Tamil Nadu Health Systems Project

Health and Family Welfare Department
Government of Tamil Nadu, Chennai.
Tamil Nadu Health Systems Project
Health and Family Welfare Department
Government of Tamil Nadu, Chennai.
HAND BOOK ON TREATMENT GUIDELINES
FOR
SNAKE BITE AND SCORPION STING
2008
HANDBOOK ON TREATMENT
GUIDELINES FOR SNAKE BITE AND
SCORPION STING
Tamil Nadu Health Systems Project
Health and Family Welfare Department
Government of Tamil Nadu, Chennai.
2008
INTRODUCTION
The Tamil Nadu Health Systems Project formed a snake bite task force in 2006
to try and understand the staggering figures that were surfacing on snake bite and
scorpion sting cases in Tamil Nadu. During the effort, it was apparent that despite
morbidity and mortality, an evidence based handbook on treatment guidelines was not
available to medical officers as a ready reckoner in dealing with affected persons.
A committee was then formed to prepare guidelines to treat snake bite and
scorpion sting with the assistance of the Health & Family Welfare department and in
particular the Poison Control, Training and Research Treatment Centre in Government
General Hospital, Chennai. The Committee has prepared this Handbook after several
rounds of discussion and has also subjected this document to a peer review.
This handbook will help to redefine patient care for those who suffer from
snake bite and scorpion sting and will be useful for health care providers, patients and
policy makers. Information provided in the following pages range from epidemiological
issues, clinical features, treatment modalities, management of complications, referral
aspects medical audit, research areas and so on.
With this handbook, we hope to ensure that a major information gap is
adequately plugged so as to ensure rational medical treatment and appropriate quality
of care for snake bite and scorpion sting victims.
November 2008
Chennai.
Dr. S. VIJAYA KUMAR I.A.S.,
Special Secretary to Government
Health & Family Welfare Dept.,
&
Project Director
Dr. S. VIJAYA KUMAR
Tamil Nadu Health Systems Project
7th Floor, DMS Building,
Chennai - 600 006.
Tel. Off : (91-44) 2434 5997
Fax : (91-44) 2434 5997
Email : mail@tnhsp.net
iii
EDITORIAL COMMITTEE
Chair Person :
Thiru.Dr.S.Vijaya kumar, I.A.S.,
Project Director and
Special Secretary to Government,
Tamil Nadu Health Systems Project,
Chennai – 6.
Members:
Dr. (Capt.) M.Kamatchi,
Expert Advisor,
TamilNadu Health Systems Project (TNHSP),
Chennai.
Dr. P. Thirumalaikolundusubramanian,
Former Director, Professor and Head, Institute of Internal Medicine,
Madras Medical College and
Emeritus Professor, The Tamil Nadu Dr.M.G.R. Medical University, Chennai.
Mr. Ian D. Simpson, Consultant,
Member of Tamil Nadu Snake Bite Task Force and
Snake bite advisor to Pakistan Medical Research Council
Dr. C. Rajendiran, Director, Professor and Head, Institute of Internal Medicine,
Madras Medical College and
Physician i/c, IMCU & Poison Control, Training and Research Centre,
Government General Hospital, Chennai.
Dr. P. Ramachandran, Pediatrician, & Registrar,
Institute of Child Health & Hospital for Children,
Madras Medical College, Chennai.
Dr. C. Ravichandran, Asst. Professor,
Institute of Child Health & Hospital for Children,
Madras Medical College, Chennai.
Mrs. Beaula Indrani, Public Health Nurse,
Reproductive & Child Health, Chennai.
Dr. G. Sasikala, Editorial Assistant, TNHSP, Chennai.
iv
ACKNOWLEDGEMENT
Tamil Nadu snakebite task force team and staff Tamil Nadu Health Systems
Project (TNHSP), Chennai thank the Ministry of Health and Family Welfare, Health
& Family Welfare Department, State Government of Tamil Nadu, Chennai, India and
Madras Medical College, Chennai for making arrangements to prepare the treatment
guidelines for snakebite and scorpion sting; and also thank the Ministry of Health
& Family Welfare, Government of India, New Delhi, for considering the treatment
guidelines prepared from Tamil Nadu for Snake bite favourably.
The encouragement provided by Thiru .V.K. Subburaj, I.A.S., Principal
Secretary to Government, Health & Family Welfare Department, Government of
Tamil Nadu, Chennai; Ms. Supriya Sahu, I.A.S., former Additional Secretary, Tamil
Nadu Health Systems Project, Chennai; Thiru. P.W.C. Davidar, I.A.S., Former Project
Director & Special Secretary to Government, Tamil Nadu Health Systems Project,
Chennai; and Thiru. Muthiah Kalaivanan, I.A.S., former Project Director, Reproductive
and Child Health (RCH), Chennai, for the preparation of the treatment guidelines for
snakebite and scorpion sting is gratefully acknowledged.
The support provided by former Director of Medical Education, Dr. Vijayalakshmi,
former Director of Medical and Rural Health Services, Dr. N. Kalyanasundaram and
former Director of Public Health and Preventive Medicine, Dr. S.Murugan are duly
acknowledged.
The services rendered by Dr. P. Padmanabhan, Director of Public Health and
Preventive Medicine, Chennai; Dr.V.K. Rajamani, Professor of Medicine, and
Dr. Saradha Suresh, Director and Superintendent, Professor and Head of Pediatrics,
Madras Medical College, Chennai; Dr. S. Shivakumar, Professor and Head of
Medicine, Stanley Medical College, Chennai; Dr. A. Ayyappan, Professor and Head
of Medicine and Dr. M.L. Vasanthakumari, Professor of Pediatrics, Madurai Medical
College, Madurai; Dr. S. Muthukumaran, Professor and Head of Medicine, Thanjavur
Medical College, Thanjavur; Dr. Vasantha Elango, Professor and Head of Community
Medicine, and Dr. K.Umakanthan, Professor and Head of Medicine, Coimbatore
Medical College, Coimbatore; Dr. K. Sathyamoorthy, Professor and Head of Medicine,
Government M.K. Medical College, Salem; and Dr. R.A. Sankaramanian, Professor
of Pediatrics, Government Theni Medical College, Theni in reviewing the manuscript
and offering suggestions are greatly appreciated.
v
STATEMENTS
1. For private circulation, not for sale
2. Acknowledging the source permits copying or translating the material
3. This module is designed to give concise information for medical practitioners and
not intended to provide comprehensive scientific information
4. For detailed and up to date information as well as to know the current developments,
users are requested to go through the original articles, review papers, case reports,
related publications, websites etc.,
5. For administration of each drug, users are informed to go through the latest product
information leaflets provided by the manufacturers
6. Users are reminded to recall the contraindications before using any drug.
7. Users have been motivated to make use of their experience and knowledge of
patients before deciding the dosage and treatment of each patient
8. The hand book has been revised as on November 2008
9. The publishers, Tamil Nadu Health Systems Project, Health and Family Welfare
Department, Chennai, Tamil Nadu, Funding agency, the contributors and reviewers
do not assume liability for any injury and / or any damage to persons or property
arising out of this publication
10. Readers are requested to submit their suggestions, views, feed back and
their experience on snakebite / scorpion sting to the following mail address
[mail@tnhsp.net] which will be helpful for modifying / revising future editions.
vi
ABBREVIATIONS
AS – Anti Snake Venom •
AT – Antithrombin •
BP – Blood Pressure •
CT – Computerised Tomography •
DIC – Disseminated Intravascular Coagulation •
FFP – Fresh Frozen Plasma •
Hg – Mercury •
HR – Heart Rate •
HCL – Hydrochloride •
ICP – Intra Compartment Pressure •
IM – Intramuscular •
IV – Intravenous •
LAB – Laboratory •
PHC – Primary Health Centre •
PIM – Pressure Immobilisation Method •
PR – Pulse Rate •
RR – Respiratory Rate •
SD – Standard Deviation •
WBCT – Whole Blood Clotting Test •
WHO – World Health Organisation •
vii
List of Tables, Figures, Pictures and Plates
List of Tables
Table 1: Statistics on clinical aspects of snake bites and outcome
Table 2: Categorisation of snakes (W.H.O.1981)
Table 3: Snakes, clinical aspects and therapeutic response
Table 4: Details of local envenomation
Table 5: 20 Minutes Whole Blood Clotting Test (20WBCT)
Table 6: Currently recommended First aid
Table 7: Principles involved in the management
Table 8: Manifestations of immediate reactions to ASV
Table 9: Dosage of adrenaline for adults and children
Table 10: ASV – Risk and Wastage (Ian D.Simpson Model)
Table 11: Surgical issues: assessment and action required.
Table 12: Initial evaluation - No systemic envenomation
Table 13: Haemotoxic envenomation
Table 14: Neurotoxic envenomation
Table 15: Referral aspects for snake bite
Table 16: Distinguishing features of lethal and non-lethal scorpion
Table 17: Influencing factors for symptoms and signs
Table 18: Local effects at the site of sting.
Table 19: Systemic signs of scorpion sting.
Table 20: Non-neurological signs
Table 21: Measures to be adopted while using Prazosin
Table 22: Initial evaluation of scorpion sting without systemic envenomation
Table 23: Evaluation of scorpion sting with systemic envenomation
Table 24: Referral aspects for scorpion sting
Table 25: Responsibilities of health care providers
viii
Table 26: Levels of analysis
Table 27: Formula to calculate case fatality rate at different levels
Table 28: Snake bite cases reported and ASV vials used in secondary care hospitals
(district wise)
Table 29: Fluid requirement chart for children
Table 30: Normal Respiratory Rate (per minute) by age.
Table 31: Normal Heart Rate (per minute) by age
Table 32: Normal Blood Pressure in children by age
Table 33: Hypotension by systolic Blood Pressure and age
List of Figures
Figure 1: Grading of scorpion envenomation
Figure 2: Nervous system signs
List of Pictures
Picture No. 1: Snakes of Medical Importance in Tamil Nadu
Picture No. 2: Typical signs of local envenomation
Picture No. 3: Cellulitis with compartmental syndrome
Picture No. 4: Showing bilateral ptosis with overaction of frontalis
Picture No. 5: Showing ophthalmoplegia
List of Plates
Plate No. 1: Snake Identification
Plate No. 2: Important Venomous Snakes of India
Plate No. 3: Primary / Community Health Care Centre - Snake bite Treatment
Guidelines
Plate No. 4: Secondary Health Care Centre - Snake bite Treatment Guidelines
ix
CONTENTS
1. INTRODUCTION iii
2. EDITORIAL COMMITTEE iv
3. ACKNOWLEDGMENT v
4. STATEMENTS vi
5. ABBREVIATIONS vii
6. LIST OF TABLES, FIGURES, PICTURES AND PLATES viii
7. SECTION I: SNAKEBITE
8. SECTION II: SCORPION STING
9. SECTION III: MISCELLANEOUS
10. SECTION IV: ANNEXURES
Titles Page
1.1 General 1
Introduction •
Magnitude of the problem •
Epidemiology of snake bite •
Ecological aspects •
1.2 Classification of snakes 4
Snakes of Medical Importance in Tamilnadu - •
Distinguishing features
1.3 Clinical aspects of snake bite 7
Pathophysiology •
Symptoms and signs •
Criteria for diagnosis •
Complications and outcome •
Investigations •
1.4 Treatment 14
First aid for snake bite •
Traditional methods followed for treating snake bite •
Newer methods - pressure pad or Monash technique •
Principles involved in the management •
Pharmacological aspects of Anti Snake Venom •
ASV Administration •
criteria
dosage
administration
Facts to be remembered before / while using Inj.ASV •
ASV reactions •
Prevention of ASV reaction(s) – prophylactic regimens •
SECTION - I
SNAKE BITE
Titles Page
Repeat doses of ASV in Anti haemostatic envenomation •
Recurrent envenomation •
Anti-hemostatic maximum ASV dosage •
Recovery phase •
ASV risk and wastage •
1.5 Clinical issues in Snakebite 29
Hypotension •
Persistent or severe bleeding •
Renal failure •
Surgical issues •
Use of Heparin and Botropase •
1.6 Snake Bite in special situations 32
Victims requiring life saving surgery •
Victims arriving late •
Snake bites again! •
Pregnancy and lactating women •
Others •
1.7 Management at Primary Health Care Centres and Block PHC 33
1.8 Referral aspects 36
1.9 Welfare measures 38
1.10 Occupational risk for snakebite 38
1.11 Preventive measures and health education 39
1.12 Resource material 39
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 1
1.1 General
Introduction
In many parts of India, snake is worshipped and in some areas special prayers
are performed. In Northern India on Naga Panjami day people worship snake idol. In
certain areas of Maharashtra and Goa the live snakes, rarely live cobras are brought
for worship. Snake charmers carry snakes especially cobra, door to door for worship.
At every house the snake’s mouth is forced open and some milk is poured down in
its throat though milk is not snake food. It is also believed that snakes bite people
who harmed them in their previous birth. When snakes are killed, people offer special
prayers and bury them. People also believe that snakes take revenge against those who
harmed them.
In view of their strong beliefs and many associated myths, people resort to magico-
religious treatment for snake bite thus causing delay in seeking proper treatment. As a
result, valuable time is lost in some of the deserving cases. It is poignant to note that
some of the cinema and TV serial stories even now propagate non-scientific ideas on
snakes and snakebites, and display traditional treatment. Hence, there is a need for
the health department to disseminate the scientific aspects related to snakebites to the
community.
Magnitude of the problem
Recently global burden of snake bite was assessed using available published data
and modeling technique. From that it is estimated that 4,21,000 envenomations and
20,000 deaths occur annually. These figures may be as high as 18,41,000 envenomation
sand 94,000 deaths.
Snake bites contribute to health problem in India and continue to be a major
medical concern. India alone contributes to 81,000 envenomations and 11,000 deaths
annually. Based on the above statistics, it appears that every 10 seconds one individual
is envenomed and one among four dies due to snake bite. Many deaths occur before
the victim reaches the hospital. Actually up-to-date national data, on the morbidity
and mortality due to snakebite is not available. Moreover there is no national snake
bite registry in India. So the available statistics is incomplete and not systematically
collected. In 1972, Dr. Sawai and Dr. Homma of the J apan Snake Institute studied
snakebite in about 10 hospitals in India. They reported that about 10% of snakebite
deaths are among the victims who come to the hospital and about 90% die outside,
having gone for other remedies like mantra, magic, and so on. However things are
very different now, after 35 years.
Government General Hospital, Chennai, from J anuary to December 2006 has
treated 281 cases of snakebites. Among them, there were 182 males and 99 females.
Treatment Guidelines for Snakebite and Scorpion sting
2 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
94 were referred after treatment in different hospitals and 187 were brought to the
hospital directly. 274 (97.5%) survived and 7 died due to various complications of
snakebite while they were in the hospital. The details on the type of snakes, clinical
signs, complications, number referred, number who received supportive therapy and
death are provided below (Table no.1).
Table No. 1: Statistics on clinical aspects of snake bites and outcome*
Type of
snake
Number
treated
Local
signs
Neuro
Toxicity
Hemo.
Toxicity
Supportive
Number
Expired
Mechnical
ventilation
Hemo-
Dialysis
Fasciotomy.
Cobra 118 80 118 - 90 - - 2
Krait 82 - 51 82 60 3 - 2
Russell’s
viper
42 42 - 42 6 23 1 1
Hump-
nosed
viper
4 4 - 4 - 4 - 1
Saw
scaled
viper
16 16 - 16 - 3 - 1
Sea
snake
3 3 - - - - - -
Non
poisonous
16 6 - - - - - -
*Government General Hospital, Chennai (J an – Dec 2006).
An equal or more number of snake bite cases were admitted and treated at other
Government Medical College Hospitals. Patients go to private hospitals mostly for
first aid purposes. Very few get adequate treatment in these hospitals.
In Tamil Nadu the total number of snake bite cases admitted (and expired) in the
secondary care hospitals alone during 2005 - 2006 and 2006 -2007 were 19321(85)
and 20677(75) respectively. The total number of ASV vials used in these hospitals
during the respective periods were 94481 and 96800 (Annexure I). Over all analysis
revealed that the snakebites and ASV usage in West, North, East, Central, South zone
of Tamil Nadu were 13, 17, 20, 24 and 26% respectively.
The Government is spending a huge sum of money in procuring and supplying anti
snake venom. On an average, Government hospitals spend a minimum of Rs.5,000/- per
case of Snake bite and patient spends an equal amount for socio-cultural and magico-
religious aspects. The money lost due to loss of job and earning as well as loss of lives
is huge, and thus has an impact on the national economy. Deaths due to snakebite can
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 3
be prevented, if some simple first aid measures are undertaken by the public and / or by
the health care providers. So, there is an urgent need to take effective steps to contain
these issues.
Many of the first aid measures carried out at present are ineffective and dangerous.
The research also concluded that the other traditional methods followed for snake
bite are not appropriate. It is gratifying to note that the traditional snake catchers in
Tamil Nadu, the Irulas with their own sophisticated herbal medicine system, have now
understood the problems? They know that the snake injects venom which goes deep
into the system and this can be neutralised only by injection of Anti snake venom
(ASV) and not by oral or locally applied remedies, no matter how famous. But this
information needs to reach other communities also.
