TREATMENT PROTOCOL
in VENOMOUS SNAKE BITE
L F Hospital, Angamaly,
Kerala
Dr Joseph K Joseph
Consultant Physician & Nephrologist
Little Flower Hospital,
Angamaly
SNAKEBITE TREATMENT
PROTOCOL
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PROTOCOL FOR DIAGNOSIS
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TREATMENT PROTOCOL
Hemostatic & clinical markers
suggesting envenomation
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I. Deranged haemostatic profile,
suggested by either or all of
-An abnormal WBCT
- PT above 1.5 times normal and
a APTT showing 6 secs above control
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11 a. The presence of significant
local inflammation
Tender enlarged lymph nodes
Recurrent nausea,vomiting and
abdominal pain
Acute abdominal tenderness
Bleeding manifestations
111. BLOOD PARAMETRES
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a) Crenated RBC in peripheral blood
smear
b) Rise in serum creatinineof >30%
of base line value
c )Proteinuria>2+
d)Raised D dimer value
e )Low platelet value<100000/mm3
Snake identification charts
Examination of the bitten part:
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Fang marks
The extent of swelling
Palpate lymph nodes
draining the limb
Limb girth
General examination
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Measure the blood pressure (sitting up and lying
to detect a postural drop indicative of
hypovolaemia) and heart rate.
Examine the skin and mucous membranes for
evidence of petechiae, purpura, discoid
haemorrhages, ecchymoses and, in the
conjunctivae, for haemorrhages and chemosis.
Thoroughly examine the gingival sulci, using a
torch and tongue depressor, as these may show
the earliest evidence of spontaneous systemic
bleeding.
Examine the nose for epistaxis.
TREATMENT PROTOCOL
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Managing pain
Handling Tourniquets
Anti snake Venom- dosage,
administration,
side effects, managing anaphylaxis
Treating complications
Managing Pain
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Causes severe pain at bite site
Pain Killers-Paracetamol 5001000mg 6 hrly orally in adults,
Pediatric dose- 10 mg /kg 4-6 hrly
orally
Severe pain-Tramadol 50 mg orally
Tramadol IV if needed
No NSAID
HANDLING TOURNIQUETS
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Recommendation- No tourniquet to be
applied
Current practice- see many victims
reaching with tourniquets
Do not suddenly remove the tourniquet
Sudden removal-massive surge of venom
causing neurological paralysis and
hypotension due to vasodilatation
Indications
Local envenoming:
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Local swelling involving more than half of
the bitten limb (in the absence of a
tourniquet) 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/ feet)
Development of enlarged tender
lymph nodes draining the bitten
limb
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Close Observation
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Patients should be
observed for a period
of at least 24 hours
• Krait & Humpnosed pit viper –
delayed
envenoming (612hrs)
Monitor
• Neurotoxic signs
• 20 min WBCT
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WBCT-½hrly – 3
hrs
hrly - 3
hrs
2hrly – 6
hrs
4hrly 12hrs
20WBCT (20 minutes Whole Blood
Clotting Test)
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Place a few ml of freshly sampled venous blood in
a new, clean, dry, small glass test tube vessel
Leave undisturbed for 20 min at ambient
temperature
Tip the vessel 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
If the vessel used for the test is not made of ordinary glass, or if
it has been cleaned with detergent, its wall may not stimulate
clotting ofthe blood sample (surface activation of factor XI –
Hageman factor)and test will be invalid
Other Tests
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Hematological-
Hb, PCV, TLC, DLC,
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Peripheral Smear,Platelet count –repeated 6
hourly for the first 24 hours in viperidae bites
C T, B T , P T, APTT
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DIC Workup- D-dimer,FDP,Fibrinogen, Repeated on the
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third day
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Renal function tests-
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Liver function tests- AST, ALT,Bilirubin, Total protein
and albumin
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Muscle enzymes,Blood sugar
Other Tests
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Urine – myoglobin, Hemoglobin and
protein
Blood group
Oxygen saturation
ABG
Tests repeated on daily basis- Hb,
PCV, creatinine, platelets, and urine
protein
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If possible,
intracompartmental
pressure should be
measured
Blood flow and patency
of arteries and veins
assessed (e.g. by
doppler ultrasound).
Measuring intracompartmental
pressure at LFH
Ventilatory capacity
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Use a peak flow
meter
Spirometer (FEV1
and FVC)
Initial management
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Tetanus toxoid
Antibiotics
Pain relief
Hydration –IV Fluids
Monitor Intake-Output
Respiratory rate
Mark the extent of
local swelling
Measure the swollen
limb
HAEMATOTOXIC ENVENOMATION
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Russel viper injects on an average 63
mg of venom[5 to 147mg]
1ml ASV neutralise 0.6 mg of russel
viper venom
1 vial-10 ml=6mg ASV
Total required dose wil be between
100ml[10 vial] to 250 ml[25 vial]
So starting with 10 vials ensures
sufficient neutralising power
Recommended Dose of ASV
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Haemotoxic Envenomation:
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Treat the patient with Anti Snake Venom(ASV)
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Start IV Normal Saline with wide bore needle
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Begin with 10 vials of ASV in 100ml of NS and to start with
10-15 drops per minute for 15 minutes & watch for
reactions.
If the patient is not having signs and symptoms of
anaphylactic shock continue the ASV drip in one hour
period.
