Introduction -

India is inhabited by more than 60 species of venomous snakes-some of which are abundant
and can cause severe envenoming. Spectacale (Naja-naja),common krait (Bungarus
caeruleus), saw-scaled viper (Echis carinatus) and Russell`s viper (Daboia russelii) have long
been recognised as the most important. As snake bite is serious problem in india since ancient
time; the Ayurveda & Modern science both have mentioned it in detail.

Modern Classification of Snake in India-

Venomous Snake Non Venomous Snake
1. Elapids (Neurotoxic) [Link] Snake
2. Viper (Vasculotoxic) [Link] Snake
3. Sea Snake(Myotoxic) 3 Python
4 Eath Boa
5 Common Sand Boa

There are two families of venomous snakes in India Elapidae and Viperidae.

Elapidae:-
Have relatively short Fixed front fangs. This family includes cobras, king cobra, kraits, coral
snakes.

Viperidae :-
Have relatively long fangs which are normally folded flat against the upper jaw but, when the
snake strikes, they are erected. There are two subfamilies, typical vipers (Viperinae) and pit
vipers (Crotalinae).

The venom apparatus-

The venom glands of Elapidae and Viperidae are situated behind the eye, surrounded by
compressor muscles. The venom duct opens within the sheath at the base of the fang and
venom is conducted to its tip through a groove or canal, as through a hypodermic needle.

Venom composition-
More than 90% of snake venom (dry weight) is protein. Each venom contains more than a
hundred different proteins: enzymes, non-enzymatic polypeptide toxins, and non-Toxic
proteins such as nerve growth factor. The physical & chemical nature of venom is as follows.

Physical- In the fresh state, Vemom is a clear transparent,amber tinted fluid & dries in to a
Yellow Granular Mass.
Chemical-
 Neurotoxin & Cholinesterage (Elapid), Haemolysin & Thromboplastin (Viper)
Myotoxin (Sea Snake).
 Enzyme- These include digestive hydrolases, hyaluronidase, and activators or
inactivators of physiological processes, such as kininogenase. Most venoms contain 1-
amino acid oxidase, phosphomono- and diesterases, z'-nucleotidase, DNAase, NAD-
nucleosidase, phospholipase A2 and peptidases.
 Low-molecular-weight-polypeptides,Glycoprotein & metal ions.
 Fibrinolysins,Proteolysins & Agglutinin.

Mode of Action of Snake Venom -

NeuroToxic Venom-
(a) It act on pre-synapse which block the release of Acetyl-Choline at Neuro-Muscular
Junction.
(b) a-bungarotoxin & cobrotoxin binds the Acetyl- Choline receptor at the motor end plate.

Vasculotoxin Venom-
(a) Fibrinogenases degrade fibrinogen directly in blood.
(b) Heamorrhagins damages vascular endothelium.
Myotoxin Venom - (a) Myotoxin & Cytotoxin causes spliting of muscle & cell.

Sr. Snake Fetal Dose Vemom Fetal Peroid

yield /Bite
1. King cobra 12 mg 170-300 mg Few [Link]
Hours
2. Cobra 12mg 200-350 mg Few Min to
hours
3. Krait 06mg 08-20 mg Few Min to
hours
4. Russel Viper 15mg 130-150 mg Few days
5. Saw Scale Viper 08mg 20-30 mg Few days
6. Green Viper -- 40-60 mg --
7. Sea Snake Viper Generally Not -- Generally Not
Fetal Fetal

Diagnosis of Snake Bite-

It should be done on the basis of Identification of Snake, Identification of Bite Mark,
Systemic Clinical Feature and Laboratory Investigations.

A. Identification of Snake-
The defensive behaviour of the cobras is well known: they rear up, spread a hood, hiss and
make repeated strikes towards the aggressor. the large white, dark-rimmed annular (ring)
spots of the Russell's vipers or the alternating black and yellow circumferential bands of the
banded krait are distinctive. The blowing hiss of the Russell's viper and the grating rasp of the
saw-scaled viper are warning and identifying sounds.

