The document outlines guidelines for the treatment of snake bites, including rapidly assessing the airway, breathing, and circulation of the patient; administering tetanus toxoid, antibiotics, and anti-venom as needed based on symptoms; and closely monitoring vital signs and administering supportive care for any complications like respiratory failure, hypotension, or renal failure. Laboratory tests are also recommended to identify coagulopathies or tissue damage from the venom.

1. Kaushik.H.M
080201388

2.  Rapid clinical assessment and resuscitation
 Detailed clinical assessment and species diagnosis
 Investigations/laboratory tests
 Specific treatment

3.  Attend to AIRWAY , BREATHING,
CIRCULATION
 Secure an IV line (wide bore).
 Booster dose of tetanus toxoid is
recommended.
 Identify the snake responsible

4.  All patients should be kept under
observation for a minimum period of 24 hrs.
 Determine the exact time of bite
 Bacterial Infections- Prophylactic course of
penicillin (or erythromycin for penicillin-
hypersensitive patients)and a single dose of
gentamicin or a course of chloramphenicol

5. •Care must be taken when removing tight tourniquets
tied by victim. Sudden removal can lead to massive
surge of venom leading to neurological paralysis,
hypotension.
•Pain-paracetamol/ 50 mg of tramadol maybe given.
NSAIDs and Aspirin are contraindicated.

6. Investigations
 20 minute whole blood clotting test -considered most
reliable test of coagulation.
 Platelet count : may be decreased – viper
 WBC cell count : Early neutrophil leucocytosis in systemic
envenoming from any species.
 Blood film : Fragmented RBC(“helmet cell”, schistocytes) are
seen in microangiopathic haemolysis.
 Plasma/serum : may be pink or brownish if there is gross
haemoglobinaemia or myoglobinaemia.

7.  Aminotransferases, creatine kinase, aldolase elevated if there
is severe local damage or, particularly generalised muscle
damage.
 Bilirubin is elevated following massive extravasation of blood.
 Creatinine, urea or blood urea nitrogen levels are raised in
the renal failure
 Early hyperkalaemia may be seen following extensive
rhabdomyolysis in sea snake bites. Bicarbonate will be low in
metabolic acidosis (eg renal failure).
 Arterial blood gases and pH may show evidence of respiratory
failure (neurotoxic envenoming) and acidaemia (respiratory
or metabolic acidosis).

8.  Urine for RBC – Viper Bite – Hematuria,
Proteinuria, Hemoglobinuria, Myoglobinuria
 ECG – Normal, Bradycardia with ST elevation or
depression, T inversion, QT prolongation.
 Chest X- ray – Normal or may show Pulmonary
Oedema, Intrapulmonary Hemorhages, Pleural
Effusion.

9. Monitor vital signs
 Observe every patient for minimum 24 hours. Monitor the
patient every 6 hours.
 Pulse, BP, Respiration
 Urine output
 Blood urea, Creatinine
 Bleeding tendency
 Local swelling
 Vomiting
 Diplopia, Ptosis, Muscle Weakness, Breathlessness

10. Anti Snake Venom
 Antivenom is immunoglobulin (usually the enzyme
refined F(ab)2 fragment of IgG) purified from the
serum or plasma of a horse or sheep that has been
immunised with the venoms of one or more species of
snake.
 It neutralises the free, unbound venom & to some
extent also dissociates the bound toxin
 ASV is manufactured in India by the Haffkine Central
Research Institute, Kasauli & Serum Institute of India,
Pune & both are POLYVALENT(neutralizes venom of
different species of snakes.)

11. 1 ml of ASV neutralises
 Cobra – 0.6 mg
 Common krait – 0.45mg
 Russels viper – 0.6 mg
 Saw scaled viper – 0.45 mg

12. Indications
 As per W.H.O Guidelines ONLY if a patient
develops one / more of the following
signs/symptoms ASV should be administered :
SYSTEMIC ENVENOMING
• Evidence of coagulopathy: detected by
20WBCT or visible spontaneous systemic
bleeding
• Evidence of neurotoxicity : ptosis,
ext.ophthalmoplegia

13. • CVS abnormalities : hypotension, shock,
arrhythmias
• Acute renal failure
• Hemoglobinuria / myoglobinuria
• Persistent severe vomiting / abdominal pain

14. LOCAL ENVENOMING
• Local swelling > ½ of involved limb
• Rapid extension of swelling
• Enlarged tender lymph nodes draining the bitten limb

15. ASV administration
 NO ASV TEST DOSE MUST BE ADMINISTERED .
 Recommended initial dosages are 100 ml( 10 vials) of
polyvalent ASV for adults & children based on
published research that russells viper injects on an
average of 63 mg of venom.
 Our initial dose must be calculated to neutralize the
average dose of venom injected.

16.  Range of venom injected = 5mg – 147 mg
 Suggested ASV dose = 100 -250 ml
 Initial dose of 100 ml must be diluted in 100 ml of NS &
given over 1 hour.
 Patient should be carefully monitored for 2 hrs.
 Local administration of ASV, near the bite site –
ineffective, painful, raises intracompartmental pressure.
– SHOULD NOT BE DONE

17. Victim who arrives late ?
 Often after several days , usually with acute renal failure.
 Are there any signs of current venom activity ?
 Perform 20WBCT & determine if any coagulopathy is
+, if + administer ASV. If - , treat ARF – dialysis
 Neurotoxic envenoming – look for ptosis, respiratory
failure , + administer 1 dose of ASV , respiratory support

18. ASV reactions
 Patient should be monitored closely
 First sign of any one of the following :
1. Utricaria 6. Vomiting 11.Bronchospasm
2. Itching 7. Diarrhoea 12.Angioedema
3. Fever 8. Abdominal cramps
4. Chills 9. Tachycardia
5. Nausea 10. Hypotension
 Discontinue ASV & give 0.5 mg of 1 :1000 adrenaline
IM/ IV diphenhydramine(antihistamines).

19. Repeat doses of ASV
 HEMATOTOXIC POISONING :
• 20 WBCT – abnormal – initial dose given over 1 hr.
• Repeat 20WBCT after 6 hrs
• Abnormal – another dose to be given. Repeat same
dose again.
• 20WBCT & Repeat doses of ASV – to be continued
on 6 hourly manner until coagulation is restored.

20.  NEUROTOXIC POISONING
• Assess the patient 1-2 hrs after the initial dose
• If symptoms persist / worsen , 2 nd dose which is
same as 1st dose is to be given & then ASV can be
discontinued

21. Role of Neostigmine in
Neurotoxic poisoning
 Anticholinestrase & prolongs life of Ach - which can
reverse resp.failure & neurotoxic symptoms ( post synaptic
)
 Neostigmine test : 1.5 -2.0 mg IM preceeded by 0.6 mg
atropine IV
• Observe for 1 hr
• If victim responds , continue 0.5 mg Neostigmine IM ½
hrly with 0.6 mg Atropine IV over 8 hrs
• If no improvement in symptoms after 1 hr , stop
Neostigmine

22. Supportive Therapy
 RESPIRATORY FAILURE :
• ABG
• Intubate & Ventilate
• Neostigmine & Atropine
 HYPOTENSION :
• Plasma expanders-crystalloids
• Dopamine 2.5 – 5 micrograms/Kg/min

23.  PERSISTANT / SEVERE BLEEDING :
• Majority – timely use of ASV will stop systemic bleed
• ASV + Blood Transfusion
 RENAL FAILURE
• Hemodialysis / peritoneal dialysis
 COMPARTMENT SYNDROME :
• Fasciotomy
 SURGICAL DEBRIDEMENT OF WOUND: Necrosis