Hence, the need to recommend the most effective first aid to the victims bitten by
snakes and to recommend effective steps in the management of this problem. Poisoning
due to cobra and viper groups are seen frequently in the state of Tamil Nadu. Very
rarely sea snakebite cases are reported. Hence, this hand book focuses on the first two.
Though the specific antidote is not available for sea snake, the same general principles
for other snakebites are applicable here too.
Epidemiology of snakebite
Snakebite is observed all over the country with a rural / urban ratio of 9:1. They
are more common during monsoon and post monsoon seasons. Snakebites are seen
often among agricultural workers and among those going to the forest. Many of the
susceptible populations are poor living below poverty line, living in rural areas with
less access to health care. The male / female ratio among the victims is approximately
3:2. Majority are young and their age is between 25 to 44 years. Most of the bites (90
to 95%) are noticed on the extremities (limbs). The hospital stay varies from 2 to 30
days, with the median being 4 days. The in-hospital mortality varies from 5 to 10%,
and the causes are acute renal failure, respiratory failure, sepsis, bleeding and others.
Ecological aspects:
By destroying forests for creating agricultural land, the prey base of the snake
(that is frogs and rats) has increased. The rice fields, which harbour millions of rats
attract a lot of snakes. The number of snakes per acre in a rice field is abnormally
high when compared to the natural population in the forest. Humans go into the field
every morning and come out in the evening, just the time when snakes are active.
Thus, the chance of an encounter between farmer and snake is very high. As more
areas are inhabited at the periphery of towns, even there the chances of human / snake
interaction increase.
Cobras flourish as long as there are rice fields; there they feed mainly on the mole
rat (varapu eli in Tamil), live and lay their eggs in the rat burrow networks. Kraits also
get by very well in rice fields because they like the plentiful small rodents such as the
Treatment Guidelines for Snakebite and Scorpion sting
4 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
field mouse (sundeli in Tamil) and rock mouse (kallu eli in Tamil). Kraits are also found
in the mounds of earth and rubble near wells. The Russell’s viper lives in the rocky
outcrops and hedgerows of cactus and other bushes which often form the boundaries of
agricultural land. There, on the high ground, they have a plentiful supply of common
gerbil (velleli in Tamil) which are also attracted to the wealth of food humans provide
by their farming activities! But thanks to snakes, we are not overrun by rodents.
1.2 Classification of Snakes:
There are more than 3000 species of snakes in the world. For the purpose of clinical
practice, snakes are classified into poisonous (venomous) and non-poisonous (non
venomous) snakes. Poisonous snakes are classified into three families and they are
Cobra group [Elapidae] •
Viper group [Viperidae] •
Sea snake group [Hydrophidae] •
For many decades, the concept of the “Big 4” snakes of medical importance has
reflected the view that 4 species and responsible for Indian snakebite mortality. They are
- the Indian cobra (Naja naja), the Common Krait (Bungarus caeruleus), the Russell’s
viper (Daboia russelii) and the Saw scaled viper (Echis carinatus). However, recently
another species, the Hump-nosed pit viper (Hypnale hypnale), has been found to be
capable of causing lethal envenomation, and that this problem had been concealed
by systematic misidentification of this species as the saw-scaled viper. The concept
of the “Big 4” snakes has failed to include all currently known snakes of medical
significance in India. This has a negative effects on clinical management of snakebite
and the development of effective snake anti venoms
In 1981, the W.H.O. developed the following definition of snakes of medical
importance (Table No.2). This model is more accurate and useful than definitions such
as the ‘Big 4’ that are inaccurate and misleading to doctors and more importantly to
ASV manufacturers.
Table No. 2: Categorisation of snakes (W.H.O. 1981)
Class Details Name of the snakes
I Commonly cause death or serious
disability
Russells viper / Cobra / Saw scaled
viper
II Uncommonly cause bites but are
recorded to cause serious effects
(death or local necrosis)
Krait / Hump-nosed pit viper /
King cobra / Mountain pitviper
III Commonly cause bites but serious
effects are very uncommon.
Water snakes, Green snake
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 5
saw-scaled viper (Echis carinatus). However, recently another species, the hump-nosed pit vipe
(Hypnale hypnale), has been Iound to be capable oI causing lethal envenomation, and that th
problem had been concealed by systematic misidentiIication oI this species as the saw-scaled vipe
The concept oI the °Big 4¨ snakes has Iailed to include all currently known snakes oI medic
signiIicance in India. This has a negative eIIects on clinical management oI snakebite and th
development oI eIIective snake anti venoms
In 1981, the W.H.O. developed the Iollowing deIinition oI snakes oI medical importance
(Table No.2). This model is more accurate and useIul than deIinitions such as the 'Big Four` that
are inaccurate and misleading to doctors and more importantly to ASV manuIacturers.

Table No: 2: Categorisation of snakes (W.H.O. 1981)
Class Details Name oI the snakes
I Commonly cause death or serious disability Russells viper/Cobra/Saw scaled viper
II Uncommonly cause bites but are recorded to
cause serious eIIects (death or local necrosis)
Krait/Hump-nosed pit viper/King
cobra/Mountain pitviper
III Commonly cause bites but serious eIIects are
very uncommon.
-Water snakes, Green snake
Snakes of Medical Importance in Tamil Nadu - Distinguishing features
Snakes of Medical Importance in Tamil Nadu - Distinguishing
features
A great deal is written concerning the problem of how to identify medically
significant species from non significant ones. A large amount of space is devoted, in
both medical and toxicology textbooks, to the problem of how to identify venomous
snakes. The problem with this information is that it is complex (involves counting
of scales) and not definitive (the identification of pre or post maxillary teeth) and of
no use to a doctor in a medical situation. On the question of description, it is worth
remembering that the least reliable means of identifying a particular species of snake
is to use colour. Virtually every species of venomous snake has a huge range of colour
manifestations and even the markings can be subjected to major variations. What is
important therefore is to focus on the key aspects of identification that enable the
medical professional to rapidly identify whether they are dealing with a venomous
species, and what that species might be.
Picture No.1 Tamil Nadu Snakes of Medical Importance
Treatment Guidelines for Snakebite and Scorpion sting
6 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
There are six medically important species in Tamil Nadu shown above. Readers are
informed to get familiarised with the pictures given at the end of Hand-book. Further
details of some of the poisonous snake are provided in the ensuing paragraphs.
Russell’s Viper (Daboia russelii)
The Russell’s Viper is a stout bodied snake, the largest of which grows to
approximately 1.8 meters in length. Like all the vipers it is a nocturnal snake, but
unfortunately for humans, during the daytime it rests up under bushes, at the base of
trees and in leaf litter. It is therefore frequently encountered by rural workers, as they
are carrying out general agricultural activities.
There are two key identification features that are worth noting. The first is a series
of chain-like or black edged almond shaped marks along the snakes back and flanks.
The second distinguishing mark is a white triangular mark on the head with the apex
of the triangle pointing towards the nostrils.
Saw scaled Viper (Echis carinatus)
The southern Indian Saw Scaled Viper is a small snake, usually between 30 and 40
centimetres long. The northern Indian species (Echis sochureki) is much larger, with
an average size of 60 centimetres. It inhabits mainly dry arid climates but can also be
found in scrubland.
One of the key identification features of this species is the posture it adopts when
it is agitated. It moves its body into a figure of eight like arrangement with its head
at the centre. It rapidly moves its coils against each other and produces a hissing like
sound which gives its name of ‘Saw Scaled’. In addition, there are often wavy hoop
like markings down both sides of the Saw Scales body. On the head, there is usually
a white or cream arrow shaped mark, pointing towards the front of the head, often
compared to the shape of a bird’s foot.
The Hump-nosed Pit viper (Hypnale hypnale)
The Hump-nosed pit viper is one of India’s tiniest venomous snakes, its total length
ranging from 28.5 to 55cm. Its distinctive features include the presence of five large
symmetrical plate scales on the top of the head in addition to the smaller scales typical
of all vipers. There are heat sensitive pits between the nostril and the eye.
Spectacled Cobra (Naja naja)
The Spectacled Cobra, is probably India’s most well recognised snake. The hood
markings of the spectacle like mark, distinguishes this snake from other species, and
its habit of rearing up when alarmed makes it distinctive but not definitive as other
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 7
species do this, notably the Trinket Snake. The Cobras coloration may vary from pale
yellow to black.
Common Krait (Bungarus caeruleus)
The Common Krait is a nocturnal snake which usually grows to approximately
1.0 to 1.2 metres in length. Its primary diet is other snakes. It can be found all over
Peninsular India and often seeks habitation near human dwellings. During the day it
rests up in piles of bricks, rat burrows or other buildings. The Common Krait is the
most poisonous snake in India and its venom is pre-synaptic neurotoxic in nature.
There are a number of key identifiers which are worth remembering. The Krait
is black, sometimes with a bluish tinge, with a white belly. Its markings consist of
paired white bands which may be less distinct anteriorly. These paired white bands
distinguish the snake from another black nocturnal snake, the Common Wolf Snake.
The Wolf Snake’s white bands usually are thicker and are singular bands equidistant
from each other. The second useful distinguishing feature is a series of hexagonal
scales along the top of the snakes back. This feature is really useful if the dead snake
has been brought to the hospital and examined.
King Cobra (Ophiophagus hannah)
The King Cobra is the least medically significant of the venomous snakes in India
in terms of both bites and fatalities. Hence, descriptive features of this are not provided
here.
1.3 Clinical aspects of Snake Bite
Pathophysiology:
Snake venom is mostly watery in nature. It consists of numerous enzymes,
proteins, aminoacids, etc., Some of the enzymes are proteases, collagenases, arginine
ester hydrolase, hyaluronidase, phospholipidase, metallo-proteinases, endogenases,
autocoids, thrombogenic enzymes, etc., These enzymes also act like toxins on different
tissues of the body, and are grouped under neurotoxins, nephrotoxins, hemotoxins,
cardiotoxins, cytotoxins etc., resulting in organ dysfunction / destruction. Enormous
clinical and experimental works have been published on the pathophysiology of snake
bite in relation to different species of snakes.
The quality and quantity of enzymes and other clinical constituents vary with
species and subspecies, and the response of the victims to those substances are also
variable, thus resulting in dissimilar features in different individuals. For example
hyaluronidase allows rapid spread of venom through subcutaneous tissues by disrupting
mucopolysaccharides, and phospholipase A2 has esterolytic effect on the red blood
cell membrane and causes hemolysis. It also promotes muscle necrosis. Thrombogenic
Treatment Guidelines for Snakebite and Scorpion sting
8 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
enzymes promote formation of weak fibrin clot, which activates plasmin and results
in consumptive coagulopathy and hemorrhagic consequences. Venom of some snakes
causes neuromuscular blockade at pre or post synaptic level. In addition to above it
causes endothelial cell damage which results in increased vascular permeability. In
short, snake venom acts on various parts / systems / organs of the body. Venom also
causes endothelial cell damage which results in increased permeability.
Symptoms and signs:
An international expert on snakebite, the late Dr. Alistair Reid of the Liverpool
School of Tropical Medicine found out that only 10 to 15% of venomous bites end
in death. The possibility of survival, even without treatment, is incredibly good in
80-90% of cases. One of the reasons for this is that many snakebites are by non-
venomous snakes. Secondly, a large percentage of venomous snakebites are dry bites
i.e., the snake does not always inject venom. Sometimes, it might inject only a tiny
quantity of venom. The snake can inject the quantity of venom it wants. This is an
entirely voluntary process. Hence, one can never know how much venom was injected
except by observing the progression of the symptoms. In other words the recovery
in snakebite without even treatment is great. Every traditional healer uses this fact
to his / her advantage and propagates his / her own method to treat snakebite viz.,
herbal details, “snakestone” or mantra, or plain soda water and most villagers would
be happy to go to him.
Also, every one should remember the systemic action of venom and the extent
varies from one snake to another. Complications and outcome due to snakebite may
also vary from each other and can’t be predicted by any means. Moreover, the status
of poisoning cannot be judged by the bite mark, reaction to envenomation, size or the
type of snake. Hence, one has to observe for signs and symptoms which may develop
within 24 to 48 hours.
The symptoms and signs of Viperine and Elapid envenomation as well as late-
onset envenomation are listed below.
General symptoms and signs of Viperine envenomation
Local effects
Swelling and local pain with or without erythema or discoloration at the site •
of bite
Tender enlargement of local lymphnodes as large molecular weight Viper •
venom molecules enter the system via the lymphatics.
Effects due to coagulopathy and hemorrhagic consequences •
Bleeding from the gingival sulci and other ori • fices.
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Epistaxis • .
The skin and mucous membranes may show evidence of petechiae, purpura •
and ecchymoses.
The passing of reddish or dark-brown urine or declining or no urine output. •
Lateralising neurological symptoms and asymmetrical pupils may be indicative •
of intra-cranial bleeding.
Vomiting. •
Acute abdominal tenderness which may suggest gastro-intestinal or retro •
peritoneal bleeding.
Hypotension resulting from hypovolaemia or direct vasodilation. •
Low back pain, indicative of early renal failure or retroperitoneal bleeding. •
Other effects
Muscle pain indicating rhabdomyolysis. •
Parotid swelling, conjunctival oedema, sub-conjunctival haemorrhage. •
General symptoms and signs of Elapid envenomation
Local effects
Swelling and local pain with or without erythema or discoloration at the site of •
bite (Cobra).
Local necrosis and / or blistering / bullae (Cobra). •
Neurotoxic effects
Descending paralysis, initially of muscles innervated by the cranial nerves, •
commencing with ptosis, diplopia, or ophthalmoplegia. The patient complains
of difficulty in focusing and the eyelids feel heavy. There may be some
involvement of the senses of taste and smell.
Problems of vision, breathing and speech. •
Paralysis of jaw and tongue may lead to upper airway obstruction and aspiration •
of pooled secretions because of the patient’s inability to swallow.
Numbness around the lips and mouth, progressing to pooling of secretions, •
bulbar paralysis and respiratory failure.
Hypoxia due to inadequate ventilation can cause cyanosis, altered sensoriun •
and coma. This is a life threatening situation and needs urgent intervention.
Paradoxical respiration, as a result of the intercostal muscles paralysis is a •
frequent sign.
Treatment Guidelines for Snakebite and Scorpion sting
10 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Krait bites often present in early morning with paralysis that can be mistaken •
for a stroke. Stomach pain which may suggest submucosal haemorrhages in
the stomach.
Other effects
Stomach pain which may suggest submucosal haemorrhages in the stomach •
(Krait).
Eye pain and damage due to ejection of venom into the eyes by spitting cobra •
(as observed in Africa)
[If features of renal failure are noted search for other causes / mechanisms]
Late-onset envenomation
The patient should be kept under close observation for at least 24 hours. Many
species, particularly the Krait and the Hump-nosed pit viper are known for the length
of time it can take for symptoms to manifest. Often this can take between 6 to 12 hours.
Late onset envenoming is a well documented occurrence. This is also particularly
pertinent at the start of the rainy season when snakes generally give birth to their
young. J uvenile snakes (young ones), 8-10 inches long, tend to bite the victim lower
down on the foot in the hard tissue area, and thus any signs of envenomation can take
much longer to appear.
Overlapping symptoms and signs
Russells Viper envenomation can also manifest with neurotoxic features. This can
sometimes cause confusion and further work is necessary to establish how wide this
might be. Development of neurotoxic features in Russells Viper bite are believed to be
pre synaptic or Krait like in nature. It is for this reason that a doubt is expressed over
the response of both species to Neostigmine. Clinical aspects and therapeutic response
in relation to some of the poisonous snakes in India is provided in Table no. 3
Table No. 3: Snakes, clinical aspects and therapeutic response
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
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Renal Complications NO* NO* YES NO* YES
Response to
Neostigmine
YES NO? NO? NOT
applicable
NOT
applicable
Response to ASV YES YES YES YES NO
[* If features of renal failure are noted search for other causes / mechanisms]
Sea snakes:
Sea snake bites are reported rarely among fishermen and / or their family members
living in the seashore area as well as among those who walk on the seashore. To begin
with there may be local pain which may be insignificat which appears within 60 to 90
minutes. There may not be obvious local swelling. Systemic manifestations noticed
among poisonous sea snake bite are neurological involvement, severe muscle pain,
rigidity, renal failure, hyperkalemia and finally cardiac arrest.
Criteria for diagnosis
An approach to snakebite is provided in Annexures VIII and IX. The criteria to
diagnose poisonous snakebite in a given clinical setting are:
a. Systemic envenomation in the form of coagulopathy and neurotoxicity.
b. Local envenomation (Table no: 4). Features of local envenomation - are grouped
under the mneumonic “PONDS”.
Table No :4 : Details of local envenomation
• Pain- pain at the site of bite, swelling and regional lymphnode
• Oozing- sero / sanguinous oozing from the site of bite
• Node- development of an enlarged tender lymphnode draining the bitten
limb
• Discoloration- discoloration at the site of bite
• Swelling – swelling is seen at the site of the bites on the digits (toes and
especially fingers); local swelling develops in more than half of the bitten
limb immediately (in the absence of the tourniquet) and swelling extends
rapidly beyond the site of bite (eg. beyond the wrist or ankle within a few
hours of bites on the hands or feet)

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12 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

Complications and Outcome
Complications in snake envenomation are due to the heterogenous composition of
the venom. In addition the quantity and quality of the venom and the response of the
individual to the components of venom influence the clinical course, complications
and outcome. The complications of venom are observed in various systems viz., the
hematological, vascular, renal, respiratory, cardiovascular, endocrine, gastrointestinal,
muscular and dermatological system.