Morphological Difference between Poisonous & Non- Poisonous Snake-

Characters Poisonous Non- Poisonous

1. Belly scale Large Small
2. Fangs Long & canalized Series of small teeth
3. Tail Compressed Not Compressed
4. Habits Nocturnal Not so
5. Bite Two fang marks Number of small
with/out teeth mark teeth mark
Morphological Difference between Cobra, Krait, Ruscel Viper, Saw Scale
Viper & Sea Snake-

Sr . Feature Neuro Toxic Vasculo Toxic Myo Toxic

1. Known Snake (a) Cobra-Nag (a)Russel Viper- Sea Snake-
& Common (b) King Cobra- Ghonas
Name Nagraj (b) Saw Scale Samudra-Sarpa
(c)Krait-Manyar Viper-Furase
(d) Coral (c)GreenViper-
Bamboo Sarpa

2. Head (a) Cobra & Russel, Saw (a) Sea Snake-

King Cobra Scale & Green Small
Hood with Viper-
Spectacle Triangular
(b) krait-Large
Shield
(c) Coral -Small

3. Colours & (a) Cobra- Russel Viper- (a) Sea Snake-

Appearance blackish white Diamond Spot Varies
(b) King Cobra- on body
Jetblack (b) Saw Scale
Shape Viper- Saw like
(c)krait Scale on body
Common Black (c) Green Viper-
& White Band Green colour
& Krait-Banded like parrot
Black & yellow
Band
(d) Coral-Black,
Yellow & Red
Band

4. Pupils Rounded Vertical Rounded

5. Fangs Short, Fixed & Long, Mobiles Short & Fixed
Grooved & Canalized
6. Maxillary Bone Two Fangs with Only Two Fangs Two Fangs with
Small Other Small Teeth
Teeth on Side
7. Tails Rounded Tapering Varies
Identification of Bite Mark & local signs-
The poisonous snakes have two fangs mark most of the time with or without marks of
multiple small teeth in rows. Some time single fang mark may be found in poisonous snake
bite. While in one or two rows of multiple small teeth marks will be found without fang mark
in non poisonous snake bite. Following the immediate pain of mechanical penetration of the
skin by the snake's fangs, there may be increasing local pain (burning, bursting, throbbing) at
the site of the bite, local swelling that gradually Extends proximally up the bitten limb and
tender, painful enlargement of the regional lymph nodes draining the site of the bite (in the
groin-femoral or inguinal, following bites in the lower limb; at the elbow -epitrochlear-or in
the axilla following bites in the upper limb). However, bites by traits, sea snakes and
Philippine cobras may be virtually painless and may cause negligible local swelling.

Signs & Symptoms of Snake Bite- Local-

Sr. Feature Neuro toxic Vasculo toxic Myo toxic

1. Fang Mark Two Mark with Two deep bite mark Two superficial
small series of bite mark
(Bite mark)
Scratches

2. Local Pain Minimum Minimum Sharp Pricking

3. Inflammation Minimum Spread rapidly & --

detecteble (15 days)
(Swelling,
Redness)

4. Local Blistering Minimum Within days --

5. Local Bleeding -- Severe with --

Incoagulable bleeding

6. Local Bruising -- Marked --

7. Lymphangitis +Onaffected Limb +On affected Limb +/-

8. Lymph-Adenitis +Onaffected Limb + On affected Limb +/-

9. Necrosis - Severe(Few days) --

10. Ecchymosed -- May be --

11. Cellulites -- Due to Infection --

[C] Systemic Clinical Feature-
Neurological (Elapidae)-
Drowsiness, paraesthesiae, abnormalities of taste and smell, "heavy" eyelids,
ptosis, External ophthalmoplegia, paralysis of facial muscles and other muscles
innervated by the cranial nerves, aphonia, regurgitation through the nose,
difficulty in swallowing, respiratory and generalised flaccid paralysis.
Bleeding and clotting disorders (Viperidae)-
Prolonged bleeding from the fang marks. Spontaneous systemic bleeding – from gums,
epistaxis, haemoptysis, haematemesis, rectal bleeding or melaena, haematuria, vaginal
bleeding, ante-partum haemorrhage in pregnant women bleeding into the tears, intracranial
haemorrhage, coma from cerebral haemorrhage.

Skeletal muscle breakdown (sea snakes, some krait species) -

Generalized pain, stiffness and tenderness of muscles, trismus, myoglobinuria,hyperkalaemia,
cardiac arrest, acute renal failure will be found in myotoxic poisonous snake.
Signs & Symptoms of Snake Bite- Specific Systemic-

Sr. Neuro Toxic Vasculo Toxic Myo Toxic

1. Ptosis Gums Bleeding Aching of muscles

2. External Nasal Bleeding Stiffness of muscles

Opthalmoplegia
(Epistaxis)

3. Paralysis of muscle of Oral Bleeding Tenderness of muscles

Face
(Hematemesis)

4. Paralysis of muscle of Blood in cough Trismus

Palate
(Hemoptysis)

5. Paralysis of muscle of Blood in Urine Myoglobinuria

Jaws
(Hematuria)