Continue to monitor the vital signs at five minutes interval
for first 30 minutes and then at 15 minutes interval for two
hours
NEUROTOXIC ENVENOMATIONNEOSTIGMINE TEST
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1.5 TO 2 mg NEOSTIGMINE IV +0.6mg
ATROPINE iv IN AN ADULT&0.04mg/kg
NEOSTIGMINE IV+0.05mg/kg ATROPINE
IN CHILDREN
OBSERVE CLOSELY FOR 1 hr TO DECIDE
THE EFFECT
NEOSTIGMINE TEST
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OBJECTIVE METHODS
Single breath count, mmof iris
uncovered [amount covered by
descending eyelid]
Inter incisor distance [distance
between upper and lower incisors]
Length of time upward gaze can be
maintained
FEV1 or FVC[ if available ]
Recommended Dose of ASV
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Neurotoxic Envenomation:
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Treat the patient with Antisnake venom (ASV) with
the same dose for Haemotoxic Envenomation  plus
If Neostigmine test is +ve 0 .5 mg neostigmine at
half hourly intervals for 5 injections followed by
repeating the same dose at increasing intervals of 212 hrs.
Each dose of neostigmine is preceeded by Inj.
Atropine 0.6 mg as iv
Neostigmine is not useful in Krait bite
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REPEAT DOSE IN HEAMATOTOXIC
ENVENOMATION
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Initial blood test reveals coagulation
abnormality – 10 vials of ASV
No additional ASV untill next 6 hrs
[liver unable to replace clotting factors
in under 6 hrs]
 After 6 hrs another 20 WBCT
 In continued coagulation disturbance
another 8-10 vials of ASV in 1 hr time
 Rpt CT &Rpt ASV 6 hrly until coagulation
is restored.
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Repeat Dose- Neurotoxic
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For Neurotoxic Envenomation: Initial dose 10
vials given and if symptoms persist or worsen
/ respiratory failure, rpt 10 vials after 1-2
hours as second dose and discontinue ASV
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20 vials is the maximum dose of ASV
If the patient is in respiratory failure & has
already received 20 vials & is on ventilator
ASV therapy is to be stopped.
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ASV in special situations
1.
2.
3.
4.
5.
Victims requiring life saving surgery.
Victims who arrive late
Repeat snake bites
Snake bite in pregnancy and lactating
women
Victims having other co morbid
conditions – Autoimmune disorders,
debilitating status, endocrine disorders,
immuno supressed status, HIV AIDS,
cancer, asthma and allergy disorders,
etc.,
Treatment of Hypotension
Maintain C V P at 8cm of water
 Maintain urine output at >30ml/hr
 Normal saline if no renal failure
 If Hb & PCV decreased [PCV<40]
 FRESH BLOOD TRANSFUSION
 If Hb & PCV increased, [PCV>50]
PLASMA EXPANDERS-FFP, Cryst- colloid
Evidence of DIC [Plat<50,000]FFP, Platelet
transfusion
If Hypotension persists- DOPAMINE
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SURGICAL INTERVENTION
Faciotomy - ICP>40mm
Clinical features-pain on
passive stretching,pain
out of proportion,
absence of pulse,pallor,
paraesthesia, paralysis
OBJECTIVE
MEASUREMENT- saline
manometers, STRYKER,
Intracompartmental
pressure monitoring
equipment
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Management of Allergic
Reactions
If signs and symptoms of anaphylactic shock develop,
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Stop the ASV drip temporarily and treat the shock with:
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Inj Hydrocortisone 100 mg IV or
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Inj.Phenaramine maleate 2ml IV
Inj,Adrenaline 1:1000 (0.5 ml)IM
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Oxygen administration
IV.Normal saline as life line
As soon as the patient recovers, restart ASV infusion slowly with
careful monitoring
Continue to monitor the vital signs at five minutes interval for first 30
minutes and then at 15 minutes interval for two hours
Stabilise the patient and refer to the higher institution – if needed
Treatment of early anaphylactic and
pyrogenic reactions
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Adrenaline should be kept loaded
Stop the ASV temporarily
Give adrenaline at the first sign of a
reaction
0.5mg IM in adults
0.01mg/kg IM in children
Repeat every 5 to 10 mins
Immediate Management
Airway and Breathing
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Oxygenate with mask
Intubate and ventilate
if necessary
Early anaphylactic reactions
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Dry cough
Fever
Nausea, vomiting, diarrhea
Abdominal colic and cramps
Rhinorrhea
Conjunctivitis
Lightheadedness
Adrenaline Infusion
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Add 1 mg adrenaline to 500 ml of 5
% Dextrose (2 µg/ml).
Infuse at 1ml / min. Titrate upwards
to 4 ml/min.
2 to 8 ug/min
Can cause life threatening
arrhythmias
Cardiac monitoring
Treatment of Hypotension
Crystalloids NS bolus 1-2L
(10 to 20ml/kg in children)
SECOND- LINE THERAPY
Corticosteroids
Hydrocortisone 200 – 500mg IV
(5-10mg/kg in children)
Methylprednisolone 125mg IV
(2mg/kg in children)
Prevents recurrent anaphylaxis
For allergic
bronchospasm
Nebulization
Salbutamol+ipratopi
um bromide
Nebulised
adrenaline if
required
Additional Treatment
H1 antihistamine,
10mg chlorpheniramine maleate IV,
(0.2mg/kg children) or
22.5mg pheniramine maleate IV or
25mg promethazine HCl IV
H2 antihistamines,
Ranitidine 50mg IV
When to restart the ASV
after a reaction
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Once the patient has stabilized
Once the BP is under control
Once the manifestations of the reaction
have subsided
In severe reactions ASV can be restarted
under cover of an adrenaline infusion
Rate of ASV infusion can be decreased
initially
Patient should be under strict monitoring
CONCLUSION
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There is need to maintain standard
regimens
National snake bite trt protocol is an
attempt to bring about uniformity in
diagnosis and management.
Awareness among community about the
proper first aid& early treatment
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Better knowledge of ASV, its complications
and treatment of complications
Thank you
Little Flower Hospital & Research centre,
Angamaly