Management of snake bite

National Guideline 2014

Dr. Forhad Uddin Hasan Chowdhury (Maruf)

Assistant Registrar (Medicine )
Dhaka Medical College Hospital
 Snake bite is an important public
health hazard in Bangladesh
INTRODUCTION
Estimated an annual incidence of
623/100,000

6,041 deaths annually.

Neurotoxic snakes like (Cobra,

Kraits) are causing significant
mortality and morbidity

Among the vipers green pit viper is

very common but there are few
cases of Russell's viper.

Rahman R,Faiz MA,Selim S,Rahman B, Bashar A,et el.Annual incidence of snake bite in rural Bangladesh.
PLoS Negl Trop Dis.2010 Oct;4(10):e860.
 Moonocled Cobra
(Naja Kaouthia)

hh

Binocellate Cobra
Naja naja
King cobra (Opiophagus hannah)
Copy right- Dr.T N S Murthy
 Bungarus walli Bungarus nijer

Branded Krait Common Krait

(Bungarus fsciatus) (Bungarus Caeruleus)
 Common vipers in Bangladesh

Spot tailed pit White lip pit Pope’s pit viper Russel’s viper
viper viper
Russell’s viper
Sea snake (Hydrophidae spp
Copy right- Prof. D A Warrell
What is venomous snake bite?
► A bite by venomous snake which produces specific
symptoms or a syndrome is considered as venomous
snake bite.

► A venomous snake may not and do not always features

of envenoming

► 50% of bites by Russell’s viper , 30 % of bite by Cobras

and 5-10% of bites by saw scaled viper do not result in
any symptoms or signs of envenoming

► A victim may develop some features due to anxiety or

apprehension in case of bite by a venomous as well as
NV snake.
History taking
Site of bite, circumstances of bite, time of bite how did
it happen?

Site
Face and limbs- Green pit
Limbs- Cobra
Any site- Krait
Forearm- See snake
Time:
Night time bite especially in Krait bite

Non specific symptoms: Headache, Nausea, vomiting,

abdominal pain, loss of consciousness, difficulty in
vision, convulsions
Neurological symptoms: Muscle paralysis, difficulty in
moving jaw,toungue,eye, heaviness of eye lids (ptosis),
weakness of neck muscles (broken neck sign), difficulty
in swallowing, dribbling of saliva, nasal regurgitation,
nasal voice, difficulty in respiration, extreme generalized
weakness

Haematological symptoms: Spontaneous bleeding from

gum,vomiting of blood, Coughing out of blood, passage
of blood per urethra, persistent bleeding from bite site,
venepuncture site and inflicted wound if any.
Others: Severe muscle pain, dark urine, scanty urination,
collapse.

Concomitant medical illness: H/O allergy, Bronchial

asthma, kidney, heart disease, bleeding disorders,
neurological disease, limb swelling etc.

In female: Whether the victim is pregnant or not, whether

the victim menstruating or not.
H/O pre hospital treatment:

1. Home treatment.
2.Treatment from traditional healers (Ozha or Baiddya).
3.Application of tourniquet.
4.H/0 immunization against tetanus.
5.Treatment by initial attending physician.
Physical examination
1.Rapid clinical assessment especially vitals: Pulse, BP,
Respiration, Temp

2.Systemic signs of envenoming: Chronology of onset

and progression of signs.

a. Neurotoxic sign:
• Ptosis(Partial or complete) usually symmetrical and
progressive
• Diplopia, external ophthalmoplegia
• Bulbar palsy
• Nasal voice
• Facial paralysis
• Inability to open the mouth and to protrude the toungue
• Paralysis of chest muscle and diaphragm (Shallow
breathing)
• Broken neck sign: Weak grip, diminished reflexes
b.Signs of haematological abnormality:
• Persistent bleeding from bite site, venepuncture site and
or inflicted wound if any
• Multiple bruise or large blood collection
• Haemorrhagic blisters
• Bleeding from gingival sulci
• Haemoptysis
• Haematuria
• Epistaxis
 Presentation of
pit viper bites