6. Paralysis of muscle of Blood in stool Hyperkalaemia

tounge
(Maleana)

7. Paralysis of muscle of Subconjuctival Cardiac Arrest

Neck Haemorrhage

8. Paralysis of muscle of Retroperitonial

Throat
Haemorrhage

9. Paralysis of Intracranial
Intercostal Muscle
Haemorrhage

10. Paralysis of Myocardial

Diaphragm Muscle
Haemorrhage

11. Respiratory Failure Hypotension & Shock

Signs & Symptoms of Snake Bite- General Systemic-

Sr. NeuroToxic VasculoToxic MyoToxic

1. Vomiting Vomiting Vomiting
2. Hypersalivation Colicky Abdomen Headache
Pain
3. Headache -- Thick Feeling
Tounge
4. Dizziness -- Excess Sweating
5. Vertigo -- --
6. Hyperacusis -- --

D. Laboratory Investigations-
20-minute whole blood clotting test (20WBCT)-
1. Place 2 ml of fresh venous blood in a small, cleaned, dry, glass vessel.
2. Leave undisturbed for 20 minutes at ambient temperature.
3. Tip the vessel once.
4. If the blood is still liquid (unclotted) and runs out, the patient has
hypofibrinogenaemia ("incoagulable blood") as a result of venom-
induced consumption coagulopathy. In the South-East Asia region,
incoagulable blood is diagnostic of a viper bite and rules out an elapid
bite.
5. If there is any doubt, repeat the test in duplicate, including a "control"
(blood from a healthy person such as a relative).
Haemoglobin concentration/haematocrit:-
A transient increase indicates haemoconcentration resulting from a generalized increase in
capillary permeability (e.g. in Russell's viper bite). More often, there is a decrease reflecting
blood loss or, in the case of Indian, Russell's viper bite, intravascular haemolysis.

Platelet count: This may be decreased in victims of envenoming by indian vipers.

White blood cell count:-
An early neutrophil leucocytosis is evidence of systemic envenoming from any species.

Blood film:- Fragmented red cells are seen when there is microangiopathic haemolysis.
Plasma/serum:- May be pinkish or brownish if there is gross haemoglobinaemia or
myoglobinaemia in case of myotoxin.

Urine Examination:-
The colour of the urine (pink, red, brown, black) should be noted and the urine should be
tested by dipsticks for blood or haemoglobin or myoglobin. Standard dipsticks do not
distinguish blood, haemoglobin and myoglobin. Haemoglobin and myoglobin can be
separated by immunoassays but there is no easy or reliable [Link] will confirm
whether there are erythrocytes in the urine.

Management of Venomonous snake bite.-

(A) Recommended first-aid methods (WHO)-
 Reassure the victim who may be very anxious.
 Immobilize the whole of the patient's body by laying him/her down in a comfortable
and safe position and, especially, immobilize the bitten limb with a splint or sling.
 Any movement or muscular contraction increases absorption of venom into the
bloodstream and lymphatic's.
 the necessary equipment and skills are available, consider pressure-immobilization or
pressure pad unless an elapid bite can be Excluded. Avoid any interference with the
bite wound (incisions, rubbing, vigorous cleaning, and massage, application of herbs
or chemicals) as this may introduce infection, increase absorption of the venom and
increase local bleeding.

(B) Indications for antivenom-

Antivenom treatment is recommended if and when a patient with proved or
suspected snake-bite develops one or more of the following signs:
1. Systemic envenoming-
 Haemostatic abnormalities:- Spontaneous systemic bleeding (clinical),
coagulopathy (20WBCT or other laboratory tests such as prothrombin time) or
thrombocytopenia (<100 & 10~/litre or 100 000/cu mm) (laboratory).
 NeuroToxic signs-: ptosis, External ophthalmoplegia, paralysis etc (clinical).
 Cardiovascular abnormalities:- hypotension, shock, cardiac arrhythmia (clinical),
abnormal ECG.
 Acute kidney injury (renal failure):- oliguria/anuria (clinical), rising blood
creatinine/ urea (laboratory).
 Haemoglobin-/myoglobin-uria :- dark brown urine (clinical), urine dipsticks,
other evidence of intravascular haemolysis or generalised rhabdomyolysis (muscle
aches and pains, hyperkalaemia) (clinical, laboratory).
 Supporting laboratory evidence of systemic envenoming.

2. Local envenoming:-
 Local swelling involving more than half of the bitten limb (in the absence of a
tourniquet) within 48 hours of the bites. Swelling after bites on the digits ( toes and
especially fingers).
 Rapid Extension of swelling (for example , beyond the wrist or ankle within a few
hours of bites on the hands or feet).
 Development of an enlarged tender lymph node draining the bitten limb.