In addition to the anti snake venom, the envenomed individual requires supportive
treatment for the complications arising out of snakebite as well as the consequences of
the complication. One must also remember to look for complications developing after
infusion of Inj.anti snake venom and get prepared to treat them also.
The outcome of snakebite depends upon amount of envenomation, bite to needle
time, individual’s response to envenomation, the complications that develop following
snakebite and response to treatment. Till the patient has recovered, one cannot predict
the complications and outcome.
Investigations
20 Minutes Whole Blood Clotting Test (20WBCT)
The 20 Minutes Whole Blood Clotting Test (20WBCT) is considered as the most
reliable test for coagulation and can be carried out at the bedside without specialised
training. It can also be carried out in the most basic settings. It is significantly superior
to the ‘capillary tube’ method of establishing clotting capability and is the preferred
method of choice in snakebite. The advantages, requirements and procedure for
20 WBCT are provided in in Table no: 5
Typical signs of local envenomation namely edema,
blister and joint swelling
Cellulitis with compartmental syndrome
Picture No.2 Picture No.3
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 13
Table No. 5: 20 Minutes Whole Blood Clotting Test (20WBCT)
Advantages Requirements Procedure
The most •
reliable test of
coagulation.
Can be carried •
out, at the
bedside.
Does not •
require
specialised
training.
Dry glass test tube •
(clean and new)
2ml disposable •
syringe
Cotton •
Antiseptic solution •
Clean gloves (one •
pair)
(The test tube •
must not have
been washed with
detergent, as this
will inhibit the
contact element
of the clotting
mechanism)
Wash hands with soap and water. •
Wear the gloves •
Collect 2ml blood from the •
peripheral vein of the unaffected
limb
Remove the needle and pour the •
blood along the walls of the test
tube
Keep the test tube untouched and •
unshaken in a safe place near
the patient’s bedside at ambient
temperature for 20 minutes
Note the time •
After 20 minutes the test tube is •
gently tilted and if the blood is
still liquid then the patient has
incoagulable blood.
If the 20WBCT is normal in a suspected case of poisonous snakebites, the test
should be carried out every 30 minutes from admission for three hours and then hourly
after that. If incoagulable blood is discovered, the 6 hourly cycle will then be adopted
to test for the requirement of repeat doses of ASV. This is due to the inability of the
liver to replace clotting factors under 6 hrs.
Other Useful Tests:
Clinical test: •
- PR / BP / RR / Postural Blood Pressure
Laboratory studies: •
- Haemoglobin / PCV / Platelet Count/ PT / APTT / FDP / D-Dimer
- Peripheral Smear / Blood grouping / Rh typing
- Urine Tests for Proteinuria / RBC / Haemoglobinuria / Myoglobinuria
- Biochemistry for Serum Creatinine / Urea / Electrolytes / Oxygen Saturation
Imaging studies : •
- X-Ray Chest / CT / Ultrasound (whenever required)
Others •
- Electrocardiogram
- Special investigations depending upon clinical status.
- Ocular fundus examination
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14 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
1.4 Treatment
First aid for snake bite
The first aid currently recommended is based around the mnemonic ‘R.I.G.H.T’.
The details are provided in Table no.6 .
Table No. 6: Currently recommended First aid
R. = Reassure the patient. •
(70% of all snakebites are from non-venomous species. Only 50% of bites by
venomous species actually envenomate the patient)
I = Immobilise in the same way • as a fractured limb.
(Use bandages or cloth to hold the splints, not to block the blood supply or
apply pressure. Do not apply any compression in the form of tight ligatures,
they don’t work and can be dangerous!)
G. H. = Get to Hospital Immediately. •
(Traditional remedies have NO PROVEN benefit in treating snakebite).
• T= Tell the doctor of any systemic symptoms such as ptosis that manifest on
the way to hospital.
This method will get the victim to the hospital quickly, without recourse to
traditional medical approaches which can delay effective treatment.
Traditional first aid methods followed for snakebite:
The traditional methods such as application of tourniquet, cutting (incision) and
suction, washing the wound, snake stone or other methods have adverse effects and
hence, they have to be discarded. The mneumonic used to recall some of the traditional
methods followed is “WHISTTLE” and these are described below.
Washing the Wound:
Victims and bystanders have a tendency to wash the wound to remove any venom
on the surface. This should not be done as the action of washing increases the flow of
venom into system by stimulating the lymphatic system.
Household remedies:
Various forms of household remedies are applied to the site of bite which may
enhance absorption of venom.
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 15
(Incision) Cutting and Suction:
Cutting the site of bite and suctioning incoagulable blood increases the risk of
bleeding to death as well as increases the risk of infection. Venom is not cleared or
removed from the snakebite site by this method.
Snake stone:
Snake stone is applied to the site of bite saying that it will absorb the venom and
falls once the venom is absorbed. This contributes to delay in seeking appropriate
health care.
Tourniquets:
Tight tourniquets made of rope, string and cloth, have been followed traditionally
to stop venom flow into the body following snakebite. The problems noticed with
tourniquets are :-
Risk of ischemia and loss of the limb •
Risk of necrosis •
Risk of massive neurotoxic blockade •
Risk of embolism if used in viper bites. •
Release of tourniquet may lead to hypotension. •
Gives patient a sense of false security, which encourages them to delay their •
journey to hospital
Thermal methods:
Cautery treatment • is followed in some areas. It is injurious and not
beneficial
Cryotherapy • involving the application of ice to the bite was proposed in the
1950’s. It was subsequently shown that this method had no benefit and merely
increased the necrotic effect of the venom.
Local application of anti snake venom:
Local application of anti snake venom has not shown any beneficial effects
Electrical Therapy:
Electric shock therapy for snakebite received a significant amount of press
coverage in the 1980’s. The theory behind it stated that applying an electric current to
Treatment Guidelines for Snakebite and Scorpion sting
16 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
the wound denatures the venom. Much of the support for this method came from letters
to journals and not scientific papers. It has been demonstrated that the electric shock
has no beneficial effect and hence, it has been abandoned as a method of first aid.
Pressure Immobilisation Method (PIM)
PIM was developed in Australia in 1974 by Sutherland and gained some supporters
on television and in the herpetology literature. Some medical textbooks have referred
to it. Further work done by Howarth demonstrated that the pressure, to be effective,
was different in the lower and upper limbs. The upper limb pressure was 40-70mm
of Mercury; the lower limb was 55-70mm of mercury. Work carried out by Norris
showed that only 5% of lay people and 13% of doctors were able to correctly apply
the technique. In addition, pressure bandages should not be used where there is a risk
of local necrosis, that is in 4/5 of the medically significant snakes of India. In view of
the difficulties encountered at every level, Pressure Immobilisation Method cannot be
recommended for use at present.
Newer Methods
‘Pressure Pad or Monash Technique’
Initial research has suggested that a ‘Pressure Pad or Monash Technique’ may have
some benefit in the first aid treatment of snakebite. This method should be subjected
to further research in India to assess its efficacy. It may have particular relevance to
the Indian Armed Forces who carry Shell Dressings as part of their normal equipment,
and would thus be ideally equipped to apply effective first aid in difficult geographic
settings where the need is great.
Treatment:
While dealing with a case of snake bite consider the mnemonic ‘RASI’.
Remember principles ( “12 As” ) •
Address the problems – clinical and social •
Seek help from others when required and •
Inform the patient and / or care givers on the status of illness, clinical course, •
management, outcome, welfare measures and follow up clearly with empathy.
Principles involved in the management of snake bite
The principles while managing cases of snake bite at any Health Centre are clubbed
under “12 As”
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 17
Table No. 7: Principles involved in the management
Admit the victim immediately. 1.
Ask effectively. 2.
Assess quickly. 3.
Act swiftly. 4.
Administer medication meticulously. 5.
Address to the wound properly. 6.
Anticipate complications keenly. 7.
Avoid errors carefully. 8.
Ascertain the status repeatedly. 9.
Amicable with patients and care givers and show empathy. 10.
Advise on follow up accordingly. 11.
Arrange for referral early. 12.
1] Admit all victims of snake bite & Keep the victims under observation for 24 to 48
hours
2] Ask effectively to get the following –
a] Ask for the description of the snake, which has bitten the patient. If snake is
brought try to identify the snake with the help of snake picture chart.
b] Ask for the site of bite and check the site. Never be carried away, by bite marks
either for diagnosis or for assessment of severity.
c] Ask for the time of the bite and correlate with the progression of symptoms and
signs due to snakebite provided in page vide supra.
d] Ask for the details of traditional medicines or household remedies used, as it
may sometimes cause confusing symptoms or interfere with other drugs to be
administered.
3] Assess the following quickly.
a] Airway, Breathing and Circulation
b] Vitals HR, RR, BP and oxygen saturation by Pulse oximetry (if required)
c] Chest expansion, and the ability to put out the tongue beyond incisors and
counting the numbers at the bed side.
d] Site of snake bite along with regional lymphadenitis clinically from head to
foot as well as back
e] For associated co-morbid illness[es]
f] For consuming any medication[s]
g] The status of envenomation - local systemic (neurotoxic, hemotoxic, myotoxic)
or a combination of them
4] Act swiftly
a] Support Airway, Breathing and Circulation
b] Start IV line [fluid for children refer to Annexure II –Table No.29]
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18 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
c] Provide supportive measures depending upon the requirements including blood
transfusion / components if required.
d] Connect to ventilator if there is a need
5] Administer medications meticulously
a] Tetanus Toxoid injection intramuscularly
b] Anti snake venum as IV drip if needed – described vide infra
(ASV is composed of large molecules (IgG or fragments) and are absorbed
slowly via lymphatics, making the bioavailability by this route poor as
compared to intravenous administration. Also, intramuscular injections
are not preferred as it could cause pain on injection and risk of hematoma
formation and sciatic nerve damage in patients with hemostatic abnormalities.
Intramuscular injections should only be given in settings where intravenous
access cannot be obtained and / or the victim cannot be transported to a hospital
immediately).
c] Ionotropics as IV drip if required
d] Antimicrobials if necessary
e] IV fluids as per need [fluid for children refer to Annexure II – Table No.29]
f] Other supportive medications including medicines to relieve pain (avoid
aspirin) as per need.
6] Address to the wound properly
Remember the surigcal issues described vide infra and Table 11 in addition to the
following.
a] Wound following snake bite may show bite marks with or without laceration.
b] Sometimes venom may penetrate deep and hence deeper tissues may be
damaged which may not be visible during initial examination.
c] At the site of bite, bleb or vesicle may develop and end in the form of an ulcer
which is a non specific one. (Non-specific ulcers are defined as ulcers due to
infection of wounds, physical or chemical agents or due to local irritation).
d] Consider the following while managing the wound / ulcer.
Minimize unnecessary blood loss •
Avoid the formation of a hematoma •
Initiate adequate cleaning with normal saline or tap water, debridement, •
and edema control
Remove debris and necrotic tissue, irrigate gently with water / normal •
saline
Expose viable tissues, excise eschar after controlling hemotoxic •
complications
Use topical antibacterial agents •
Apply dressings after complete debridement. •
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 19
Maintain proper wound environment and prevent ischemia. •
Keep the bacterial count as low as possible. •
Facilitate healing of acute wound by applying non adherent dressing to •
ensure adequate epithelialisation and to prevent contamination of the
wound.
Keep wounds clean and dry. •
Avoid soaking or scrubbing the wound. •
Teach & explain the care of wound to the patients. •
Educate on good personal hygiene and nutrition. •
Control diabetes if identified. •
7] Anticipate complications keenly.
a] Examine the victims at regular intervals for alterations in symptoms and signs
b] Observe for anti snake venom related systemic changes and drug toxicity and
manage them as described vide infra under treatment for ASV reactions.
8] Avoid errors carefully while assessing the case, investigating the victims,
administering medications, following the case at hospital, undertaking any procedures,
referring to other specialists or hospital, communicating with patient / and care
givers, and planning for discharge as well as preparing reports, filling up the forms,
reviewing the data and conducting the audit.
9] Ascertain the status repeatedly and provide supportive measures as these cases
of snake bite victims may develop covert signs during hospital stay while on
treatment.
10] Amicable interaction with patient and care givers with empathy is essential in
view of the socio clinical aspects of snake bite.
11] Advise on follow up accordingly in view of the systemic toxicity and the nature of
wound following snake bite. Patients may be also motivated to attend the nearest
Health centre / Hospital for follow up care. Follow-up checks are required for
assessment of long term effects on different organs / systems and for appropriate
management wherever required / needed.
12. Arrange for referral early - One should also remember the criteria for referral and
provide clear instructions while referring the case. The details on referral aspects
of snake bite is provided vide infra in Table 15.
Pharmacological aspects of Anti snake venom
The goals of pharmacotherapy with injection Anti snake venom (ASV) are to
neutralise the venom, reduce morbidity and mortality, and prevent complications.
Treatment Guidelines for Snakebite and Scorpion sting
20 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Currently available Anti Snake Venom (ASV) in India is polyvalent i.e., it is effective
against all the four common species; Russells Viper (Daboia russelii), Common
Cobra (Naja naja), Common Krait (Bungarus caeruleus) and Saw Scaled Viper (Echis
carinatus). Indian ASV is a F(ab)
2
product derived from horse serum and has a half-
life of over 90 hours. Though it is purified, it still can be immunogenic.
At present, no monovalent ASV is available primarily because there are no objective
means of identifying the snake species, in the absence of the dead snake. Moreover it
is difficult for the physician to determine which type of Monovalent ASV to employ
in treating the patient. In addition there are difficulties to prepare, supply and maintain
adequate stock of species specific monovalent ASV.
There are other known species such as the Hump-nosed pitviper (Hypnale hypnale)
where polyvalent ASV is known to be ineffective. In addition, there are regionally
specific species such as Sochurek’s Saw Scaled Viper (Echis sochureki) in Rajasthan,
where the effectiveness of polyvalent ASV may be questionable. Further work has
to be carried out with ASV producers to address this issue of preparing ASV useful
against other poisonous snakes observed in India.
In India ASV is manufactured by Bengal Chemicals & Pharmaceuticals, Kolkata;
Bharat Serums, Mumbai; Biological Evans, Hyderabad; Central Research Institute,
Kausali; Haffkins Pharmaceuticals, Mumbai; King Institute of preventive medicine,
Chennai; Serum Institute, Pune and Vins bio-products, Hyderabad.
ASV is produced in both liquid and lyophilised forms. There is no evidence to
suggest which form is more effective and many doctors prefer one or the other based
purely on personal choice. Liquid ASV requires a reliable cold chain and refrigeration
and has a 2 years shelf life. Lyophilised ASV, in powder form, requires only to be kept
cool and hence, is useful in remote areas where power supply is inconsistent. The
details of pre hospital treatment and issues related to ASV may be recorded in the form
provided in Annexure IV.
ASV Administration
Criteria
ASV is prepared from animal and hence, it should only be administered when there
are definite signs of envenomation. Anti-Snake Venom carries risks of anaphylactic
reactions and should not therefore be used unnecessarily. Unbound, free flowing
venom, can only be neutralised when it is in the bloodstream or tissue fluid. Also it
is a scarce and costly commodity. Hence, ASV may be administered only if a patient
develops one or more of the following signs / symptoms.
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 21
Systemic envenoming
Evidence of coagulopathy primarily detected by 20 WBCT or visible •
spontaneous systemic bleeding, bleeding gums, etc., Further laboratory tests for
thrombocytopenia, Hb abnormalities, PCV, peripheral smear etc may provide
confirmation, but 20 WBCT is paramount.
Evidence of neurotoxicity: ptosis, external ophthalmoplegia, muscle paralysis, •
inability to lift the head etc.,
Cardiovascular abnormalities: hypotension, shock, cardiac arrhythmia, •
abnormal ECG.
Persistent and severe vomiting or abdominal pain. •
Local envenomation (Refer Table No: 4)
Purely local swelling, even if accompanied by a bite mark from an apparently
venomous snake, is not grounds for administering ASV if a tourniquet or tourniquets
have been applied. These themselves can cause swelling. Once they have been removed
for 1 hour and the swelling continues, then it is unlikely to be as a result of the tourniquet
and administration of ASV may be justified.
Dosage
In the absence of definitive data on the level of envenomation, symptomatology is
not a useful guide to the level of envenomation. Any ASV regimen adopted is at best
only an estimate. What is important is to establish a single guideline which could be
adhered to, in order to enable sensitization results to be reliably reviewed.
The recommended dosage level has been based on published research that Russells
Viper injects on average 63mg (SD 7) of venom. Logic suggests that our initial
dose should be calculated to neutralise the average dose of venom injected. This ensures
that the majority of victims should be covered by the initial dose and keeps the cost of
ASV to acceptable levels. The range of venom injected is 5mg to 147mg.