1.Local swelling
2.Spontaneous bleeding
from bite site
3.Haemorrhagic blister
4.Myotoxicity
5.Renal failure
6.Intracranial haemorrhage
c.Signs of Renal failure:
Scanty or no micturation,dark urine
Clinical uraemic syndrome: Nausea, vomiting, hiccups,
fetor, drowsiness,coma, flapping tremor, muscle
twitching, convulsion, pericardial friction rub, signs of
fluid over load

d.Signs of myotoxicity:
Muscle tenderness, weakness, respiratory failure,
black urine, renal failure

c.Signs of local envenoming:

Swelling, tenderness, bleeding, ulceration,necrosis,
local lymphnode enlargement
GREEN PIT
COBRA COBRA

COBRA KRAIT NON VENOMOUS

 Identification of snake
• Identification of snake by description or by model,
photograph, brought snake, preserved specimen.

By local examination-
• Classic fang and teeth mark rarely occur and if present
indicate venomous snake bite
• Scratch usually indicates nonvenomous snake bite but
may rarely found in krait bite
• Snake may bite through clothing
Syndromic approach
 Syndrome-1
LOCAL ENVENOMING (SWELLING OF
LIMBS)

+
BLEEDING OR CLOTTING
DISTURBANCE

Green pit Rassell’s viper

 Syndrome -2
LOCAL ENVENOMING
(SWELLIMG)
+
BLEEDING OR CLOTTING
DISTURBANCE (WBCT >20MINS
+
SHOCK OR AKI
+
NEUROTOXIC SIGN
+
DARK BROWN URINE

Rassell’s viper
LOCAL Syndrome -3
ENVENOMING
(SWELLING)
+
NEUROTOXIC
FEATURE
+
NO CLOTTING
DISTURBANCE
(WBCT <20 MINS)

COBRA
 Syndrome -4

NO LOCAL ENVENOMING
+
NEUROTOXIC FEATURES
+
WBCT <20 MINS

Bite in land while sleeping = Bite in the sea= SEA SNAKE

KRAIT
 Syndrome -5

PARALYSIS
+
DARK BROWN URINE
+
NO LOCAL SWELLING Bite in the sea=
SEA SNAKE
+
WBCT <20 MINS
+
SEVERE MUSCLE PAIN

Bite in the land= KRAIT

KEEP IT IN MIND: Identification of snake the offending
snake from fang mark is impossible.

Local swelling and tissue damage:

• First sign of envenoming
• Exceptions kraits sometimes in cobras
• Blister necrosis

Other systemic examinations:

Laboratory investigations
• Coagulation test- 20 min whole blood clotting test
• ECG
• CBC
• Blood urea, S.Creatinine
• Urine R/E and naked eye examination of urine
• APTT ,PT
• S.CPK
• ELISA
• Blood grouping and Rh typing
 20 min whole blood clotting test. (20 WBCT)

• Place a few mls of freshly sampled venous blood in a

small glass tube

• Leave undisturbed for 20 minutes at ambient

temperature, erect.
• Tip the tube once

• 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 perspective of Bangladesh, incoagulable blood is

diagnostic of a viper bite and rules out an elapid bite.
The management of snake bites
 Recommended first aid

1. Reassurance

2. Immobilization

3. Lower limb- DO NOT WALK

4. Upper limb- DO NOT MOVE the limb

5. Should not be used for Viper Bites.

 QUICK TRANSFER

1.COMMUNITY CLINIC

2.UHC

3.DISTRICT HOSPITAL

4.MEDICAL COLLEGE HOSPITAL

Pressure immobilization method
 PLEASE KEEP IT IN MIND
• DO NOT WASTE TIME TO ANY OZHA
OR TRADITIONAL HEALERS

1.NOT scientific
2.Waste of time
3.May cause infection, bleeding, gangrene
4.Damage to artery , vein
5.Loss of life
6.Always Harmful
 HARMFUL- NOT RECOMMENDED

1.Tight tourniquets
2.Incision at the bite site
3.Local suction
4.Cauterization by chemicals
5.Application of materials
6.Ingestion of herbal products to induce vomiting
7.Unnecessary delaying
 Treatment in hospital

