SNAKE

BITE

Background

India: Highest snakebite mortality in the world

2,00,000 bites annually; 50,000 die
Traditional Harmful First aid continues (Incision, suction, tourniquets)

The Big Four in India

About 231 species in India, only about 13 poisonous

Concept of Big Four
1. Indian Cobra (post synaptic toxin)
2. Russells Pit Viper
3. Saw Scaled Viper
4. Indian Krait (pre synaptic toxin)
Concept of Big four: Recently criticized due to the recognition of other
poisonous species like hump nosed viper.

India: Only Polyvalent Antivenom is available, covering the big four species.

Signs and Symptoms

Local: fang marks, pain, spontaneous systemic bleeding, LN enlargement,

blistering, Limb swelling (compartment syndrome)
Neurologic: neck muscle weakness, paresthesia, ptosis, facial palsy,
ophthalmoplegia, slurred speech, dysphagia, respiratory muscle weakness,
areflexia, fixed dilated pupils
Hematotoxic: Bleeding manifestations (consumptive coagulopathy)
Cardiac: Arrythmias, Shock, hypotension
Renal: hematuria, myoglobinuria, loin pain, and symptoms of uremia
Others: Nausea, Vomiting, abdominal pain, weakness, prostration


Clinical
Cobras
Kraits
Russells Saw
Hump
Features
pit Viper scaled
nosed
viper
viper
Local damage
Yes
No
Yes
Yes
Yes
Neurotoxicity
Yes
Yes
Yes
No
No
Hematotoxicity No
No
Yes
Yes
Yes
Renal Failure
No
No
Yes
No
Yes
Response to
Yes
No
No
No
No
neostigmine
Response to ASV Yes
Yes
Yes
Yes
No

Krait bite can be painless, may present only with paralysis
Do not assume that snake bitten patients are brain dead just because
their eyes are closed, they are unresponsive to painful stimuli or have fixed
dilated pupils. They may just be paralysed!

Investigations

CBC, LFT, Creat, Urea, Serum Electrolytes

Coagulation parameters
Venous Blood Gas (Avoid arterial puncture: Coagulopathy)
CPK (for rhabdo)
Urine Analysis
20WBCT (20 minute whole blood clotting test)
Place 2 mls of freshly sampled venous blood in a small, new or heat
cleaned, dry, glass vessel and leave undisturbed for 20 minutes at
ambient temperature.
If the blood is still 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.

Management

DO NO HARM FIRST

What not to do: incisions, sucking the wound, tourniquets, ice application, do not
try to catch the snake
Most of the traditional first aid is ineffective (Reassure, Immobilize the limb with
crepe bandage and get to the hospital ASAP)

ABC
Analgesia: Acetaminophen/Tramadol (Avoid NSAIDs)
Tetanus Prophylaxis (only in the absence of coagulopathy)
Antibiotics (Augmentin): Controversial unless suction/incision is done
ASV

ASV (the earlier, the better; Use judiciously when benefits > harm, not for all)
No test dose recommended

Indications:

Systemic envenoming
Haemostatic abnormalities: Spontaneous systemic bleeding, coagulopathy (see
20WBCT, PT) or thrombocytopenia (<100 x 109/litre or 100 000/cu mm)
Neurotoxic signs: ptosis, external ophthalmoplegia, paralysis etc
Cardiovascular abnormalities: hypotension, shock, cardiac arrhythmia, abnormal
ECG.
Acute kidney injury: oliguria/anuria, rising blood creatinine/ urea

 (Haemoglobin-/myoglobin-uria:) dark brown urine, urine dipsticks, other

evidence of intravascular haemolysis or generalised rhabdomyolysis
Local envenoming
Local swelling involving more than half of the bitten limb (in the absence of a
tourniquet) within 48 hours of the bite. Swelling after bites on the digits
Rapid extension of swelling (for example, beyond the wrist or ankle within a few
hours of bite on the hands or feet).
Development of an enlarged tender lymph node draining the bitten limb


Dose: (Same dose for adult and children)
Start with 10 vials (can give with IV Push @2ml/min or Slow IV infusion
in 500ml NS/D5 over 1 hour)
Maximum vials for neurotoxicity: 20 (10+10), repeat after 1-2 hours if no
improvement in symptoms
Maximum vials for Hematotoxicity: 30 (10+10+10), repeat after 6 hours
based on 20WBCT or coagulation parameters OR can also repeat after 1-2
hours if bleeding continues

ASV reactions:
Premed : No great evidence to support them (Avil/Rantac/hydrocort or SC
0.3mg Epi)
If develops a reaction: Stop ASV, Give IM Epi 0.5mg, restart infusion at a slower
rate

Role of anticholine esterase
Recommended for all neurotoxic bites
May avert intubation neurotoxic envenoming
Use atropine to prevent muscarinic side effects
IV Neostigmine 0.5-2mg for adults and watch for next 30-60 min for
improvement in symptoms, repeat q30min X 8hrs if it works

Don't delay intubation to give neostigmine trial
Decision to intubate is clinical

Supportive Care: Renal Replacement Therapy/Blood Products/ Mechanical
Ventilation

Disposition: Observer all for at least 24 hours if labs are okay + good discharge
instructions


Take Home

Know when/how to use ASV

Stay away from traditional measures (get to the hospital ASAP)
Don't delay intubation to give neostigmine trial

For further reading:

1. Mortality Predictors of Snake Bite Envenomation in Southern IndiaA
Ten-Year Retrospective Audit of 533 Patients. Suresh David, Sarah
Matathia, and Solomon Christopher, J Med Toxicol. Jun 2012; 8(2): 118
123.
2. http://apps.searo.who.int/PDS_DOCS/B4508.pdf
3. http://www.asiatox.org/9th%20apamt/OP/NATIONAL%20SNAKEBITE
%20MANAGEMENT%20PROTOCOL%202008%20_INDIA_.pdf
4. http://www.apiindia.org/medicine_update_2013/chap94.pdf
5. http://www.apiindia.org/pdf/medicine_update_2010/critical_care_emer
gency_medicine_03.pdf
6. Snake Bite in South Asia: A Review Emilie Alirol mail, Sanjib Kumar
Sharma, Himmatrao Saluba Bawaskar, Ulrich Kuch, Franois Chappuis
7. Emergency treatment of a snake bite: Pearls from literature, Syed Moied
Ahmed, Mohib Ahmed, Abu Nadeem, Jyotsna Mahajan, Adarash
Choudhary, and Jyotishka Pal J Emerg Trauma Shock. 2008 Jul-Dec; 1(2):
97105.




Questions/Comments:

Lakshay Chanana FEM (Vellore), MCEM (UK)
Department of Emergency Medicine
Apollo Health City, Hyderabad

drlakshay_em@yahoo.com
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