One vial of ASV neutralises 6mg of Russells Viper venom. So, to neutralize
63mg of venom, 10 vials are needed. Not all victims will require 10 vials as some may
be injected with less than 63mg. However, starting with 10 vials ensures that there is
sufficient neutralising power to neutralise the average amount of venom injected and
during the next 12 hours to neutralise any remaining free flowing venom.
Warrell et al based on their study have shown that test doses for ASV have no
predictive value in detecting anaphylactoid or late serum reactions and should not
be used. These reactions are not IgE mediated but Complement activated. They may
also pre-sensitise the patient and thereby create greater risk. For Neurotoxic / Anti
Haemostatic envenomation, 8 to 10 vials of ASV is recommended to be administered
Treatment Guidelines for Snakebite and Scorpion sting
22 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
as initial dose. Children receive the same ASV dosage as adults, as snakes inject the
same amount of venom into adults and children. The ASV is targeted at neutralising
the venom.
Administration
ASV may be administered in two ways over a period of one hour at a constant speed
and the patient should be closely monitored for 2 hours:
Infusion: liquid or reconstituted ASV is diluted in 5-10ml/kg body weight •
of isotonic saline or glucose and administered as infusion usually. (Fluid
requirement for children refer to Annexure II)
Intravenous Injection: Rarely reconstituted or liquid ASV is administered by •
slow intravenous injection. (2ml / minute). Each vial is 10ml of reconstituted
ASV.
Facts to be remembered before / while using of Anti Snake Venom (ASV)
1. ASV is available in a polyvalent form and marketed in liquid or lyophilised
preparations in 10ml vial / ampoule.
2. Remember to use and maintain cold chain systém for liquid form. Users are
informed to ascertain whether the cold chain is maintained.
3. There is no dose adjustment for ASV administration for children.
4. Before administering ASV, health staff should read and check the status of vial or
ampoule containing ASV.
5. Elicit history of prior exposure to ASV. If a patient had received ASV earlier
and comes back with features of snake envonemation again, he / she has to be
considered as a fresh case and treated accordingly. However, care should be taken
while administering ASV, since he / she has been sensitised.
6. ASV treatment should not be initiated without adequate agents for managing
anaphylaxis or anaphylactoid reaction.
7. Anaphylactic or late serum sickness cannot be determined or prevented by test
dose.
8. ASV neutralises the unbound venom, hence give it early.
9. ASV administration should not be delayed or denied on the grounds of anaphylactic
reactions to a deserving case.
10. ASV is required only to those who show definite signs and symptoms of
envenomation.
11. ASV should not be pushed as IV bolus or IM directly. ASV has to be administered
slowly as IV infusion in normal saline or glucose water over a period of one hour.
12. Local administration of ASV near the site of bite has been proven to be ineffective
and painful, and raises the intra-compartmental pressure, particularly in the digits.
Hence, it should not be adopted.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 23
13. There is no prophylactic dose of ASV.
14. Total dose requirement cannot be decided on the basis of (WBCT) Whole blood
clotting test (or) clinical signs and symptoms.
15. Even if the patient develops reaction(s), the total dose required should be
administered slowly after the patient recovers from the reaction(s).
16. There is no other drug of choice other than ASV for the treatment of poisonous
snakebite.
17. The patient has to be closely monitored for manifestations of reactions to ASV for
atleast 2 hours continuously.
18. No interaction with ASV has been reported.
19. Fetal risk due to ASV has not been established or studied in humans.
20. Safety status for use of ASV during pregnancy has not been established.
21. Timely administration of ASV will not guarantee the recovery or protect the
individual from the venom induced toxicity or complications definitely.
ASV Reactions
* Reaction to ASV develop usually within 15 to 30 minutes or within 2 hours. So
monitor the case on ASV at 5min. interval for first 30min. and then at 15min.
interval for two hours. The details of pre hospital treatment and issues related
to ASV may be recorded in the form provided in Annexure IV.
* Some times, anaphylaxis (Type I) following ASV may develop rapidly and
deteriorate into a life-threatening emergency, and hence anticipate and observe
for it in every case. If the correct guidelines are followed, anaphylaxis can be
effectively treated.
* Therefore get alert if the patient develops of any reactions to ASV as shown in
Table no: 8.
Table No. 8: Manifestations of immediate reactions to ASV
Itching (often over the scalp) •
Urticaria, even a single spot •
Nausea •
Vomiting •
Abdominal colic / pain •
Diarrhoea •
Tachycardia (PR >120/min) (for •
children refer age specific chart)
Fall in blood pressure •
Low volume pulse •
Dry cough •
Bronchospasm / rhonchi •
Stridor (rarely) •
Angio-oedema of lips and mucous •
membrane
Fever •
Shaking chills (rigors) •
Sweating •
Cold and clammy skin •
Central cyanosis •
Febrile convulsions (in children) •
Anaphylaxis (Type I ) •
Treatment Guidelines for Snakebite and Scorpion sting
24 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Treatment for ASV reactions
Discontinue ASV •
Maintain IV line •
Administer Inj. Adrenaline 0.5ml of 1:1000 IM, (Adults) / Inj. Adrenaline •
0.1ml/Kg body weight of 1:10,000 IM (paediatric dose). Details are provided
in Table no.9.
(If after 10 to 15 minutes the patient’s condition has not improved or is worsening,
a second dose of 0.5 ml of Adrenaline IM is given. This can be repeated for a third
and final occasion but in the vast majority of reactions 2 doses of Adrenaline will
be sufficient).
Studies have shown that adrenaline reaches necessary blood plasma levels in
8 minutes in the IM route, and in 34 minutes in the subcutaneous route . The early use
of adrenaline has been selected as a result of study evidence suggesting better patient
outcome if adrenaline is used early.
In extremely rare, severe life threatening situations, 0.5mg of 1:10,000 adrenaline
can be given IV slowly. This carries a risk of cardiac arrhythmias however, and
should only be used if IM adrenaline has been tried and the administration of IV
adrenaline is in the presence of ventilatory equipment and ICU trained staff.
Table No. 9: Dosage of adrenaline for adults and children
Adults *Children (upto 25 kg)
Inject adrenaline 1:1000 intramuscularly:
Weighing <50 kg give 0.25 ml •
Weighing 50 -100 kg give 0.50 ml •
Weighing >100 kg give 0.75 ml •
Inject adrenaline 1:10,000 dilute
1ampoule (1 ml) of adrenaline 1:1000
with 9ml water for injection or normal
saline.
Inject intramuscularly 1:10,000
adrenaline according to the guide
(approximates to 0.1ml/kg).
1 year (10 kg) give 1 ml •
3 years (15 kg) give 1.5ml •
5 years (20 kg) give 2ml •
8 years (25 kg) give 2.5ml •
Children > 25 kg as for small •
adults
Approximate body weight for children may be calculated by the formula; •
2 x Age +9 =weight in kg. •
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 25
Start an adrenaline infusion if the patient remains shocked, (preferably via a •
central venous line), commencing at 0.25 microgram/kg/minute, and titrating as
required to restore blood pressure. Large doses of adrenaline may be needed.
Consider additional measures:
Administer Salbutamol or Terbutaline by aerosol or nebuliser (Beta2 agonists) •
for bronchospasm.
Antihistamines: Administer both H •
1
receptor blockers Inj. Chlorpheniramine
maleate 10 - 20mg as IV / intramuscularly or Promethazine 0.5 - 1mg/kg
and H
2
receptor blockers Inj.Ranitidine 1mg/kg or Famotidine 0.4mg/kg or
Cimetidine 4mg/kg slowly intravenously.
The dose for children is of Pheniramine maleate at 0.5mg/kg/day IV •
or Promethazine HCl can be used at 0.3 - 0.5mg/kg IM or 0.2mg/kg of
Chlorpheniramine maleate IV, and 2mg/kg of Hydrocortisone IV, antihistamine
use in pediatric cases must be deployed with caution.
Administer Corticosteroids intravenously: Hydrocortisone 2 - 6mg/kg or •
Dexamethasone 0.1 - 0.4mg/kg
Try nebulised Adrenaline (5ml of 1:1000) in case of laryngeal oedema which •
often will ease upper airways obstruction. However, do not delay intubation if
upper airways obstruction is progressive.
IV fluids should be given for haemodynamic instability. •
Once the patient has recovered, the ASV can be restarted slowly for •
10 - 15minutes, keeping the patient under close observation. Then the normal
drip rate should be resumed.
Monitor vitals and provide supportive measures •
Late Serum sickness reactions (delayed hypersensitivity) to ASV
Serum sickness may occur one to two weeks after administration of ASV. Late
Serum sickness reactions can be easily treated with an oral steroid such as prednisolone,
adults 5mg 6 hourly, paediatric dose 0.7mg/kg/day. (Duration of treatment has to be
adjusted with case). Oral H
1
Antihistamines provide additional symptomatic relief.
Prevention of ASV Reactions – Prophylactic Regimens
The conclusion in respect of prophylactic regimens to prevent anaphylactic
reactions, is that there is no evidence from good quality randomized clinical trials to
support their routine use. If they are used then the decision must rest on other grounds,
such as policy in the case of hospitals, which may opt for a maximum safety policy,
irrespective of the lack of definitive trial evidence.
Treatment Guidelines for Snakebite and Scorpion sting
26 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Two prophylactic regimens normally recommended are given below:
100mg of Hydrocortisone and H •
1
antihistamine (10mg Chlorphenimarine
maleate; or 22.5mg IV Phenimarine maleate IV or 25mg Promethazine
hydrochloride IM) 5minutes before ASV administration. The dose for children
is 0.1-0.3mg/kg of antihistamine IV and 2mg/kg of Hydrocortisone IV.
Antihistamine should be used with caution in pediatric patients.
0.25-0.3mg Adrenaline 1:1000 given subcutaneously. •
If the victim has a known sensitivity to ASV, pre-medication with adrenaline,
hydrocortisone and anti-histamine may be advisable, in order to prevent severe
reactions.
Repeat Doses of ASV in Neurotoxic Envenomation
The ASV regime relating to neurotoxic envenomation has caused considerable
confusion. If on reassessment after 1 - 2hrs the initial dose has been unsuccessful in
reducing the symptoms / if the symptoms have worsened / if the patient has gone into
respiratory failure then a further dose should be administered. This dose should be
the same as the initial dose, i.e., if 10 vials were given initially then 10 vials should
be repeated for a second dose and then ASV is discontinued. 20 vials is the maximum
dose of ASV that should be given to a neurotoxically envenomed patient.
Once a patient in respiratory failure, has received 20 vials of ASV and is supported
on a ventilator, ASV therapy should be stopped. This recommendation is due to the
assumption that all circulating venom would have been neutralised by this point.
Therefore further ASV serves no useful purpose.
Evidence suggests that ‘reversibility’ of post synaptic neurotoxic envenoming is
only possible in the first few hours. After that the body recovers by using its own
mechanisms. Large doses of ASV, over long periods, have no benefit in reversing
envenomation.
Confusion has arisen due to some medical text books and journal articles
suggesting that ‘massive doses’ of ASV can be administered, and that there need
not necessarily be a clear-cut upper limit to ASV. These texts are talking about snakes
which inject massive amounts of venom, such as the King Cobra or Australian Elapids.
There is no justification for massive doses of 50+vials in India, which usually results
in the continued use of ASV whilst the victim is on a ventilator. No further doses of
ASV are required; unless a proven recurrence of envenomation is established.
Additional vials to prevent recurrence are not necessary.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 27
Repeat Doses of ASV in Anti Haemostatic envenomation
In the case of anti haemostatic envenomation, the ASV strategy will be based around
a six hour time period. When the initial blood test reveals a coagulation abnormality,
the initial ASV amount will be given over one hour. No additional ASV will be given
until the next Clotting Test is carried out. This is due to the inability of the liver to
replace clotting factors within 6 hours.
After 6 hours a further coagulation test should be performed and a further dose
should be administered in the event of continued coagulation disturbance. This dose
should also be given over one hour. Clotting tests and repeat doses of ASV should
continue on a 6 hourly pattern until coagulation is restored, unless a species is identified
as one against which Polyvalent ASV is not effective.
The repeat dose should be 5 -10 vials of ASV i.e., half to one full dose of the
original amount. The most logical approach is to administer the same dose again, as
was administered initially. Some, argue that since the amount of unbound venom is
declining, due to its continued binding to tissue, and due to the wish to conserve scarce
supplies of ASV, there may be a case for administering a smaller second dose. In the
absence of good trial evidence to determine the objective position, a range of vials in
the second dose has been adopted.
Recurrent Envenomation
When coagulation has been restored, no further ASV should be administered,
unless a proven recurrence of a coagulation abnormality is established. There is no
need to give prophylactic ASV to prevent recurrence. Recurrence has been a mainly
U.S. phenomenon, due to the short half-life of Crofab ASV. Indian ASV is a F(ab)
2

product and has a half-life of over 90 hours, and therefore is not required in a prophylactic
dose to prevent re-envenomation.
Case of cobra snake bite in the recovery
phase showing bilateral ptosis with
overaction of frontalis
Neuroparalysis recovering only showing
Ophthalmoplegia
Picture 4 Picture 5
Treatment Guidelines for Snakebite and Scorpion sting
28 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Anti Haemostatic Maximum ASV Dosage Guidance
The normal guidelines are to administer ASV every 6 hours until coagulation has
been restored. However, what should the clinician do after say, 30 vials have been
administered and the coagulation abnormality persists? There are a number of questions
that should be considered.
Firstly, is the envenoming species one for which polyvalent ASV is effective?
For example, it has been established that envenomation by the Hump-nosed pitviper
(Hypnale hypnale) does not respond to normal ASV. Coagulopathy can / may continue
for up to 3 weeks as in the case of Hypnale.
The next point to consider is whether the coagulopathy is resulting from the action
of the venom. Published evidence suggests that the maximum venom yield from say a
Russells Viper is 147mg, which will reduce the moment the venom enters the system
and starts binding to tissues. If 30 vials of ASV have been administered that represents
180mg of neutralising capacity, this should certainly be enough to neutralise free
flowing venom. At this point the clinician should consider whether the continued
administration of ASV is serving any purpose, particularly in the absence of proven
systemic bleeding. At this stage the use of Fresh Frozen Plasma (FFP), cryoprecipitate
(fibrinogen, factor VIII) fresh whole blood, thrombocytes or coagulation factors can
be considered, if available. Plasmapheresis has been used successfully under such
circumstances amidst controversies. More clinical trails are warranted in these areas.
Recovery Phase
If an adequate dose of antivenom has been administered, the following responses may
be seen:
a) Spontaneous systemic bleeding such as gum bleeding usually stops within
15 - 30 minutes.
b) Blood coagulability is usually restored in 6 hours. (Principal test is
20 WBCT).
c) Post synaptic neurotoxic envenoming such as the Cobra may begin to improve
as early as 30 minutes after antivenom, but can take several hours.
d) Presynaptic neurotoxic envenoming such as the Krait usually takes a
considerable time to improve reflecting the need for the body to generate new
acetylcholine emitters.
e) Active haemolysis and rhabdomyolysis may cease within a few hours and the
urine returns to its normal colour during the course of treatment.
f) Patients in shock blood pressure may increase after 30 minutes while on
treatment.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 29
ASV risk and wastage
Definitive diagnosis and proper utilisation of ASV helps the patient. Otherwise
the patients are subjected to risk of receiving excessive / inadequate dosage of ASV.
More over the availability of ASV and doctors views and experience may influence the
utilisation of ASV for a given patient. Thus there is a possibility of first aid wastage of
ASV. The details of provided in Table No.10.
Table No. 10: ASV – Risk and Wastage (Ian D.Simpson Model)
Low wastage High wastage
High risk ASV - Not available
- Insufficient
administration
ASV – Too little supply and species
are different
Low risk Effective dose of ASV to
envenomed patients
Receive ASV when not required
Too much ASV when not required
Unnecessary ASV
1.5 Clinical issues in Snakebite
Hypotension
Hypotension can have a number of causes, particularly loss of circulating volume
due to haemorrhage and vasodilation due to the action of the venom or direct effects
on the heart. Test for hypovolaemia by examining the blood pressure lying down and
sitting up, to establish postural hypotension. Usually crystalloids are used for volume
expansion. However, there is no conclusive trial evidence to support a preference for
colloids or crystalloids.
In cases where increased generalised capillary permeability has been established,
a vasoconstrictor such as dopamine can be used, dose being is 5 - 10μ /kg/minute
in normal saline or glucose solutions as IV drip. The flow rate may be adjusted to
maintain blood pressure adequately. Rarely Russell’s Viper bites are known to cause
acute pituitary and / or adrenal insufficiency. This condition may also contribute to
shock. Hence, this entity has to be remembered while dealing with hypotension in
snakebite as these cases require long term follow up.
Persistent or Severe bleeding
In the majority of cases the timely use of ASV will stop systemic bleeding. However
in some cases the bleeding may continue to a point when further appropriate treatment
should be considered. The major point to note is that clotting must be re-established
before additional measures are taken. Adding clotting factors, fresh frozen plasma
Treatment Guidelines for Snakebite and Scorpion sting
30 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
(FFP), cryoprecipitate or whole blood in the presence of un-neutralised venom will
increase the amount of degradation products with the accompanying risk to the renal
function. Plasmapheresis has been used successfully in such situation.
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,
and hypotension and rhabdomyolysis.