1.Rapid clinical assessment and resuscitation (ABC)

2.Detailed clinical assessment

(Local, Neurological, Haematological)

3.Identification of species
(Brought snake live, dead or description, photograph
20 min WBCT
Syndromic approach)
N.B-. DO NOT ATTEMPT TO KILL THE SNAKE ,
AS THIS MAY BE DANGEROUS. DO NOT
HANDLE THE SNAKE WITH BARE HANDS, AS
EVEN A SEVERED HEAD CAN BITE!
Treatment:
a.Antibiotic
b.Tetanus prophylaxis
c.Antivenom
d.NBM

Polyvalent Antivenom:
In our country now only Polyvalent antivenom from Vins
(lindia) is available in lyophilized powder form. Each vial
contain 10 mg of antivenom, which is effective against
systemic envenoming by Cobra, Krait, Russell's Viper and
Saw scaled viper only (there is no evidence of Saw scaled
viper in Bangladesh). So this type of antivenom should not
be used in bites by Green snake, Sea snakes and identified
non-venomous snake.
 Antivenom treatment

Indication /criteria for using antivenom:

(Not indicated in Green snake and sea snake)

1.Neurotoxic signs.
2.Rapid extension of swelling (more than half of the bitten
limb). N.B- not due to green snake bite or tight
tourniquet.
3.AKI (not due to see snake).
4.Crdiovascular abnormalities
5.Bleeding abnormalities.
6.Haemoglobinuria/myoglobinuria not due to sea snake.
 Anti snake venom therapy

• Dose:
Each dose consists of 10 vial of polyvalent antivenom
irrespective of age and sex of the victim.

• Time and administration:

Each vial is diluted with 10-ml. of distilled water. 10 such vials
(100 ml) is further diluled or mixed with 100 ml of fluid
(Dextrose water or saline). Then it is administered with
intravenous infusion within 40-60 min (60-70 drops/min).

• Observation and monitoring:

Continuous observation and frequent monitoring of vital signs
should be ensured during antivenom therapy and few hours
after its completion. Careful clinical assessment for appearance
of signs and symptoms of antivenom (A/V) reaction should be
performed.
Polyvalent anti-snake venom

Active against
1.Indian cobra
2.Common Krait
3.Russsel’s viper
4.Saw scaled viper
 Antivenom reaction:
Three types of reaction occurs

1.Early anaphylaxis

2.Pyrogenic reaction

3.Late reaction (serum sickness type)

1.Early anaphylaxis:
• Usually develops within 10-180 min of starting of
antivenom
• C/F- Itching,urticaria,fever,angiooedema,dspnoea,
bronchospasm,laryngeal oedema, hypotension,
abdomina pain, vomiting, diarrhoea etc

Treatment of anaphylaxis

• Temporary suspension of antivenom administration

• Inj.Adrenalin (I/M) (1 amp=1ml=1mg)
For adults: 0.5ml (1/2 amp)
For children: 6-11 years 0.25 ml (1/4TH amp)
• Antihistamin (Inj.Chlorpheniramin)
Adult= 10 mg IV slowly after dilution
Child=0.2 mg/kg slow after dilution

• Inj.Hydrocortisone 100 mg for adults

(2mg/kg for children.)

• Inj.Ranitidine 50 mg IV slowly
1mg/kg for children.

(N.B- Should be given at the very 1st sign of reaction and

can be repeated every 5-10 mins intervalif condition is
deteriorating)
2.Pyrogenic reaction:
• Usually develops 1-2 hours after treatment
• C/F- chills, fever, fall of BP, febrile convulsion in children
• Treatment- Tepid sponging,fanning,IV fluid, Paracetamol
suppository.

3.Late reaction (Serum sickness type):

• May develop 1-12 days (mean 7 days) after treatment.
• C/F-Fever ,itching,urticaria, arthralgia,myalgia,
lymphedenopathy, proteinuria etc.
• Treatment- Antihistamin, prednisolone (if no response to
antihistamin)
N.B- If any concomitant medical illness like COPD,
Bronchial asthma or pregnancy ½ of the dose of
adrenalin (1/4th amp) should be given S/C before giving
antivenom
Additional treatment:
Inj.Atropine (15µg/kg ) IV (1.5 amp for adult) 4 hourly &
Inj.Neostigmine (50-100 µgm/kg) S/C (2.5 amp for adult) in
each thigh 4 hourly until neurotoxic features improve

Respiratory support- Incase of respiratory failure

Blood transfusion: For patients with coagulopathy.

