Snake bite Treatment Protocol

First Aid

• The first aid recommended is based around the mnemonic:

• "Do it R.I.G.H.T."

• It consists of:

• R. = Reassure the patient. Seventy per cent of all snakebites are from non-venomous
species. Only 50% of bites by venomous species actually envenomate 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 that manifest on the way to
hospital.

Pressure Immobilization: Its purpose is to retard the movement of venom from bite site into
circulation, thus buying time for the patient to reach medical care.

‘Do Nots’ in First Aid

• 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 near the 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.
• Do not attempt to suck out venom with your mouth.
• Do not give the victim anything to drink alcohol or other drugs.
• Do not attempt to capture, handle or kill the snake.

Treatment Protocol
• The initial management includes dealing with airway, breathing and treatment of shock.
• Administer tetanus toxoid.

Emergency Care
Try to identify the snake responsible.
• Snake colouration, its pupil shape and bite marks.
• 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
symptom.
• IV access established in unaffected extremity.
• Dose of IV broad spectrum antibiotic should be given.
• Tetanus toxoid must be given if not immunized for age.
• 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.
• All the patients should be kept under observation for a minimum of 24 hours.
• Many species, particularly the Krait and the hump-nosed pit-viper are known for delayed
appearance of symptoms which can develop after 6–12 hours.

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.
• A few ml of fresh venous blood should be placed in a fresh, clean and dry glass vessel
preferably 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 incoaguable. The test should be carried out every 30 minutes from admission for 3
hours and then hourly after that.
• Hb /platelet count /peripheral smear prothrombin time (PT) /activated partial
thromboplastin time.
• Urine examination for proteinuria /RBCs / hemoglobinuria / myoglobinuria
• Biochemistry for serum creatinine/Urea/Potassium
 • X-ray chest to look for evidence of any collapse / aspiration
• Oxygen saturation/arterial blood gas (ABG)

Treatment Phase
• Pain can be relieved with oral paracetamol or tramadol.
• Aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) should not be administered.

Severity of envenomation-

Types of signs Minimal Moderate Severe

and
symptoms
Local Swelling erythema Progression of swelling, Rapid swelling, erythema or
or ecchymosis erythema or ecchymosis ecchymosis involving the entire body
confined to the site beyond the site of the part
of the bite bite
Systemic No systemic signs Non-life-threatening Markedly severe signs and symptoms
or symptoms signs and symptoms (hypotension-systolic Blood pressure
(nausea, vomiting, <80mmHg) altered sensorium,
perioral paraesthesia, tachycardia, tachypnoea
myokymia,
hypotension)
Coagulation No coagulation Mildly abnormal Markedly abnormal coagulation
abnormalities or coagulation profile profile with evidence of bleeding or
other important without clinically threat of spontaneous haemorrhage
laboratory significant bleeding. (unmeasurable INR APTT and
abnormalities Mild abnormalities on fibrinogen. Severe thrombocytopenia
other laboratory test with platelet count <20,000 per mm3)
results of other laboratory test maybe
severely abnormal

Anti-snake venom

Anti-snake venom (ASV) is the mainstay of treatment. It is an immunoglobulin [usually pepsin-

refined (Fab2) fragment of whole IgG] purified from the plasma of a horse, mule or donkey (equine)
or sheep (bovine) that has been immunized with the venoms of one or more species of snake.

In India, polyvalent ASV, i.e. effective against all the four common species; Russell’s viper, common
cobra, common Krait and saw-scaled Viper and no monovalent ASVs are available.

Indications for ASV administration

Evidence of systemic toxicity

Hemodynamic or respiratory instability

- Hypotension, respiratory distress

Hematotoxicity

- Clinically significant bleeding or abnormal coagulation studies

Neurotoxicity
 - Any evidence of toxicity usually beginning with CN abnormalities and progressing to
descending paralysis including diaphragm
Evidence of local toxicity

- Local swelling involving more than half bitten limb (in absence of tourniquet) within 48 hr of
the bite; swelling after bites on digits; rapid extension of swelling beyond wrist/ankle within
few hours of bites on hand/foot); enlarged tender lymph node draining bitten limb
How to administer ASV

Freeze-dried (lyophilized) anti-venoms are reconstituted, usually with 10ml of sterile water for
injection per ampoule. Two methods of administration are recommended:

(1) Intravenous “push” injection: Reconstituted freeze-dried anti-venom is given by slow

intravenous injection (not more than 2 ml/minute).

(2) Intravenous infusion: Reconstituted freeze-dried anti-venom is diluted in approximately 5-10

ml of isotonic fluid per kg body weight) and is infused at a constant rate over a period of
about one hour.

Patients must be closely observed for at least one hour after starting intravenous anti-venom
administration, so that early anaphylactic anti-venom reactions can be detected and treated early
with epinephrine (adrenaline).

Local administration of ASV or intramuscular injection are not recommended.

Initial Dose - The recommended dose is often the amount of anti-venom required to neutralize the
average venom yield when captive snakes are milked of their venom. In practice, the choice of an
initial dose of anti-venom is usually empirical.

• Each vial is 10 ml of reconstituted ASV. Initial dose is 8-10 vials for both adults and children.