Renal damage can develop very early in cases of Russells Viper bite and even when
the patient arrives at hospital soon after the bite, the damage may already have been
done. Studies have shown that even when ASV is administered within 1-2 hours after
the bite, it is incapable of preventing ARF. Declining renal parameters require referral
to a higher centre with access to dialysis. Peritoneal dialysis could be performed in
secondary care centres.
Surgical issues
The surgical issues observed in snake bite cases are
Ulcer following snakebite •
Necrosis of the skin and underlying tissues •
Gangrene of the toes and fingers •
Debridement of necrotic tissues •
Compartment syndrome and others •
Practitioner while dealing a case of snake bite with one or other surgical
issues has been informed to remember the following and keep the patient
and the care givers accordingly.
Fasciotomy does not remove or reduce any envenomation.
Visual impression is an unrealistic guide to estimate the ICP.
Tissue injury after compartment syndrome may be disproportionate to
the clinical status.
Fasciotomy is not required for every case.
The details and approach to some of the surgical issues are provided in Table no. 11.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 31
Table No. 11: Surgical issues: Assessment and action required
Assess for internal and external •
surgical issues related to
envenomation carefully and observe
for the same while the victim is at
hospital and / or during follow up
care.
Wound status •
Use of topical agents / traditional •
medicine
Compartment syndrome •
- Less common
- Consider compartment syndrome
of the limb if any of the following
6 Ps. or a combination of them
appear.
Pain on passive stretching •
Pain out of proportion •
Pulselessness •
Pallor •
Paresthesia •
Paralysis •
The limb can be raised in the initial
stages to see if swelling is reduced.
However, this is controversial as
there is no trial evidence to support its
effectiveness.
Care of the wound •
- Apply appropriate topical agents
and dressing
- Maintain proper wound
environment
- Do surgical debridement, if
needed refer to surgeon
Prepare and proceed to skin grafting •
later (if required)
Measure intra compartmental •
pressure (ICP) in suspected cases
by Intra compartmental monitoring
machine (Stryker pressure monitor)
or by use of a saline monitor
(normal <20mm Hg)
Monitor ICP every 30 to 120 •
minutes if required
Proceed with fasciotomy if the ICP •
exceeds 30 to 40mm of Hg.
Restore coagulation time before •
commencing the procedures.
Use of Heparin and Botropase in Viper Bites
Heparin has been proposed as a means of reducing fibrin deposits in DIC. However,
heparin is contraindicated in Viper bites. Venom induced thrombin is resistant to
Heparin, the effects of heparin on antithrombin III (ATIII) are negated due to the
elimination of ATIII by the time Heparin is administered and hence, heparin can cause
bleeding by its own action. Clinical trial did not show any beneficial effect.
Treatment Guidelines for Snakebite and Scorpion sting
32 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Botropase is a coagulant compound derived from the venom of one of two South
American pit vipers. It should not be used as a coagulant in viper bites as it simply
prolongs the coagulation abnormality by causing consumption coagulopathy in the
same way as the Indian viper venom currently affecting the victim. To conclude,
heparin and botropase have to be avoided.
1.6 Snake Bite in special situations
ASV Dosage in Victims Requiring Life Saving Surgery
In very rare case of snake bite life saving surgery is required in order to save the
victim. An example would be a patient who presents with signs of an intracranial
bleed. Before surgery can take place, coagulation must be restored in the victim in
order to avoid catastrophic bleeding. In such cases a higher initial dose of ASV is
justified (upto 25 vials) solely on the basis of guaranteeing restoration of coagulation
after 6 hours.
Victims Who Arrive Late
A frequent problem is victims who arrive late after the bite, often after several
days, usually with acute renal failure. Should the clinician administer ASV? The key
determining factor is, are there any signs of current venom activity? Venom can only be
neutralised, if it is unattached! Perform a 20 WBCT and determine if any coagulopathy
is present. If coagulopathy is present, administer ASV. If no coagulopathy is evident,
assess the case for evidences for one or other complications and consequences secondary
to complication of snake bite. Such cases require appropriate supportive measures.
In the case of neurotoxic envenoming where the victim is having symptoms such
as ptosis, respiratory failure etc, it is probably wise to administer one dose of 8-10 vials
of ASV to ensure that no unbound venom is present. However, at this stage it is likely
that all the venom is bound and patient requires respiratory support.
Snake bites Again!
If a patient has been bitten by a poisonous snake and received ASV earlier and
comes back with features of repeat snake bite, he / she may be considered as a fresh
case and treated accordingly (Whatever the interval between the snakebite). However,
care should be taken while administering ASV, since he / she has been sensitised.
Pregnancy and Lactating woman
There is very little definitive data published on the effects of snakebite during
pregnancy. Though spontaneous abortion of the foetus has been reported, this is not
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 33
the outcome in the majority of cases. It is not clear if venom can pass the placental
barrier. Pregnant women are treated in exactly the same way as other victims. The
same dosage of ASV is given. The victim should be re-assessed for the impact on the
fetus. One should be alert and rule out retro placental clot. The effects of venom and
antivenom on the mother and fetus need further exploration. ASV may be administered
to lactating woman if bitten by a poisonous snake and be treated like any other persons.
Breast feeding is not contraindicated.
Others:
Even if the patients belong to any of the following category viz., autoimmune
disorders, debilitating status, endocrine disorders, Immuno-suppressed status, HIV/
AIDS, cancer, asthma and allergic disorders or any other illness arrive with features of
snake envenomation, they also require ASV in the same manner like any other case of
poisonous snake bite.
1.7 Management in Primary Health Centre (PHC) and Block PHC
A key objective of this guideline is to enable even the doctors working in Primary
Care Institutions as well as private practitioners treat snakebite with confidence.
Evidence suggests that doctors are not willing to make use of ASV and other
medications, even when equipped, due to lack of confidence and guidelines. The
present handbook on guidelines is prepared to suite their needs and outlines how they
should proceed within their context and setting. The principles envisaged to treat snake
bite at all Health Centres / Hospitals irrespective of the status - Government or Private
are given below in Table no: 7. The initial evaluation and systemic manifestations
following envenomation, and treatment aspects are provided in Tables 12, 13 and 14
respectively.
Table No. 12: Initial evaluation – No Systemic Envenomation
ASSESS CLASSIFY TREATMENT
Vital signs
Pulse •
BP •
Respiration •
Vital signs (Adult)*
Pulse rate: 60-100/min •
BP 110 / 70 to 140/95 •
Respiratory r • ate <20/
min
Tab.Paracetamol
Inj.Tetanus Toxoid IM
Routine antimicrobials are
not necessary
Treatment Guidelines for Snakebite and Scorpion sting
34 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Symptoms and signs
Bite marks •
Ptosis •
Double vision •
Difficulty in •
swallowing
Bleeding sites •
Reduced urine output •
Swelling and local •
pain
Local necrosis •
Descending paralysis •
Unconsciousness •
Regional •
lymphadenitis
Any other symptoms •
and signs noted down
Symptoms and signs
Local pain and/ or •
swelling+
Bite mark present, •
skin broken
No other symptoms •
and signs present
Laboratory test:
20 Minutes Whole Blood
Clotting Test - blood clot
formed
If above findings are there
at the time of assessment
classify as No systemic
envenomation
Monitor Pulse, Respiration
& BP every ½ hourly for 3
hours and every 4
th
hourly
for remaining 48 hours.

If normal send the
patient home
*Vital signs for children (see age specific chart) are provided in Annexure II.
If the patient has any systemic manifestations refer to Table.13 and 14 for hemotoxic
and neurotoxic envenomation respectively. The details of local envenomation are
provided in Table 4.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 35
Table No. 13: Haemotoxic envenomation
ASSESS CLASSIFY TREATMENT
Vital signs
Pulse •
BP •
Respiration •
Symptoms and signs
Bite marks •
Ptosis •
Double vision •
Difficulty in •
swallowing
Bleeding sites •
Reduced urine output •
Swelling and local •
pain
Local necrosis •
Descending paralysis •
Unconsciousness •
Lymphadenitis •
Breathing difficulty •
Any other, note •
down
Vital signs (Adult)*
Pulse rate >120 per
minute, feeble (a
response to hypotension)
Respiratory rate >20/min
Hypotension <
90/60 mmHg
Symptoms and signs
Swelling and local pain
or painful enlargement of
nearby lymphnodes
Bleeding from the
Gingival sulci •
Epistaxis •
Petechiae, purpura,
ecchymoses
Hematuria
Intracranial bleeding:
asymmetrical pupils •
unconsciousness •
convulsions •
Persistent and severe
vomiting or abdominal
pain
Low back pain
No urine output or
decreased urine output
Laboratory test:
20 Minutes Whole Blood
Clotting Test.
Blood clot not •
formed
If above findings are
there at the time of
examination classify as
Haemotoxic
envenomation
Treat the patient with Anti
Snake Venom (ASV)
Start IV Normal Saline with •
wide bore needle
Begin with one vial of ASV •
in one point of NS and start
10-15 drops per minute for
15 minutes & watch for
reactions.
If signs and symptoms of •
anaphylactic shock (cold
and clammy skin, rapid
pulse, dyspnoea, etc.)
develop, stop the ASV drip
temporarily and treat the
shock with:
Inj.Hydrocortisone 100 mg IV or
Inj.Dexamethasone 8 mg IV
Inj.Pheniramine maleate 2ml IV
Inj.Adrenaline 1:1000 (0.5ml)IM
Inj.Deriphyline 2ml IV
Oxygen administration
IV Normal saline as life line
As soon as the patient •
recovers or
If the patient is not having •
signs and symptoms
of anaphylactic shock
continue the ASV drip with
remaining seven vials /
ampoules
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
Aspirin should not be used
Treatment Guidelines for Snakebite and Scorpion sting
36 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Fluid requirements per day should be kept in mind while giving ASV. For children
readers are requested to see the fluid requirement chart provided in Annexure II.
[Table No.29]
* Vital signs for children (see age specific chart) are provided in Annexure III.
[Table no.30 to 33].
Table No. 14: Neurotoxic envenomation
ASSESS CLASSIFY TREATMENT
Symptoms and signs
Swelling and local pain •
Local necrosis •
Descending paralysis starting with •
ptosis, external ophthalmoplegia
Numbness around the lips and •
mouth progressing to pooling of
secretions, difficulty to talk and
respiratory failure
Paradoxical respiration •
Paralysis •
Abdominal pain •
Laboratory test:
20 Minutes WBCT - Blood clot formed
If above signs & symptoms are
present at the time of admission
classify as Neurotoxic envenomation
Treat the patient with ASV
as mentioned in Table 13
and add the following:
Inj.Neostigmine 1.5 mg
(Therapeutic Test dose) as
IM and
Inj.Atropine 0.6 mg (Test
dose) as IV
After that observe patient
for every five minutes for
30 minutes for signs of
response
1.8 Referral aspects
The medical officer who is treating the cases of snake bite should take meticulous
care to look in to the patient’s status and provide first aid as well as supportive measures
before referring the case to higher centre / speciaslist. The details are furnished in
Table 15 below.
For local
envenomation
refer to Table
4.
For systemic
envenomation
refer to Tables
12 and 13
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 37
Table No. 15: Referral aspects for snakebite
Who needs? When to refer? Where to refer?
Patient requiring
Respiratory support •
Deteriorating •
neurologic
manifestations
Surgical •
intervention-Necrosis
/ Fasciotomy
Spontaneous •
persistent bleeding
Co-morbid diseases •
Acute impending •
kidney failure
Refer the patient •
after stabilising the
case and after giving
injection ASV (Refer
to Annexure VIII and
IX)
Refer to higher institution
having
Ventilator •
Dialysis facilities •
Measures to provide •
further supportive
treatment.
Referral Criteria for Haemotoxic envenomation
Once the ASV is finished and the adverse reaction dealt with the patient should be
automatically referred to a higher centre with facilities for blood analysis to determine
any systemic bleeding or renal impairment. The 6 hours rule ensures that a six hours
window is now available in which to transport the patient.
Referral Criteria for Neurotoxic envenomation
If after one hour from the end of the first dose of ASV, the patient’s symptoms have
worsened i.e., paralysis has descended further, a second full dose of ASV is given over
one hour. ASV is then completed for this patient. If after 2 hours the patient has not
shown worsening symptoms, but has not improved consider this case for referral to a
higher centre
Instructions while referring
Inform the need for referral to the patient and / care giver [family member or •
the accompanying attendant]
Give prior intimation to the receiving center using available communication •
facilities
Arrange for an ambulance •
Transfer in a vehicle to Secondary Care Hospital or Tertiary Care Hospital •
where mechanical ventilator and dialysis facilities are available
Treatment Guidelines for Snakebite and Scorpion sting
38 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Continue life supporting measures •
Provide airway support with the help of an accompanying staff •
Send the referral note with details of treatment given •
Instruct one staff to accompany the patient during transportation if required. •
Hand over the referral form with details regarding treatment given •
Mention the clinical status clearly in the referral form at the time of referral. •
1.9 Welfare measures
The Government of Tamil Nadu is providing solatium to the family members of
the deceased snake bite victims. The amount is disbursed by the respective district
collector based on the application made by the family members along with the medical
certificate mentioning the cause of death as complications following snakebite in
a clear manner (as observed while on treatment). The amount varies from state to
state. Treating doctor should inform the family members of the deceased, and guide
them regarding the ways and means for getting the welfare measures provided by the
government.
1.10 Occupational risk for Snake bite
The normal perception is that rural agricultural workers are most at risk and the
bites occur first thing in the morning and last thing at night. However, this is of very
little practical use to rural workers in preventing snakebite since it ignores the fact that
often snakebites cluster around certain bio-mechanical activities, in certain geographic
areas, at certain times of the day.
Grass-cutting remains a major situational source of bites. •
In rubber, coconut, palmyra and arecanut plantations clearing the base of the •
tree to place manure causes significant numbers of bites.
Harvesting high growing crops like millet which require attention focused •
away from the ground.
Rubber tapping workers are susceptible and it happens often in the early hours •
03:00-06:00.
Agricultural workers involved in vegetable harvesting / fruit picking. •
Tea and coffee plantation workers face the risk of arboreal and terrestrial vipers •
when picking or tending bushes.
Clearing weeds exposes workers to the same danger as their grass-cutting •
colleagues.
Walking at night without a torch, barefooted or wearing sandals accounts for a •
significant number of bites.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 39
Bathing in ponds, streams and rivers, in the evening. It should not be assumed •
that because the victim is bitten in water that the species is non-venomous.
Cobras and other venomous species are good swimmers and may enter the
water to hunt.
Walking along the edge of waterways. •
Plucking flowers in areas of flower cultivation •
Plucking hay / straw from bundle of hay / straw •
Persons involved in picking up dry fire wood, loose stones, heaps of paddy, •
sugar cane or jowar husk.
1.11 Preventive measures and health education
Walk at night with sturdy footwear and a torch and use the torch! When walking, •
walk with a heavy step as snakes can detect vibration and will move away!
Carry a stick when grass cutting or picking fruit or vegetables or clearing the •
base of trees. Use the stick to move the grass or leaves first. Give the snake
chance to move away. If collecting grass that has previously been cut and placed
in a pile, disturb the grass with the stick before picking the grass up.
Keep checking the ground ahead when cutting crops like millet, which are often •
harvested at head height and concentration is fixed away from the ground.
Pay close attention to the leaves and sticks on the ground when wood •
collecting.
Keep animal feed and rubbish away from your house. They attract rats and •
snakes will follow.
Try to avoid sleeping on the ground. •
Keep plants away from your doors and windows as plants help snakes to climb •
up and into windows.
1.12 Resource materials
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J indal. S.K. Management of Respiratory Failure in Severe Neuroparalytic
Snake Envenomation. Neurol India 2001: 49: 25 – 28.
2. Agarwal R. Singh AP, Agarwal AN. Pulmonary oedema complicating snake
bite due to Bungarus caeruleus. Singapore Med J 2007 Aug;48(8):e227-30.
3. Ahmed SM, Ahmed M, Nadeem A, Mahajan J , Choudhary A, Pal J . Emergency
treatment of a snake bite: Pearls from literature. J Emerg Trauma Shock
2008;1:97-105.
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40 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
4 Alvares R. (Goanet) Myths and Snake bites. http://lists/whatwg.org/goanet-
goanet.org/2004-september/017828.html accessed on 28.01.08.
5. Amarel CFS, Campllina D, Dias MB, Bleno CM, Razende NA. Tourniquet
ineffectiveness to reduce the severity of envenoming after crotalus durissus
snakebite in Belo Horizonte, Minas Gerasis, Brazil. Toxicon 1998, 36(5): 805-
808.
6. Athappan G, Balaji MV, Navaneethan U, Thirumalikolundusubramanian P
Acute renal failure in snake envenomation: a large prospective study. Saudi J
Kidney Dis Transpl. 2008 May; 19(3):404-10
7. Babu N, Rajendiran C, simpson ID, Ravi .G, Thirumalaikolundusubramanian
P. Snake bites in South India: Community concepts and indigenous methods-
cause and concern (PP-099). Abstract book of 6
th
annual conference of Asia
Pacific Association of Medical Toxicology held at Bangkok, Thailand, December
12-14, 2007 P.204
8. Bambery P.snakebites and arthopod envenomation. In: Shah SN, etal. [Edrs]
API text book of Medicine 8
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edition. The Association of Physicians of India,
Mumbai 400 011. 2008; Volume 2: section 24, chapter 11 : 1517-20.
