Management of Snake Bites

Mabel Vasnaik
Dept of Emergency Medicine
St Johns Medical College Hospital

Overview
Epidemiology
Antisnake venom (ASV) &
complications
Treatment of ASV
reactions
Other supportive
management

Incidence of Snakebite
Globally 50 to 60,000 people die of snake bite each year
90% from Asia and Africa

Kasturiratne A, Wickremasinghe AR et al. Estimating the global burden of snakebite: A

literature analysis and modelling based on regional estimates of envenoming and deaths.
PLoS Med 2008;5: e218. doi:10.1371/journal.pmed.0050218

Snakes of Medical Importance in

South East Asia
Viperidae
Russells viper (Daboia russelli)
Saw-scaled viper (Echis carinatus)
Hump nosed pit viper (Hypnale hypnale)
Elapidae
Indian cobra (Naja naja)
Common krait (Bungarus caeruleus)

Etiology of Snake bite

Common in rural areas
Occupational hazard for farmers,
fishermen, snake handlers.
Snake accidentally trodden upon
Picked up in a handful of crops.
People who sleep on the floor at night

First Aid
Do it RIGHT

Reassure patient. 70% nonvenomous

Immobilise as in a fractured limb
GH Get to a hospital as soon as possible
Tell the doctor symptoms
of envenomation

Simpson ID. Snakebite Management in India,

The First Few Hours: A Guide for Primary
Care Physicians. J Indian Med Assoc 2007;105:324-335

Symptoms of Envenomation
Neurological impairment
ptosis, muscle weakness, respiratory
distress/arrest
Hematological
bleeding from bite site, epistaxis,
hemoptysis, hematuria, ecchymosis
Painful Progressive Swelling

Feature

Cobras Kraits

Russells
Viper

Saw Scaled
Viper

Hump
Nosed
Viper

Local Pain/ Tissue

Damage

YES

NO

YES

YES

YES

Ptosis/ Neurological
Signs

YES

YES

YES!

NO

NO

Haemostatic
abnormalities

NO

NO!

YES

YES

YES

Renal Complications

NO

NO

YES

NO

YES

Response to Neostigmine

YES

NO?

NO?

NO

NO

Response to ASV

YES

YES

YES

YES

NO

Patient Assessment Phase: On arrival

Airway, Breathing and Circulation

Resuscitate as necessary
Tetanus Toxoid
Anti-biotic for cellulitis
or necrosis.

Diagnosis Phase: General Principles

Identify the snake if possible

Fang marks
Look for features of envenomation
Observation for 24 hrs
Document time of
bite

Late-onset envenoming
Krait and viper can take 6 to 12hrs
Juvenile snakes, 8-10 inches long

Diagnosis Phase: Investigations

20 Minute Whole Blood Clotting Test (20WBCT)

Most reliable bedside coagulation test

Clean dry glass vessel
Leave few ml of blood undisturbed for 20 mins

Simpson ID. Snakebite Management in India, The First Few Hours: A Guide
for Primary Care Physicians. J Indian Med Assoc 2007;105:324-335

Other Investigations
Hb/ PCV/ Platelet Count/ PT/ APTT/ FDP
D-Dimer
Peripheral Smear
Urine for Protein/ RBC/ Haemoglobinuria/
Myoglobinuria
Serum Creat / Urea/ Potassium

Management

Initial resuscitation
Pain management
Antisnake venom (ASV)
Supportive treatment
Treatment of complications

Pain management
Paracetamol
Opiates like Tramadol
Avoid aspirin/NSAIDs

ANTI SNAKE VENOM

TOXIC COMPONENTS OF
SNAKE VENOM
Protein components: 90-95%
Consist of Enzymes (Phospholipase
A2,Proteolytic enzymes,Hyaluronidase)
Polypeptides Pre-synaptic (Beta-bungarotoxin)
Post-synaptic (Alpha) neurotoxins (Bungarotoxin
and cobrotoxins)
Non-protein components: 5-10%

Monovalent Vs polyvalent ASV

Polyvalent is cheaper
Very often snake is not identified
ELISA kits not available

Anti Snake Venom (ASV)

Polyvalent, effective against

Russell's viper
Common Cobra
Common Krait
Saw Scaled viper
Ineffective against
Humpnosed pit viper

ASV Preparation
Liquid:
2yr shelf life, reliable cold chain,
no reconstitution
Lyophilised:
5 yr shelf life, no cold chain,
30 60 mins to reconstitute

Should not be used indiscriminately

Scarce, costly
Administer only with definite signs of envenomation.
Unbound venom, neutralised when in bloodstream
or tissue fluid.
Risk of anaphylactic reactions
Simpson ID, Norris RL. The global snakebite crisis-A public health issue
misunderstood, not neglected. Wilderness and Environmental Medicine,
2009;20:43-56