 Endotracheal intubation is the most essential part of the
management of venomous snakebite with respiratory failure
DAY 1 DAY 1 DAY 2

DAY 3 DAY 4
AFTER ADMISSION BITE SITE

AFTER ASV
TREATMEN RECOVERY
TT
Criteria for repeating the initial dose of antivenom:
Persisting or deteriorating signs of systemic antivenom.eg.

1.If no improvement or deterioration of neurotoxic features

(cobra or krait) 1-2 hours completion of antivenom.

2.Persistence or recurrence of blood incoagulopathy after 6

hours of antivenom teatment.
Drugs not recommended:
1. Antihistamine except for antivenom reaction
2. Corticosteroid except antivenom reaction
3. Sedative
4. Antifibrinolytic agent
5. Heparin
6. Traditional medicines (from ozahs)
Treatment of bitten part:

• Elevation of limb with rest

• Simple washing with antiseptic solution
• Broad spectrum antibiotic (especially when there is
features of contamination, multiple incisions)
• In case of local necrosis and gangrene:
Broad spectrum antibiotic
Surgical debridement and split thickness skin
grafting is indicated.
Follow up:
Local envenomation: The snake bite cases with Local
envenomation (commonly in cobra cases) need to follow up for at
least 5- 7 days to see the sequential changes of color changes,
blisters, ulceration, necrosis and desquamation. In viper bites, the
haemorrhagic manifestation should also follow up to see complete
recovery. A comprehensive approach with advice from surgeons
are important in this regard

Children : The neurotoxic snake bite cases should be followed up

to observe any neurological residual deficit present or not with also
attention to neurocognitive function.

Pregnancy: The pregnancy outcome after a venomous bite with

long term follow up of children is also needed to see the
neurological cognitive function
Rehabilitation:

Physiotherapy
Reconstructive surgery
What should we do when no antivenom is
available?
Incase of neurotoxity:
• Assisted ventilation via ambu bag or mechanical
ventilation
• Inj.Atropine and Neostigmine:

In case of Haematological abnormality:

• Strict bed rest to avoid even minor trauma
• I/M injection must be avoided
• Fresh whole blood or FFP transfusion should be given
List of Essential Logistics for snake bite Management:

• One 10 cc syringe
• One 20 cc syringe
• Two 50 cc syringe
• IV infusion set- two sets
• IV blood transfusion set – One set
• IV canula (JMS): two sets
• IV Normal Saline -500 ml
• Indwelling catheter
• Urinary bag
• Antivenom -10 vials with diluents
• Inj Atropine – 6- 10 amp: 15 mcg/kg
• Inj Neostigmine (500 mcg)- 20-25 amp (For adults)- 50mcg/kg
• Inj antibiotics
• Tetanous Toxoid- 1amp
• Inj Adrenaline (1:1000)- 2-3 amp
• Inj Chlorphenarmine- 1-2 amp
• Paracetamol Suppository- 1-2 stick
• Inj Hydrocortisone- 4-5 vials
• Inj Ranitidine- 4-5 ampoules
• Water and soap
• Antiseptic lotions or cream
• Gauze and coton (For wound care and sling)
• Insulin syringe (For collection of wound swab)
• Sterile vials (for collection of swab, blood etc)
• 10 cc dry test tube with holding stand (For 20 min WBCT)
• Sterile test tube (For blood sample)
• Endotracheal tube- 2 set (One for pt and one reserve)
• 5 cc syringe-2 ( for balloon inflation of ET tube and catheter)
• Umboo bag- one at least dedicated for snake bite
• Orogastric tube
• Laryngoscope
• Battery for laryngoscope
• Trolly with tray- dedicated for snake bite logistics
ANY QUESTION?
THANK YOU