9. Banerjee RN, Sahni AL, Chacko KA. Neostygmine in the treatment of Elepidae
bites. J ournal of Association of Physicians of India 1972; 20: 503-509.
10. Bawaskar HS, Bawaskar BH. Profile of snake bites envenoming in western
Maharashtra, India. Trans Roy Soc Trop Med Hyg 2002; 96: 79-84.
11. Bawaskar HS. Snake bite and scorpion stings.In; Khubchandani R,
Gajendrsgadkar A, Bavdekar SB, Shah NK. [Edrs] Frequently asked questions
Ask IAP: a series. Basics and Beyond. IAP Action Plan 2006; 109-118.
12. Bawaskar HS, Bawaskar BH, Punde DP, Inamdar MK, Dongare RR, Phoite RR
Profile of snakebite envenomation in rural Maharashtra. J ournal of Association
of Physician of India 2008:56: 88 – 95
13. Bhat R.N., Viperine Snake Bite Poisoning in Jammu. JIMA 1974:63:383 – 392.
14. Chugh K.S. Snake Bite induced Acute Renal Failure. Kidney International
1989:35:891 – 90
15. Daga S, Biswas K, Roy K. Editorial: Medical record keeping- are we prepared?
J Indian Med Assoc 2008; 10: 145.
16. Dutta T.K., Mukta V. Snake Bite. J IMA 2006:104, 251 – 254. Guidelines for
the Clinical Management of Snake Bites in the South East Asian Region.
World Health Organization, Regional Office for South East Asia, New Delhi
2005;PP67 +viii.
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 41
17. Ghosh S. Management of snake bite – an update. In: Bichille SK, Hasa NK,
Mehta SS. (Edrs). Medicine update. The association of physicians of india
2008; 18(chapter 90): 691-696.
18. Government Order (D) No.46, Health and Family Welfare Department, State
Government of Tamilnadu, Chennai, dated 19.01.2006.
19. Government Order (2D) No.125, Health and Family Welfare (EAP 1/1)
Department, State Government of Tamilnadu, Chennai, dated 02.11.2007.
20. Government Order (MS) No.10, Health and Family Welfare (MCA 1)
Department, State Government of Tamilnadu, Chennai, dated 09.01.08
21. Health and Family Welfare (P1) Department, State Government of Tamilnadu,
Chennai, Letter No. 637/P1/06-2 dated 27.01.06
22. Ho M, Warrell MJ , Warell DA, Bidwell D, Voler A. A critical appraisal of the
enzyme linked immunosorbent assays in the study of snake bite. Toxicon 1986;
24:211-221.
23. Howarth DM, Southee AS, Whytw IM, Lymphatic flow rates and first aid
in simulated peripheral snake or spider envenomation. Medical J ournal of
Australia 1994; 161: 695-700
24. Jeganathan N.Siddha Medicine for poisons. In: Subramanian SV, Madhavan VR.
Heritage of tamils: Siddha Medicine. International Institute of Tamil studies,
T.T.T.I, Taramani, Chennai 600 113. March 1983; chapter 31; 504 – 522.
25. Kalantri S, Singh A, J oshi R, Malamba S, Ho C, Ezoua J , Morgan M. Clinical
Predictors of in-hospital mortality in patients with snakebite: a retrospective
study from a rural hospital in central India Tropical medicine and International
health. 2005; 11(1): 22-30
26. Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK,
Pathmeswaran A, etal. (2008) The global burden of snakebite; A literature
analysis and modeling based on regional estimates of envenoming and deaths,
PLoS Med 5(11): e218 doi:10.1371/journal.pmed.0050218
27. Kularetra SAM, Reaction of snake venom antisera: study of pattern, severity
and management at General Hospital, Anuradhapurra, Sri Lanka J Med 2000: 9:
8-13.
28. Management of Snakebite. Training module for staff nurse and auxillary nurse
midwife. Basic emergency services for poisoning, State Health Mission Health
and Family Welfare Government of Tamil Nadu, Chennai. 2007, 33-42, i-vii
29. Medical management of severe anaphylactoid and anaphylactic reactions.
www.australianprescriber.com/magazine/24/5/artid/546/ accessed on 08.02.08
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42 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
30. Nayak KC, Jain AK, Sharda DP, Mishra SN. Profile of cardiac complications
of snake bite. Indian Heart J . 1990 May-J un;42(3):185-8
31. Norris RL, Ngo J , Nolan K, Hooker G, Physicians and lay people are unable
to apply Pressure Immobilisation properly in a simulated snakebite scenario
Wilderness and Environmental Medicine 2005;16:16-21
32. Norris RL, Bite marks and the diagnosis of venomous snakebite. J ournal of
Wilderness Medicine 1995; (6): 159-161
33. Pahlajani DB, Iya V, Tahiliani R, Shah VK, Khokhani RC. Sinus node
dysfunction following cobra bite:case reports. Indian Heart J . 1987:39:48-9
34. Pillay VV. (Edrs). Modern Medical Toxicology. Third Edition. J aypee Brothers.
medical publication(P) Ltd., New Delhi 110 002. 2005; PP 499 +xviii
35. Rajendiran C, Simpson ID. Indian National Snake bites Protocol-2007
(OP-040). Abstract book of 6
th
annual conference of Asia Pacific Association of
Medical Toxicology held at Bangkok, Thailand, December 12-14, 2007 P.104
36. Sarangi A, Jena I, Sahoo H, Das JP. A profile of snake bite poisoning
with special reference to haematological, rental, neurological and
electrocardiographic abnormalities. J
37. Singh S, Dass A, Jain S, Varma S, Bannerjee AK, Sharma BK. Fatal
non-bacterial thrombotic endocarditis following viperine bite. Intern Med.
1998 Mar;37(3):342-4.
38. Senthilkumaran S. Cardiac complications among snake bite victims. Personal
communication
39. Simpson ID. The paediatric management of snake bite . The National Protocol.
Indian Pediatrics 2007,44:173-176
40. Simpson ID, Norris RL. Snakes of Medical importance in India: In the concept
of the “ Big 4” still relevant and useful? Wilderness and Environmental Medicine
2007; 18(1) : 2-9
41. Simpson ID. Snake bite management in India, the first few hours: a guide for
primary care physicians. J ournal Indian Medical Association 2007;105: 324,
326, 328, 330, 332, 334 & 335.
42. Simpson ID. Indian National Snake bite Protocol. www.indianwildlifeclub.
com/blog/topic.asp?id_top=10 accessed on 28.01.08
43. Sharma S, Chappins F, J ha N, Bovier PA, Loutan I, Koriala S. Impacts of snake
bites determinants of fatal outcomes in Southern Nepal. Amer J Trop Med Hyg
2004; 71(2):234-38
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 43
44. Srivastava RK. Director General, Office of the Directorate General of Health
Services, Nirman Bhawan, New Delhi – 110011. Letter D.O.No.D.32020/3/2008
– EMR, Dated 5
th
February, 2008.
45. Training module Poison First aid and Treatment Centre (BEmONC, PHC),
State Health Mission Health and Family Welfare Government of Tamil Nadu,
Chennai. 2008.
46 Thirumalaikolundusubramanian P, Areas for research on Snake Bite / Scorpion
Sting, Personal records.
47. Thirumalaikolundusubramanian P, Rajendiran C. Medical audit for snake bite
and scorpion sting. Unpublished records
48. Tun Pe, Tin-Nu-Swe, Myint-Lwin, Warrell DA, Than-Win, The efficacy of
tourniquets as a first aid measure for Russells Viper bites in Burma Trans. R
Soc Trop Med Hyg 1987; 81:403-405
49. Tun P, Khin Aung Cho. Amount of venom injected by Russells Viper (Vipera
russelli) Toxicon 1986; 24(7): 730-733
50. Veerapandian R. [Edrs]. Guidelines for common surgical interventions in
the elderly. Developed under WHO – Government of India collaborative
programme 2006-07. August 2007.
51. Visweswaran RK, George J . Snake bite induced acute ranal failure. Indian J
Nephrol 1999; 9(4): 156-159.
52. Warrell, D.A. (Edrs). 1999. WHO/SEARO Guidelines for The Clinical
Management sof Snakebite in the Southeast Asian Region. SE Asian J . Trop.
Med. Pub. Hlth. 30, Suppl 1, 1-85.
53. Warrell, D.A., Davidson, N. McD., Greenwood, B.M., Ormerod, L.D., Pope,
H.M., Watkins, B. J ., Prentice, C.R.M.. Poisoning by bites of the saw-scaled or
carpet viper (Echis carinatus) in Nigeria. Quart. J . Med. 1977;46: 33-62.
54. Wen Fan H, Marcopito LF, Cardoso J LC, Franca FOS, Malaque CMS, Ferrari
RA, Theakston RD, Warrell DA, Sequential randomised and double blind trial
of Promethazine prophylaxis against early anaphylactic reactions to antivenom
for Bothrops snake bites. BMJ . 1999; (318):1451-1453
55. When a cobra strikes. The Hindu (Online edition of India’s National newspaper)
J une 13,2004. www.thehindu.com accessed on 30th J une 2008.
56. Yildirim C, Bayraktaroglu Z, Gunay N, Bozkurt S, Kose A, Yilmaz M. The
use of therapeutic plasmapheresis in the treatment of poisoned and snake bite
victims: an academic emergency department’s experiences. J ournal of Clinical
Apheresis 2006;21(4):219-23.
Titles Page
2.1 General 45
Introduction •
Epidemiology •
Eco-biological aspects of scorpion •
Distribution of various species of scorpions •
Socio cultural aspects •
2.2 Clinical aspects 47
Components of venom and mechanisms of action •
Pathophysiology •
Symptoms and signs. •
Criteria for diagnosis •
Differential diagnosis •
Investigations •
Clinical course •
Complications •
2.3 Treatment 54
First aid measures •
Traditional methods •
Principles involved in the management •
Pharmacological aspects of Prazosin •
2.4 Scorpion sting in special situations 60
2.5 Management at PHC and Block PHC 60
2.6 Referral aspects 62
2.7 Occupational risk, patient education and prevention 63
2.8 Prognosis 64
2.9 Resource Material 64
SECTION - II
SCORPION STING
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 45
2.1 General
Introduction
Scorpion sting is a life threatening medical emergency. The effect of envenomation
is greatest among children below 5 years of age. Adults too can succumb to scorpion
sting. Many social and environmental factors contribute to scorpion sting. Hence, it
becomes an important public health problem. The epidemiology, presenting features,
clinical course, complications, therapeutic response and outcome are variable in
different series. However, early recognition and appropriate intervention influence the
outcome. Hence, scorpion sting deserves special attention and cases should never be
taken lightly.
Though the research on scorpion venom and knowledge on treatment of scorpion
sting have advanced, these newer ideas are yet to reach the health care provider and
the community. In this context, it is worthwhile to remember Dr.H.S.Bawaskar, a
private practitioner from Maharashtra who for the first time in world has introduced
the usefulness of alpha blocker in scorpion sting nearly 25 years ago. This has been
accepted globally now in the treatment of scorpion sting.
Epidemiology
In general for every case of snakebite, there may be 10 or more numbers of scorpion
stings. If that is the case, the number of cases of scorpion sting may run to millions.
There is no reliable statistics on the scorpion sting in India. Scorpion sting is under-
reported. Published reports are institution based, hence include only serious cases of
scorpion sting treated in such institutions. As most of the cases of scorpion sting have
mild symptoms, the general practitioners or family physicians or a traditional medical
practitioners provide treatment and they never appear in health statistics.
In Mexico, 1000 deaths due to scorpion sting occur per year whereas in USA four
deaths were reported in 11 years. Of the 13,000 stings reported in USA, majority was
due to non lethal scorpions. Most deaths occur during the first 24 hours of the scorpion
sting and are secondary to respiratory and cardiovascular failure. Children and elderly
are at great risk of death due to their decreased physiological reserve. Death due to
scorpion sting occurs in 25% of children below 5 years, if not treated, whereas only
1% of scorpion stings are lethal to adults.
In India too, deaths due to scorpion sting occurs across the country but do not get
due attention. Larger the scorpion population, greater is the number of scorpion sting
cases. Scorpion stings are reported more from rural areas and the rural to urban ratio
is approximately 3:1. Mostly stings occur between 6 P.M. to mid-night and between
6 A.M. to 12 Noon, which correlate very well with human activity. Scorpion sting
occur more in temperate and tropical zones, and more during summer than winter.
Treatment Guidelines for Snakebite and Scorpion sting
46 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
The Institute of child health, Madras Medical College, Chennai, has recorded nearly
1900 cases between 1980 and 1999 and the death rate varied from 4 to 7%. Of the 727
cases of scorpion stings treated during the period of 2000-2007 which included 406
males and 321 females [M: F=4:3]; the death among them were 11 and 8 respectively.
The death rate in children due to scorpion sting was 2% which has come down from
4 to 7% earlier.
In general, male to female ratio of scorpion sting is approximately 2:1 but females
suffer more due to lower body weight. There is no racial predilection but clinical
symptoms, course, and outcome vary because of individual’s genetic constitution and
other factors [vide infra]. Human stinging occurs accidentally, when scorpions are
touched, threatened, cornered or disturbed (stepped upon) while in their hiding places.
So, people involved in handling construction materials, carpentry works, clearing
bushes or house cleaning as well as children playing nearby these areas are susceptible
to scorpion sting.
Eco- biological aspects of scorpion
Scorpions are shy creatures and not aggressive by and large. These are nocturnal
creatures and hunt for their prey at night. Scorpions hide normally in crevices and
burrows during daytime to avoid light. Scorpions are found elsewhere outside the
environmental range. eg., accidentally crawl into luggage, boxes, containers, or shoes,
pile of bricks, wooden materials, firewood, etc. They may also be transported in
traveller’s luggage and cargo.
There are about 1500 scorpion species of which 50 are dangerous. In India 86
species of scorpion have been identified. Among them, Mesobuthus tamulus and
Palamneus swammer-dami are important medically. Except Hemiscorpius species,
all lethal scorpions belong to the family called the Buthidae. The lethal members
of Buthidae family include the genera of Buthus, Parabuthus, Mesobuthus, Tityus,
Leiurus, Andractonus and Centruroides. Among the 30 scorpion species found in USA,
only one of them is dangerous to human beings.
Scorpions live in temperate and tropical regions especially between the latitudes of
50
o
north and 50
o
south of equator. The distinguishing features between lethal and non
lethal scorpions are provided in Table 16 given below.
Table No. 16: Distinguishing features of lethal and non-lethal scorpion
Structure Lethal Scorpion Non lethal scorpion
Sternum Shape • Triangular Pentagonal
Pincers • Weak looking Strong and Heavy
Body • Thin in a empathetic manner. Thick
Tail • Thick Thin
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 47
Scorpions use their pincers to grasp the prey. It arches its tail over its body and
stings into its prey. Thus it injects its venom, sometimes more than once. The venom
glands are situated in the tail. The striated muscles in the stings regulate the amount of
venom injected. When entire venom is used, it takes several days to replenish venom.
Scorpion with large venom sacs such as Parabuthus species can even squirt their
venom.
Distribution of various species of scorpions
Buthus is found in Mediterranean area, Parabuths in Western andSouthern Africa,
Mesobuthus in Asia, Tityus in Central and South America, and Caribbean, Leiurus
in Northern Africa and Middle East, Andractanus in Northern Africa to Southeast
Asia, and Centruroides in South West USA, Mexico and Central America.
Socio cultural aspects
For scorpion sting also, patients are taken for magico religious treatment where
mantras are chanted, herbal medicines are applied externally and / or given orally. Since
the scorpion sting has mild effects in many, most of them improve with local practices.
Hence the community has confidence on the local / traditional practitioner or priest. If
the pain continues or symptoms get aggravated or general condition deteriorates and
in children if crying or restlessness continues, the patients are brought to the hospital.
Thus local practices contribute to delay in health seeking.
2.2 Clinical Aspects
Components of Venom and Mechanisms of action
The components of venom are cardiotoxin, hemotoxin, nephrotoxin, neurotoxin,
hyaluronidases, phosphodiesterases, phopholipases, glycosaminoglycans, histamine,
serotonin, tryptophan and cytokine releasers. Among all, the most potent is the
neurotoxin. There are two classes of neurotoxins (long chain & short chain polypeptide)
which are heat stable, have a low molecular weight and are responsible for causing cell
impairment in nerves, muscles, and the heart by altering sodium and potassium channel
permeability. The long chain polypeptide neurotoxin induces continuous, prolonged,
repetitive firing of somatic, sympathetic and parasympathetic neurons which results
in autonomic, and neuromuscular over excitation symptoms. It also prevents normal
nerve impulse transmissions. Further, it results in release of neurotransmitters viz.,
epinephrine, nor-epinephrine, acetylcholine, glutamate, and aspartate excessively. The
short chain polypeptide neurotoxin blocks the potassium channels.
Treatment Guidelines for Snakebite and Scorpion sting
48 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Pathophysiology
The venom is produced by columnar cells of the venom glands. Scorpion venom
is water soluble, antigenic and positively charged. It is a heterogenous mixture and
this can be easily demonstrated by electrophoresis method. Also, the heterogenisity of
the venom explains the variable response to venom as observed in different people.