ASV Dosage
Russells Viper injects on average 63mg SD 7 mg of
venom. Range 5mg 147 mg.
Each ASV vial neutralises 6mg of venom.
Initial dose should neutralise the average dose of
venom injected.(10 vials)
Total required dose between 10 to 25 vials

Tun P, Khin Aung Cho. Amount of venom injected by Russells Viper

(Vipera russelli) Toxicon 1986; 24(7): 730-733

ASV dosage
Neurotoxic/ Anti Haemostatic 8-10 Vials

ASV can be administered in two ways:

Slow IV (2ml/min). Each vial is 10ml
Infusion: ASV diluted in 5-10ml/kg NS/ 5D.
Administer over 1 hr at constant speed.
Closely monitor patient for 2 hrs.
Do not inject ASV locally at the site of bite.

Repeat Doses: Anti Haemostatic

Initial 10 vials of ASV over 1 hr.

Repeat a CT 6hrs later.
If deranged give 2nd dose of ASV.
Repeat CT every 6 hrs and give ASV if indicated upto
a maximum of 25 vials.

Ghosh S, Maisnam I, Murmu BK, Mitra PK, Roy A, Simpson ID. A locally
developed snakebite management protocol significantly reduces overall anti
snake venom utilization in West Bengal, India. Wilderness Environ Med;
2008;19;267-74

Repeat Doses: Neurotoxic

Give an initial dose of 10 vials.
If neurotoxicity persists after 2 hrs give 10 more vials.
If respiratory failure still persists continue ventilation.
Evidence suggests that reversibility of post synaptic
neurotoxic envenoming is only possible in the first few
hours.

Srimanarayana J, Dutta TK, Sahai A, Badrinath S. Rational use of Anti snake

venom (ASV): Trial of various Regimens in Hemotoxic Snake Envenomation.
Journal of Assoc of Physicians India. 2004;52:788-793

Local envenoming
Local swelling involving more than half of the bitten
limb (in the absence of a tourniquet).
Rapid extension of swelling
Development of an enlarged tender lymph node
draining the bitten limb.

Initial dosing exceptions

Vital life saving surgery
To resolve serious complications of snake bite
Intracranial bleed
Restore coagulation in shortest time
Initial dose 2-3 times the normal starting dose

ASV in pregnancy
Dosage is the same
Greatest risk in 1st trimester with coagulopathy
Spontaneous abortions can occur within 7 days
of the bite

Sebe A, Satar S, Acikalin A. Snakebite during pregnancy. Hum Exp Toxicol.

2005;24:341-5.

ASV in children
Snake injects the same amount of venom
whether it is a child or adult.
Hence the dose of antivenom remains the same

Simpson, I.D., Norris, R.L, Snake antivenom product guidelines in India:

The devil is in the details. Wilderness Environ Med. 2007;18:163-168

Renal Failure and ASV

Renal failure is a common complication of Russell's
Viper and Hump-nosed Pit viper bites
The contributory factors are intravascular haemolysis,
DIC, direct nephrotoxicity, hypotension &
rhabdomyolysis.
Renal damage can develop very early in cases of
Russell's Viper bite.
ASV even if given 1-2 hours after the bite, is
incapable of preventing ARF
Shastry JCM, Date A, Carman RH, John KV. Renal failure following snake
bite. Am J Trop Med Hyg 1977;26:1032-1038

Recovery Phase
If an adequate dose of antivenom has been given
systemic bleeding stops within 15-30 mins &
coagulability is restored in 6 hrs.
Post synaptic neurotoxic envenoming (Cobra) may
begin to improve as early as 30 mins after antivenom.
Presynaptic neurotoxic envenoming (Krait) usually
takes a longer time.
In hypotension, BP may increase after 30 mins

Recurrent Envenomation
Once coagulopathy settles no further ASV
should be administered, unless a proven
recurrence of a coagulation abnormality is
established.
Prophylactic ASV not indicated to prevent
recurrence
Indian ASV is a F(ab)2 product and has a halflife of over 90 hours

Victims who arrive Late, after several

days
Document time of bite
Asymptomatic 24 hrs after bite.
Symptomatic 24 hrs after bite.
Venom can only be
neutralised if it is unattached!

