemoglobin-/myoglobin-uria
– Supporting laboratory evidence
• Local envenoming:
– Local swelling involving more than half bitten limb
– Swelling after bites on digits
– Rapid extension of swelling beyond wrist/ankle
– Enlarged tender lymph node draining bitten limb