Normally injected venom is between 0.1 to 0.6mg. Generally most lethal scorpions
have a lethal dose (LD50) below 1.5mg. The potency varies with species causing mild
flu to death with in an hour. Humans are much more sensitive than mice.
Once the venom is injected, it is distributed rapidly into the tissues. If the venom
is deposited into a vein, the symptoms develop within 4 to 7 minutes after injection,
with a peak concentration in 30 minutes. The half life of venom varies from 4.2 to 13.4
hours.
Symptoms and signs
Symptoms and signs are influenced by factors related to “3 Ss” viz., scorpion, sting
and the status of the patient.
Table No. 17: Influencing factors for symptoms and signs
Scorpion Sting Status of the patient
Species •
Age, size and •
nutritional status •
Stinging apparatus •
(telson)
Time of sting •
Number of stings •
Quantity of venom •
injected (low dose –
adrenergic, high dose
– cholinergic)
Depth of the sting •
penetration
Site of sting IV/SC/IM •
Components of venom •
Age of the patient •
Health status •
Comorbid conditions •
Weight of the victim •
Physiological response •
of the individual
Sensitivity of •
the systém to the
neurotransmitters and
toxins
Usual signs of scorpion sting are as follows
Mydriasis •
Nystagmus •
Hyper salivation •
Dysphagia •
Restlessness •
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 49
Usual mode of death is via
Respiratory failure secondary to •
Anaphylaxis
Broncho constriction
Bronchorrhoea
Pharyngeal secretion
Pulmonary edema
Diaphragmatic paralysis
Venom induced multi organ failure •
In view of the numerous toxins and enzymes released from the scorpion venom,
the clinical signs and symptoms of envenomation may vary at local and at systemic
level. The local signs are provided in Table 18. Grading of scorpion envenomation is
based on neurological and non neurological predominance as shown in Figure 1. The
local signs and systemic signs are provided in Table 18, 19 and 20 respectively.
Figure 1: Grading of scorpion envenomation
(83%)
(10%)
(5%)
Local signs at the site of sting are further classified into non-lethal local effects as well
as neurotoxic and cytotoxic local effects. The details are provided in Table No: 18.
Treatment Guidelines for Snakebite and Scorpion sting
50 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Table No. 18: Local effects at the site of sting
Nonlethal local
effects
Neurotoxic local signs at
the site of sting
Cytotoxic local signs at the
site of sting
Pain •
Erythema •
Induration •
Wheal •
(due to activation
of kinins and
slow releasing
substances of
venom)
Local effect of sting •
minimal or absent •
Tissue necrosis (rare) •
Sharp burning pain •
Erythema •
Local tissue swelling •
Ascending hyperasthesia •
(paresthesia persists for
several weeks and the
last symptom to resolve)
Appearance of a macule •
or papule within first
hour
Diameter of the lesion •
vary with quantity of
venom injected
Progress of the lesion to •
a purpuric plaque which
will necrose and ulcerate
Nonlethal local
effects
Neurotoxic local signs at
the site of sting
Cytotoxic local signs at the
site of sting
Positive “Tap test”- •
(Paresthesia worsens
with gentle tapping at the
site of sting)
Hypersensitive to touch •
and temperature
Lymphangitis (if the •
venom is transferred
through lymphatics)
Systemic signs are grouped into neurologic signs and non-neurologic signs, and a brief
description of the same is provided in Table 19.
Table No. 19: Systemic signs of scorpion sting
Neurologic signs [refer Figure No.2]
Non neurologic sytemic signs [refer
Table 20]
Central nervous system signs •
Autonomic nervous system signs •
Sympathetic signs
Parasympathetic signs
Somatic signs
Cranial nerve signs •
Peripheral nervous systém signs •
Cardiovascular signs •
Respiratory signs •
Gastro intestinal signs •
Hematological signs •
Metabolic signs •
Genitourinary signs •
Allergic signs •
Pregnancy signs •
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 51
Figure 2: Nervous system signs
Non-neurologic systemic signs:
The scorpion venom affects all systems and details of non neurological signs are
depicted in Table 20. However, the commonly observed were local, respiratory,
cardiovascular and neurologic manifestations.
Treatment Guidelines for Snakebite and Scorpion sting
52 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Table No. 20: Non-neurological signs
* Cardiovascular signs
Hypotension •
Hypertension •
Tachycardia (bradycardia at •
times)
Cardiac dysrhythmia •
Transient apical pansystolic •
murmur
Cardiovascular collapse •
Cardiogenic shock •
Cardiac dysfunction •
* Respiratory Signs
Tachypnoea •
Pulmonary edema •
Respiratory failure •
* Gastro intestinal Signs
Dysphagia •
Excessive salivation •
Nausea and vomiting •
Gastric hyperdistension •
Increases gastric acid out put •
and gastric ulcer
Acute pancreatitis •
Liver glycogenolysis •
Toxic hepatitis •
* Hematologic Signs
Platelet aggregation •
Disseminated intra vascular •
coagulation (DIVC)
* Metabolic Signs
Hyperglycemia •
Increased lactic acidosis •
Electrolyte imbalance •
* Genitourinary Signs
Acute renal failure •
Rhabdomyolysis •
Priapism •
* Allergic Signs
Urticaria •
Angioedema •
Bronchospasm •
Anaphylaxis •
* Pregnancy Signs
Toxin induced uterine contraction •
Criteria for diagnosis
Definite confirmatory signs
Witnessed sting •
A dead scorpion •
Evidence at the site of sting - single puncture mark •
Local pain – positive tap sign •
Local and systemic manifestations •
(Absence of pain or manifestations does not rule out scorpion sting)
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 53
Probable scorpion sting
Local edema •
Pin hole bleeding •
Profuse sweating – Local or generalised •
Differential diagnosis
Botulism •
Tetanus •
Organophosphorus toxicity •
Less common conditions for differential diagnosis
Myasthenia gravis •
Guillain barre syndrome •
Neuroleptic syndrome •
Sympathomimetic over dose •
Envenomation due to snake •
Investigations
Haematology
- Complete Blood Count (CBC)
- Leukocytosis
- Hemolysis (variable)
- Coagulation profile
- Defibrination [if required]
Blood Chemistry
- Blood sugar
- Serum creatinine
- Serum creatine kinase
- Serum amylase / lipase
- Serum aspartate / alanine amino transferase
- Arterial blood gas (ABG) analysis [if required]
Imaging studies
Chest x – ray •
Other investigations
Electro cardiogram & serial ECG (monitor ST, T & others) during follow up. •
Treatment Guidelines for Snakebite and Scorpion sting
54 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Special investigations [if required]
Echocardiogram / and repeat for follow up studies •
Color-flow doppler •
Pulmonary artery catheterisation studies •
Serial spirometry to measure pulmonary functions •
Hormone studies •
Estimation of different cytokines •
Serum venom level •
Clinical Course
Clinical course of scorpion sting is usually less alarming but in some cases it
may progress to maximum severity in about 5 hours to 12 hours and starts subsiding
within a day or two. Even if the patient has features of autonomic nervous system
manifestations, it may start subsiding by 12 hours after initiating treatment. Tachycardia
usually subsides within 24 to 48 hours. Hypertension may last for 4 to 8 hours.
Hypotension and bradycardia are encountered usually within 2 hours. Once treatment
is started, the signs of recovery begins within 48 or 72 hours. In some cases pulmonary
edema may develop within 30 minutes to 3 hours, usually secondary to myocardial
dysfunction. Unfortunately some cases of scorpion sting may die within 30 minutes
and this may be related to ventricular arrhythmias or non cardiac pulmonary edema
due to ARDS [often reported from Brazil]. Central nervous system manifestations with
or without convulsions may occur within one to two hours in fatal cases.
Complications
Various complication of scorpion sting are:
Respiratory failure •
Multi organ failure •
Dilated cardio myopathy •
Rhabdomyolysis •
Persistent paresthesia •
Anti venom anaphylaxis and serum sickness •
Ankylosis of small joints if sting occurs at a joint •
Iatrogenic high dose sedative hypnotic respiratory arrest •
2.3 Treatment
The first aid currently recommended is based around the mnemonic ‘R.I.G.H.T’. The
details provided earlier in Table no.6 is again furnished below for easy reading.
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 55
Table No. 6: Currently recommended First aid
R =Reassure the patient. •
I = Immobilisation of the limb in the same way as a fractural limb helps to •
prevent rapid absorption of the venom into the circulation. (Use bandages
or cloth to hold the splints, not to block the blood supply or apply
pressure. Do not apply any compression in the form of tight ligatures,
they don’t work and can be dangerous!).
G. H. = Get to Hospital Immediately. (Traditional remedies have NO PROVEN •
benefit in treating scorpion sting).
T = Tell the doctor all that happened from the time of scorpion sting along •
with symptoms that developed till reaching (or arrival) the hospital.
This method will get the victim to the hospital quickly, without recourse to
traditional medical approaches which can delay effective treatment.
Traditional methods
The traditional methods such as application of counter irritants, herbal materials
or paste over the site of sting or tight tourniquet (it may intensify local effects of
venom), or hot fomentation should be avoided as they may enhance the effects of
venom. Also avoid cutting and suction (oral extraction of venom from the site), or
cutting and letting out the blood, or washing the wound with chemicals or alcohol or
other methods as they facilitate the absorption of toxin. In view of the consequences
noticed, these traditional methods have to be discarded.
However, local application of ice bags (one of the traditional methods) to reduce
the pain is acceptable for some time if not contraindicated. This method slows down
the absorption of venom via vasoconstriction. This is the most effective one during the
first 2 hours following the scorpion sting. One should not cause freezing injury, while
using ice cubes / bag.
While dealing a case of scorpion sting consider mnemonic ‘RASI’.
R • emember principles
A • ddress the problems – clinical and social
S • eek help from others when required and
I • nform the patient and / or care givers on the status of illness, clinical course,
management, outcome, welfare measures and follow up clearly with empathy.
Treatment Guidelines for Snakebite and Scorpion sting
56 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Principles involved in the management of scorpion sting
The principles envisaged to treat scorpion sting at all Health Centres / Hospitals
irrespective of the status (Government or Private) are given below (the same given
under snake bite) under “12 As”.
Table No. 7: Principles involved in the management
1. Admit the victim immediately.
2. Ask effectively.
3. Assess quickly.
4. Act swiftly.
5. Administer medication meticulously.
6. Address to the wound properly.
7. Anticipate complications keenly.
8. Avoid errors carefully.
9. Ascertain the status repeatedly.
10. Amicable with patients and care givers and show empathy.
11. Advise on follow up accordingly.
12. Arrange for referral early.
1) Admit all victims of scorpion sting & keep the victims under observation for
24 to 48 hrs. (If scorpion is brought try to identify the colour and size of it).
2) a) Ask for the details of scorpion sting and never be carried away with the sting
marks either for diagnosis or for assessment of severity.
Time of sting •
Number of stings •
Nature of the incident •
Depth of the sting •
Site of envenomation-close to head & torso [results in quicker venom •
absorption & onset of symptoms in the former]
b] Ask for the time interval between the sting and arrival at the hospital.
c] Ask for the details of traditional medicines or household remedies used, as it
may sometimes cause confusing symptoms or interfere with other drugs to be
administered.
d] Ask for clinical symptoms and correlate with the progression of symptoms and
signs due to scorpion sting [provided in page vide supra]
3] Assess the following quickly.
a] Airway, Breathing and Circulation
b] Vitals HR, RR, BP and Pulse oximetry (if required)
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c] Site of sting and the probable route of envenomation - (Intravenous have
immediate effects, while subcutaneous and intramuscular routes take several
minutes to hours to cause effect)
d] Chest expansion
e] Clinically from head to foot as well as back
f] For associted co-morbid illness[es]
g] For consuming any medication[s]
h] Status of envenomation – mild, moderate and severe
[in view of neurotoxic, cardiotoxic, hemotoxic, myotoxic or a combination of them]
4] Act swiftly
a] To support Airway, Breathing and Circulation
b] To start IV line [fluid for children - refer Annexure II Table No.29]
c] To provide supportive measures depending upon the requirements
d] To connect ventilator if there is a need
5] Administer medication meticulously
a] Tetanus Toxoid injection intramuscularly
b] Topical anaestetic agent to the site of sting to decrease paraesthesia.
c] Injection lignocaine 1% without adrenaline; 2ml as local infiltration
(after test dose for lignocaine) (0.1 to 0.2mg/kg body weight for children)
d] Oral rehydration solution to hydrate the patient if not contraindicted.
e] Tab. Paracetamol 10mg/kg body weight to reduce pain
f] Tab. Prazosin [plain 1mg]
Pharmacological aspects of Prazosin
Prazosin is an alpha blocker. It counteracts scorpion induced adrenergic
cardiovascular effects and reduces pulmonary edema through vasodilatory effect,
Usually it is started with small dose using plain tablet but not exceeding 5mg/day.
For children the dose preferred is 30 microgram / kg body weight. Though pediatric
requirement has not been established, it is started with small dose. Prazosin can be
given irrespective of blood pressure, provided there is no hypovolemia
It should be avoided, if the patient is hypersensitive to prazosin. Always exercise
caution if patient has renal insufficiency and hypertension. Users must remember that
it interacts with beta blocker and causes hypotension. Also, verapamil may increase
serum levels of prazosin and increase patient’s sensitivity to prazosin and cause
postural hypotension. Interestingly, prazosin decreases the anti hypertensive effect of
clonidine. Safety in pregnancy has not been established. Also, users are informed to
follow standard measures while using prazosin (Refer Table No.21).
Treatment Guidelines for Snakebite and Scorpion sting
58 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Table No. 21: Measures to be adopted while using Prazosin
Prazosin should not be given as prophylactic dose when pain is the only •
symptom.
Give Prazosin through nasogastric tube, if baby has vomiting. •
Keep the patient in lying posture for about 3 hours (even while examining •
the case) in order to prevent ‘first dose phenomenon’ (hypotension) due to
Prazosin.
Monitor pulse, BP, and respiration every 30 minutes for 3 hours. •
Reassess for warmth and return of pain at the site of sting. •
Continue monitoring of pulse, BP, and respiration every 60 minutes for next •
6 hours.
Recheck the same every 4 hours till improvement is visible. •
Repeat Tab. Prazosin in the same dose at the end of 3 hours according to •
clinical response and later every 6 hours till extremities are warm, dry and
peripheral veins are visible easily.
* Alternative to Tab. Prazosin is Nifidipine, Nitroprusside, Nitroglycerine, Isosorbide
di-nitrate, Hydralazine or Angiotensin converting enzyme inhibitors (ACEIs).
However, users have to remember the constraints while prescribing such drugs.
g] Beta-blockers in small doses along with alpha blockers if needed and if not
contraindicated.
h] Nitrates if patient has hypertension and myocardial ischemia
i] Ionotropics such as digitalis (has little effect), or dobutamine (refer snake bite
section for details). Avoid Dopamine as it aggravates the myocardial damage.
j] Nor-epinephrine as IV drip to correct hypotension refractory to fluid therapy.
k] Antimicrobials if infection is suspected
l] Inj. Atropine (required at times) to counter venom induced parasympathetic
effects.
m] Inj. Insulin has been shown to prevent multiorgan failure (especially cardio-
pulmonary) in animal experiments.
n] Barbiturate and / or benzodiazepine as continuous infusion for severe /
excessive motor activity
o] Steroids to decrease shock and edema is of unproven benefit.
p] Antivenom for scorpion sting is not used commonly in India (as species specific
antivenom is not available and usage has not demonstrated any benefit)
q] Vaccine – not available (tried in experimental animals).
r] IV fluids as per need [fluid for children- refer Annexure II Table No.29].
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 59
s] Other supportive medications such as sodium nitroprusside (0.3 –0.5 mcg/
kg/min with upward titration), or nitroglycerine as per need (usually in
pulmonary edema)
Though Inj. Morphine is used as a standard therapy for pulmonary edema, it should
be avoided in scorpion sting since narcotics worsen dysrhythmias in children
6] Address to the wound properly
The details of wound care are provided below. However, one should also remember
the other surgical issues described vide Table 11 in the snake bite section.
a] Wound following scorpion sting may show sting marks with or without local
manifestations.
b] Sometimes venom may penetrate deep and hence deeper tissues may be
damaged which may not be visible during initial examination (rare).
c] At the site of the sting a bleb or vesicle may develop and end in the form of non
specific ulcer. (Non-specific ulcers are defined as ulcers due to infection of
wounds, physical or chemical agents or due to local irritation).
d] Consider the following while managing the wound / ulcer (uncommon in
scorpion sting).
Minimize unnecessary blood loss. •
Initiate adequate cleaning with normal saline or tap water, and edema •
control.
Remove debris and necrotic tissue, irrigate gently with water / normal •
saline.
Expose viable tissues, excise eschar after controlling hemotoxic •
complications.
Use topical antibacterial agents. •
Apply dressings after complete debridement. •
Maintain proper wound environment and prevent ischemia. •
Keep the bacterial count as low as possible. •
Facilitate healing of acute wound by applying non adherent dressing to •
ensure adequate epithelialization and to prevent contamination of the
wound.