Antivenom Reactions
20%of patients
Early (within 10 to 180 mins)
Late ( 5 days or more)

Pathophysiology
Complement mediated anaphylactic reaction.
Not IgE mediated

No role for test dose of ASV

Skin/conjunctival sensitivity, tests IgE
mediated type 1 hypersensitivity
May delay treatment
Can be sensitizing

ASV Reactions

ASV Reactions

Urticaria, itching, fever, chills,

Nausea, vomiting, diarrhoea, abdominal cramps,
Tachycardia, hypotension,
Bronchospasm and angio-oedema

McLean-Tooke A P C, Bethune C A, Fay A C, Spickett G P. Adrenaline in the

treatment of anaphylaxis: what is the evidence? BMJ. 2003; 327: 1332-1335

Treatment of ASV Reactions

Adrenaline should be kept loaded before giving ASV

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

Persistent hypotension,
Life threatening anaphylaxis
Adrenaline 0.2mg(200ug) of 1:10,000
dilution, IV bolus
Repeat if necessary
If hypotension refractory to bolus dose start
an adrenaline infusion
Immediate Management of Airway &
Breathing

Epinephrine infusion
1mg epinephrine in 500ml of 5%D / NS
1-4ug/min (0.5 to 2ml/ min)
Titrate to effect

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+ipratopium
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

Prophylaxis for ASV

Reactions

Prophylaxis with hydrocortisone and

chlorpheniramine bolus reduces incidence of
anaphylactic reactions
52 patients were randomised into 3 groups
Group 1: 1000mg hydrocortisone in 300ml NS
infusion 5 mins before and continued 30 mins
after ASV
Group 2: Chlorpheniramine 10mg IV bolus was given
5min after ASV infusion was started in addition
to the hydrocortisone
Group 3: Placebo
Gawarammana IB, Kularatne M et al, Parallel infusion of hydrocortisone chlorpheniramine bolus
injection to prevent acute adverse reactions antivenom for snakebites Med Journal of Australia.
2004;180(1):20-3.

Efficacy of subcut adrenaline in

prevention of anaphylaxis
0.25 ml of subcut adrenaline vs placebo
immediately before infusion of ASV in 101
patients and observed for anaphylactic
reactions within 24 hrs.
The incidence of anaphylaxis was 11% in
the study group and 43% in the control
group, showing a statistically significant
difference.
Premawardhena A, de Silva CE et al, Low dose subcutaneous adrenaline to prevent acute
adverse reactions to antivenom serum in people bitten by snakes: randomised, placebo
controlled trial BMJ. 1999; 318: 1041-1043

When to restart the ASV

after a reaction
Once the manifestations of the reaction have
subsided
Once the BP is under control
In severe reactions ASV can be restarted
under cover of an adrenaline infusion
Rate of ASV infusion can be decreased initially
Monitor the patient.

No absolute contraindications to
antivenom
Patients with previous reactions to
antitetanus, antirabies serum
Atopic diseases like severe asthma
Give only with systemic envenomation
Prophylactic regimes can be used

Repeat bite
Dosage and schedule of ASV remains
the same
Higher risk of adverse reactions
Prophylactic regimes can be used

Supportive management
of snake bite victims

Neurotoxic envenomation
Bulbar and respiratory paralysis.
Aspiration, airway obstruction or
respiratory failure.
Intubate and mechanically ventilate.

Neurotoxic Envenomation-Role of
Neostigmine
An anticholinesterase like Neostigmine prolongs
the life of acetylcholine and can reverse the
respiratory failure and neurotoxic symptoms due
to snake venom.
Neostigmine TEST:
1.5-2.0 mg neostigmine with 0.6mg atropine IV
Observe for 1 hr

Neostigmine particularly effective for

post synaptic neurotoxins (Cobra).
Improvement in ptosis, neck lift & single
breath holding counts over 60 minutes
0.5mg neostigmine IV q 30 mins for 12 hrs
Add 0.6mg atropine to 2.5mg neostigmine
Neostigmine & atropine can be given as a
continuous IV infusion in the above dosage
for a period of 12 hours.

Haemostatic abnormalities:
Strict bed rest to avoid even minor trauma
Transfusion of FFP, cryoprecipitate, platelet
concentrates, or even fresh whole blood can
be life saving.
Avoid intramuscular injections

Shock and myocardial damage:

Correct hypovolemia with fluids

CVP monitoring
Inotropes if hypotension persists.

Renal failure
Dialyze if necessary.
Treat the Hyperkalemia

Bacterial infections:
Infection at the site of the bite is common.
Broad spectrum antibiotics
Anti-tetanus toxoid

Surgical Intervention
Debridement of necrotic tissue
Fasciotomy for intracompartmental
syndrome

Handling Tourniquets
Sudden removal can lead to a massive surge of
venom leading to neurological paralysis,
hypotension.
IV line, O2, to handle above complications

Nishioka SA. Is tourniquet use ineffective in the pre-hospital management

of South American rattlesnake bite? Toxicon 2000;38(2):151-2

Snake Venom Ophthalmia

Cobras spit venom at the victim and can
cause pain in the eyes and conjunctivitis.
Immediately irrigate with large quantities of
water
Pain relief with 0.5% lignocaine eye drops.
Topical antimicrobials

Prevention of Snake Bite

Prevention of Snake bites

1. Education
2. Protection of human dwelling
places
3. Precautions to be taken while
working in the fields
4. Prompt treatment

To Summarize

Problem of immense magnitude

Diagnosis of envenomation
Resuscitation
Antisnake venom
ASV Reactions