• Common krait- 100ml ASV; Russell’s viper-100ml; Saw scaled viper-50 ml; Indian cobra-
100ml

If an adequate dose of appropriate anti-venom has been administered, the following responses
may be observed.

(a) General: The patient feels better. Nausea, headache and generalised aches and pains may
disappear very quickly. .

(b) Spontaneous systemic bleeding (e.g. from the gums): This usually stops within 15-30
minutes.

(c) Blood coaguability (as measured by 20WBCT): This is usually restored in 3-9 hours.

(d) In shocked 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
anti-venom, but usually takes several hours.

(f) Active haemolysis may cease within a few hours and the urine returns to its normal colour.

Criteria for giving more anti-venom

 • Persistence or recurrence of blood incoaguability after 6 hours (measured by 20WBCT) or of
bleeding after 1-2 hours.

• Deteriorating neurotoxic or cardiovascular signs after 1-2 hours of administering initial dose
of ASV

Range of venom injected is about 5mg-147mg. Maximum dose of ASV is around 25 vials. ASV should
be administered over a period of 1hour.

• In hematotoxic envenomation; once initial dose has been administered over one hour, no
further ASV is given for 6 hours.

• Twenty WBCT test every 6 hours will determine if additional ASV is required. If the blood
remains incoaguable (as measured by 20WBCT) six hours after the initial dose of anti-
venom, the same dose should be repeated. This is based on the observation that, if a large
dose of anti-venom (more than enough to neutralize the venom procoagulant enzymes) is
given initially, the time taken for the liver to restore coaguable levels of fibrinogen and other
clotting factors is 3-9 hours. This reflects the period the liver requires to restore clotting
factors.

• In neurotoxic bites; anti-venom treatment alone cannot be relied upon to save the life of a
patient with bulbar and respiratory paralysis.

• Death may result from aspiration, airway obstruction or respiratory failure. A patent 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, a cuffed endotracheal tube or
laryngeal mask airway should be inserted.

Neostigmine test

• A trial of anticholinesterase (eg “Tensilon test”) should be performed in every patient with
neurotoxic envenomation.

• Atropine sulphate (0.6 mg for adults; 50 μg/kg for children) or glycopyrrolate is given by
intravenous injection followed by neostigmine bromide in appropriate doses) by
intramuscular injection 0.02 mg/kg for adults, 0.04 mg/kg for children.

• The patient is observed over the next 30-60 minutes (neostigmine) or 10-20 minutes
(edrophonium) for signs of improved neuromuscular transmission. Ptosis may disappear and
ventilatory capacity (peak flow, FEV-1 or maximum expiratory pressure) may improve.

• If the child is responsive, continue Neostigmine every 30 minutes for first 2 hours and
thereafter as and when necessary if the response is sustained. Atropine may be repeated
every 2 hours in that phase.

• If response is transient after first 2 hours, then give Neostigmine every 2 – 4 hours and
continue intermittent Atropine.

Adverse reactions to ASV

IgE-mediated Type I hypersensitivity after previous exposure to equine serum is uncommon.

Early anaphylactic reactions (1 – 180 minutes after starting anti-venom) can have all classic features
of anaphylaxis from urticaria to life-threatening shock, bronchospasm and angio-oedema.
Pyrogenic (endotoxin) reactions (within 1-2 hours) involve rigors, fever (risk of febrile convulsions in
children), vasodilatation, hypotension and a fall in blood pressure.

Late (serum sickness-type) reactions (1-12, mean 7, days after treatment) involve fever, nausea,
vomiting, diarrhoea, itching, recurrent urticaria, arthralgia, myalgia, lymphadenopathy, periarticular
swellings, mononeuritis multiplex, proteinuria, immune complex nephritis, rarely encephalopathy.

At the first sign of any of the following: urticaria, itching, fever, shaking chills, nausea, vomiting,
diarrhea, abdominal cramps, tachycardia, hypotension, bronchospasm and angioedema:

1. ASV should be discontinued

2. 0.5 mg. of 1:1000 adrenaline should be given IM

The Pediatric dose is 0.01 mg/kg body weight of adrenaline IM.

100 mg of hydrocortisone and 10 mg of H1 antihistamine will be administered IV.

The dose for children is 0.2 mg/kg of antihistamine IV and 2 mg/kg of Hydrocortisone.

· If after 10 to 15 minutes the patient’s condition has not improved or is worsening, second
dose of 0.5 mg of adrenaline 1:1000 IM is given.

This can be repeated for a third and final occasion but in the vast majority of reactions, 2 doses of
adrenaline will be sufficient.

Once the patient has recovered ASV can be restarted. Given slowly for 10-15 minutes. Then the
normal drip rate should be resumed.

Treatment of bitten part

• Nurse painful, swollen limb in the most comfortable position, avoiding excessively elevation.

• Leave blisters, aspirate abscesses and culture pus.

• Early surgical debridement and split-skin grafting.

• Antibiotics

• Direct measurement of intra-compartmental pressure is mandatory and fasciotomy must

not be attempted before haemostatic disturbances have been corrected by anti-venom.

• Rehabilitation: conventional physiotherapy accelerates functional recovery of the bitten

limb, but is often forgotten.

Follow up

• 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.