1. Composition- Each Cobra Venom-o.6mg+Krait Venom-0.45mg+Russel

1ml contain Venom-0.6mg+ Saw Scale Venom-0.45mg

2. Indication Cobra + Krait + Russel Viper + Saw Scale Viper

3. Contra-Indication Hypersensitivity
4. Dose/Route 5-10 Vial (50-100 ml) with Ringer Lactated solution/IV
for 10 min & Repeat 4 hourly till the signs & symptoms
will be reverse.

5. Precaution Sensitivity Test before [Link] sensitive if Urticaria

Rashes, Itching. Vertigo, Hypotension, Shock or
Branchospasm.

6. Adverse Reaction Early anaphylactic reactions, Pyrogenic (endotoxin)

reactions and Late (serum sickness type) reactions.

7. Pre Treatment Antihistamine, Corticosteroide & Cemetidine to prevent

reaction of Antivenom.

Polyvalent Antivenom (ASVS-Anti Snake Venom Serum) available in

India-

(C) Symptomatic T/t-

(a) NeuroToxic bite Inj Neostigmine 0.25-0.5mg/IV/half hourly if there are
Neuroparalysis and (Inj. Atropine 0.6mg/EV before every Inj. of
Neostigmine)

(b) VasculoToxic bite Inj. Ethamsylate to prevent systemic bleeding. [Link] 1000
IU in Normal Saline/Iv drip to prevent DIC and [Link].K +
Platlet/fresh Blood for Coagulopathy.

(c) Myotoxic bite Inj. Insulin in Dextrose 5% /IV drip for Hyprekalaemia.

(D) Other (a) [Link] (Tetanus Toxid) 0.5cc/IM/Stat.

(b) Antibiotic to prevent secondary infection.
(c) Police Inform for MLC (Medico-Legal-Case).
(E) Mangement of Pateints from Dry Bite-
Approximately 75% of sea snake, 20% of Pit Viper & somewhat Other Poisonous Snake may
be bites without Venom & hence have no mortality. So treatment of Dry bites include.
 Reassureance & Relieve Anxiety.
 24 hours Observation of Patients.
 watch for Signs & Symptoms of poisonous Venomous.

Postmortem Appearance-
External-
(a) NeuroToxic bite Two Bite Marks about 1cm deep. Minimum Local Sign
like Swelling, Blister & Necrosis. Lymph-Adenitis will
found.
(b) VasculoToxic Bite Two Bite Marks about 2 cm deep. Inflammation Swelling,
Redness, Local Blistering, Local Bleeding, Local Bruising,
Lymph-Adenitis, Ecchymoses, Abscess.
(c) MyoToxic Bite Superficial two bite marks.

(a) NeuroToxic bite Signs of Asphyxia like Internal Organ Congestion,Petecheal

Haemorrhage etc.
 (b) VasculoToxic Bite Hemorrhage in Lung, Plura, Endocardium, Pericardium,
Intracranial & Kideny. The reginal lymph node are swollen &
heamorrhagic.

(c) MyoToxic Bite Not specific

Chemical Analysis & Laboratory-

(a)Skin & underlying tissue surrounding the fang punctures, wound & blister aspirate.
(b)Serum & Urine.

Medicolegal Aspect-
(a) Accidental- Snake bites are accidental often.
(b)Suicidal-Not Reported.
(c)Homicidal- It was found in ancient time. Now a day it is rare.

Bibliography-
To make this compilation,I tookhelpfromvarioussources. Some of
them are listed below :
 Agad Tantra – Dr. Sharad Porte
 A text book of Agadtantra – [Link] Kumar Sharma
  The Essential of Forensic Medicine and toxicology by Reddy
K., S. Narayan Reddy.
 Illustrated textbook of Agad Tantra & Vidhi Vaidyak by
[Link].
 Wikipedia

But the most help was provided by our Agadtantra department

especially by [Link] Gupta & [Link].

I thanks all the people who helped me in completion of my

compilation.

Index
[Link]. Topic Page Number
1. Introduction 1
2. Modern 1
Classification Of
Snake In India
3. Mode of Action Of 2
Snake Venom
4. Fetal Dose and 3
Period In Snake
Bite

5. Diagnosis In 3
Snake Bite
6. Identification Of 3-6
Snake
7. Identification Of 7-8
Bite mark And
Local Sign
8. Systemic Clinical 8-11
Feature
9. Laboratory 11-15
Investigation
10. Medico Legal 15
Aspects
11. Bibliography 16