Keep wounds clean and dry. •
Avoid soaking or scrubbing the wound. •
Teach & explain the care of wound to the patients and / or care givers. •
Educate on good personal hygiene and nutrition. •
Control diabetes if identified. •
Treatment Guidelines for Snakebite and Scorpion sting
60 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
7] Anticipate complications keenly.
a] Examine the victims at regular intervals for alterations in symptoms and signs
b] Anticipate dysrhythmias during the first 24 to 48 hours after sting
c] Start tapering prazosin after the clinical improvement begins to manifest
d] Observe for drug related systemic changes and drug toxicity, and treat them
accordingly.
8] Avoid errors carefully while assessing the case, investigating the victims,
administering medications, following the case at hospital, undertaking any
procedures for the patient, referring to other specialists or hospitals, communicating
with patients / and care givers, planning for discharge, preparing reports, filling up
the forms, reviewing the data and conducting the audit.
9] Ascertain the status repeatedly and provide supportive measures, as these cases
may develop covert signs during hospital stay while on treatment.
10] Amicably interact with patient and care givers and show empathy to them in
view of the socio clinical aspects related to scorpion sting.
11] Advise on follow up accordingly in view of the systemic toxicity. Patients may
also be motivated to attend to the nearest Health Centre / Hospital for follow up
care. Follow-up checks are required for assessment of long term effects on different
organs / systems and for appropriate management wherever required / needed.
12. Arrange for referral early - One should also remember the criteria for referral and
provide clear instructions while referring the case. The details on referral aspects
are provided in Table 24.
2.4 Scorpion sting in special situations
If patients already suffering from one or other illness(es) with or without medications
for the underlying illness, suffers from scorpion sting, these patients have to be treated
like any other case of scorpion sting. However, treating doctor has to exercise caution
while prescribing and using medications, consider drug interaction, contraindications,
absorption, and excretion of the drugs used so as to avoid toxicity.
Also, one has to carefully monitor the status of underlying illness. Pregnant women
and lactating women with scorpion sting have to be treated like any other women.
Remember to consider the baby in utero by clinical and technological means.
2.5 Management in Primary Health Centres (PHC) and Block PHC
The key objective of this guideline is to enable even the doctors working in Primary
Care Institutions as well as private practitioners to treat scorpion sting with confidence.
Evidences suggest that doctors are not willing to make use of the medications and
devices, even when available, due to lack the confidence and guidelines. The present
handbook provides guidelines to meet their needs, and outlines how they should proceed
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 61
within their context and setting. The principles envisaged to treat scorpion sting at
all Health Centres / Hospitals irrespective of the status (Government or Private) are
given in Table no: 7 (vide supra under treatment) The initial evaluation and systemic
manifestations following scorpion envenomation (described in Table 18, 19 and 20,
and Figure 1 and 2), and treatment aspects are provided in detail vide supra. However,
a format for quick assessment is provided in Table 22 and 23 (refer Annexure VIII
and X).
Table No. 22: Initial evaluation of scorpion sting without
Systemic Envenomation
ASSESS CLASSIFY TREATMENT
Vital signs
Pulse •
BP •
Respiration •
SYMPTOMS AND
SIGNS
Local effects (Table 18)
Sting marks and site •
Swelling and local •
pain
Pain, erythema & •
wheal
Induration, macule/ •
papule
Progress to purpuric •
plaque
Local necrosis •
Lymphangitis •
Ascending •
hyperesthesia
Positive “Tap test” •
Conscious level •
Any other systemic •
effects
Vital signs (Adult)*
Pulse rate: 60-100/ •
min
BP 110 / 70 to 140/95 •
Respiratory rate <20/ •
min
SYMPTOMS AND
SIGNS
Local pain and/ or •
swelling
Sting mark present •
No other symptoms •
and signs
If the patient has
above findings at the
time of assessment,
classify as No systemic
envenomation
Tab.Paracetamol
Inj.Tetanus Toxoid IM
Routine antimicrobials are
not necessary
Monitor Pulse, Respiration
& BP every ½ hourly for 3
hours and every 4 hourly for
remaining 48 hours.
If normal send the
patient home
If the patient develops one or
other systemic manifestations
as described in Table 18, 19
and 20, and Figure 1 and 2,
proceed to treat as given in
Table 23.
*Vital signs for children (see age specific chart) are provided in Annexure III
(Table No.30 to 33). If the patient has any systemic manifestations as described in
Table 19 and 20, and Figure 1 & 2, proceed to manage as described in Table 23. The
details of local envenomation is provided in Table 18.
Treatment Guidelines for Snakebite and Scorpion sting
62 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Table No. 23: Evaluation of scorpion sting with Systemic Envenomation
ASSESS CLASSIFY TREATMENT
Vital signs
Pulse •
BP •
Respiration •
SYMPTOMS
AND SIGNS
In addition to
those described in
Table 22, look for
those mentioned
in Table 19 and 20
as well as figure
1 and 2 for one
or other systemic
manifestations as
described in Table
19 and 20, and
Figure 1 and 2.
Vital signs (Adult)*
Pulse rate >120 per
minute, feeble (a
response to hypotension)
Respiratory rate >20/min
Hypotension <90/60
SYMPTOMS AND
SIGNS
Swelling and local pain
If systemic findings
are there at the time of
examination, classify as
systemic envenomation
Oxygen administration if •
required
Follow various principles •
described vide supra
Start IV Normal Saline with •
wide bore needle as life line
Treat the patient with Tab. •
Prazosin (Plain)
Continue to monitor the vital •
signs at five minutes interval
for first 30 minutes and then
at 15 minutes interval for two
hours.
For further details while using •
Prazosin follow the details
provided in Table No.21.
Stabilise the patient and •
refer to the higher institution
keeping the patient in lying
posture.
Fluid requirements per day should be kept in mind while managing the case.
For children readers are requested to see the fluid requirement chart provided in
Annexure II.
* Vital signs for children (see age specific chart) provided in Annexure III.
2.6 Referral aspects
The medical officer who is treating the cases of scorpion sting should take meticulous
care to look into the patient’s status and provide first aid as well as supportive measures
before referring the cases to higher centre / specialist(s). The details are furnished in
Table 24 below.
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 63
Table No. 24: Referral aspects for scorpion sting
Who needs When to refer Where to refer
Patient requiring
Respiratory support •
Cardiac failure/shock •
Surgical intervention •
Spontaneous •
persistent bleeding
Co-morbid diseases •
Acute impending •
kidney failure
Multi-system •
involvement
Refer the patient after •
stabilising the case and
after giving Tab.Prazosin
and other supportive
measures (refer to
Annexure VIII and X)
Refer to higher institution
having ventilator and other
measures to provide
further supportive
treatment.
Instructions while referring
Inform the need for referral to the patient and / care giver [family member or •
the accompanying attendant]
Give prior intimation to the receiving center •
Arrange for an ambulance •
Transfer in a vehicle to Secondary Care Hospital or Tertiary Care Hospital •
where facilities are available for further management
Continue life support measures •
Provide airway support with the help of an accompanying staff •
Send the referral note with details of treatment given •
Instruct one staff to accompany the patient during transportation if required •
Hand over the referral form (Annexure V) with details regarding treatment •
given
Mention the clinical status at the time of referral clearly in the referral form •
2.7 Occupational risk, Patient Education and Prevention
Occupational risk for scorpion sting is noticed frequently among those handling •
building materials, fire wood, etc., where scorpions hide.
Educate the patients and community on how to avoid scorpion and scorpion •
sting.
To check shoes, gloves, clothing and package before use. •
To keep yards free of debris, which serve as places for scorpions to hide. •
To prevent entry of scorpion into home (make sure windows and doors fit •
tightly).
Avoid walking barefoot especially at night. •
Treatment Guidelines for Snakebite and Scorpion sting
64 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Encourage biological methods to control scorpion by introducing chicken, •
ducks, owls etc.,
Use chemicals such as (organo-phosphates, pyrethrum and chlorinated •
hydro carbons) which help to control.
2.8 Prognosis
Prognosis is related to species of scorpion, the venom injected (amount and •
components), physiological response of the individual to the venom, and
individual’s response to pharmaco therapy as well as supporting measures.
Symptoms generally persist for 24 – 48 hours, if the patient survives without •
severe toxic effects on cardio respiratory or neurologic systems or multi organ
failure.
Greater the systemic symptoms and poorer the response to therapy, worse is •
the prognosis.
2.9 Resource material
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include both a potent specific antivenom and support of vital functions. Toxicon.
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51 cases. Clin Pediatr. (Phila). 1985:24(3):136-40
3. Abroug F, Nouira S, Haguiga H, Bouchoucha S. High dose hydrocortisone
hemisuccinate in scorpion envenomation. Ann Emerg Med 1997; 30: 23-27.
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pulmonary edema. Ann Trop Med Parasitol 1987; 81: 710-723.
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neurotoxins and therapeutics. Trop Doct 2000; 30: 23-25.
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Medicine 8
th
edition. The Association of Physicians of India, Mumbai 400 011.
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Gajendragadkar A, Bavdekar SB, Shah NK. [Edrs] Frequently asked questions
Ask IAP: a series.. Basics and Beyond. IAP Action Pl25. Biswal N, Mathai B,
Bhatia BD. Scorpion sting envenomation: complications and management.
Indian Pediatr. 1993:30 (8): 1055 – 9
8. Brand A, Keren A, Kerem E, Reifen RM, Branski D. Myocardial damage
after a scorpion sting: long-term echocardigraphic follow-up. Pediatr. Cardiol
1988:9(1):59-61.an 2006 ; 109-118.
9. Baldessarini RJ . Drugs acting on the central nervous system. In: Goodman and
Gilman’s: The Pharmacological Basis of Therapeutics, 9
th
edn. Eds. Hardman JG,
Limbird LE. New York, McGraw Hill, 1996; pp 411- 412.
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10. Bawaskar HS, Bawaskar PH. Role of atropine in management of cardiovascular
manifestations of scorpion envenoming in humans. J Trop Med Hyg
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manifestations of scorpion sting. Lancet 1986; 1: 510-511.
12. Bawasker HS, Bawaskar PH. Clinical profile of severe scorpion envenomation
in children at rural setting. Indian Pediatr. 2003:40(11):1072 – 5.
13. Bawasker HS, Bawasker PH. Severe envenomoing by the Indian red scorpion
Mesobuthus tamulus: the use of prazosin therapy. QJ M. 1996:89(9):701 – 4.
14. Bharani AK, Sepaha GC. Myelopathy after Scorpion sting. Arch Neurol.
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G. Defibrination syndrome due to scorpion venom poisoning. Br Med
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envenomation. J Toxicol Clin Toxicol. 1992:30(2):245 -5.
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envenomation. Toxicon. 1993 ; 31 (9) : 1071-83.
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-a 5 year surveillance report. Toxicon. 2007:50 302-5.
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34. Molhotra KK, Mirdehghan CM, Tandon HD. Acute renal failure following
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Titles Page
3.1 Quality of Care 69
3.2 Responsibilities of health care providers / professionals 69
3.3 Maintenance of records and reports 70
3.4 Utilisation of Information, Education and Communication
(IEC) materials 70
3.5 What patients and care givers should know about
snake bite / scorpion sting? 70
3.6 What health care providers / professionals should know
on snake bite and scorpion sting? 73
3.7 Medical pitfalls 74
3.8 Medical audit for snake bite and scorpion sting 74
3.9 Areas for research on snake bite / scorpion sting 79
3.10 Key points for snake bite and scorpion sting 84
3.11 Conclusions 85
SECTION - III
MISCELLANEOUS
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 69
3.1 Quality of Care
The Medical Officer of a Health Centre / Hospital should be competent enough to
manage cases of snake bite and scorpion sting. For all practical purposes competency is
defined as the point at which the doctor or a health care provider – knows the principles /
steps involved in the treatment of cases, has acquired skills [cognitive, psychomotor
and affective] to manage the cases confidently with available resources and materials,
and refers the deserving cases to higher centre or specialist[s] in time when required.
Quality of care has to be assessed by objective means for the purpose of approving
health centre / hospital for health care services, accreditation, third party payment,
upgrading the status, research, etc., Some of yardsticks to measure the services are
provided below:
1. Case fatality rate for snake bite / scorpion sting,
2. Ratio of time interval for treatment,
3. Referral rate, and
4. Availability of drugs and devices
5. Utilization of Anti-snake venom
3.2 Responsibilities of health care providers / professionals
The responsibilities of health care provider with reference to quality of care have
been narrated under “10 Rs” provided in Table 25 below.
Table No. 25: Responsibilities of health care providers / professionals
1. Recognise the case and distinguish it from other conditions.
2. Remember the principles of management.
3. Resuscitate if required.
4. Reassure patients in an empathetic manner.
5. Reassess to estimate the clinical status and complications.
6. Refer to higher centre or specialist[s] in time if required.
7. Review the health services and effectiveness of health education with health
care team.
8. Retrain the health care team to raise their standard and quality of service.
9. Reeducate the community for empowerment in terms of prevention, control
and welfare as well as in the treatment and follow up.
10. Revise the strategies for constant availability of drugs and devices all through
the year.
Treatment Guidelines for Snakebite and Scorpion sting
70 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
3.3 Maintenance of records and reports:
Medical record (MR) is systematic documentation of sequential events of patients’
medical history and health care. Medical records serve multi-dimentional roles viz.,
serve as educational material, provide data for research works, act as material for
medical audit, safe guard physician / practitioner from legal wrath, help medical
insurance / third party, help authorities for the purpose of accreditation or approval,
assist patients for follow-up and to know the status of illness, act as a source to assess
quality of care and guide health care planners. Medical council act gives clear directions
on maintenance of medical records. So, in the context of snakebite and scorpion sting,
the medical officers have to maintain the treatment records of the victims and send
the reports periodically to higher authorities for further monitoring and surveillance.
The model forms are provided in Annexure IV, V, VI, XIII and XIV. List of drugs
and devices required at health centres to provide first aid treatment for snakebite and
scorpion sting are provided in Annexure VII.
3.4 Utilisation of Information, Education and Communication (IEC)
materials:
The medical officers and public health staff should make use of the information,
education and communication (IEC) materials, and disseminate the correct knowledge
on snakebite / scorpion sting management and prevention to the community in order
to reduce morbidity and mortality. For this purpose, one has to organise programmes
with clear direction. The steps involved are:
1] Identify goals
2] Set objectives
3] Analyse the details required
4] Review the health needs
5] Determine key issues
6] Find out the areas that need change
7] Conduct IEC programmes
8] Reassess the status
9] Provide feed back and
10] Continue the programme with necessary modifications.
3.5 What patients and care givers should know about snake bite /
scorpion sting?
Snake and Scorpion
Snakes move • frequently in agricultural area to catch its prey
Krait bite is more fatal than bite from other three of the “Big 4” •
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 71
Scorpions are shy creatures, which hide in crevices and burrows, and sting if •
cornered, disturbed or threatened
Destruction of snake / scorpion will not have any effect on mortality •
Venom variation has been identified among the subsets of snakes / scorpions •
Venomous snakes / scorpions do not inject venom sometimes or inject only •
small quantity of venom
Bite and Sting
All venomous bites / stings do not end in death or complications. •
Farmers encounter snakebite more than people in forests •
Children encounter scorpion sting more than adults •
Snake / scorpion never runs out of venom •
Bites / stings due to venomous snake / scorpion may be insignificant at times •
Antivenom
Separate ASV is not available for individual venomous snakebites in India. •
Antivenom made for Indian Russell’s Viper, may not be effective for Russell’s •
Viper bite of Srilanka
Anti venom is effective but not without side / adverse effects •
Adverse effects have to be observed and tackled immediately •
Clinical course, complications and outcome: Preventive measures
and health education:
Symptoms, signs, clinical course, complications, therapeutic response and •
outcome may vary from patient to patient bitten by the same species of the
snakebite / scorpion sting.
Consider whether poisoning due to snake bite / scorpion sting is of different •
species, if the clinical course and complications are different or the patient is
not responding to treatment.
At any point of time, clinical course, complications and outcome cannot be •
categorically predicted in a given case despite available drugs and devices.
Early arrival and treatment may help to improve outcome. •
Recovery is a natural process and treatment is an adjuvant to assist the process •
of recovery.
Complications can be minimized and avoided to some extent but can neither be •
predicted nor avoided totally.
Treatment Guidelines for Snakebite and Scorpion sting
72 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Co-morbid status / preexisting illness[es] and medication[s] of any sort may •
influence the response to venom as well as treatment and outcome.
Each case is different from another in one or other aspects. •
Follow up
Follow-up checks are required for assessment of long term effects on different •
organs / systems and appropriate management has to be instituted wherever
required / needed.
Limitation
Laboratory investigations are of little value in the diagnosis of severity of •
envenomation or the sub-type of snake due to biological variations, but assist
for intervention
Currently available treatment modalities and supportive care attempt to reduce •
morbidity, alter the clinical course, enhance natural process of recovery and
minimize mortality.
Welfare measures
More deaths occur following snake bite / scorpion sting outside the hospitals, •
and at times deaths occur inside the hospital despite treatment, because of the
patients’ biological characteristics
Many state governments in India provide solatium to the family members of •
the deceased snake bite victims.
Prevention
At present no effective vaccine is available against snake bite and scorpion sting. •
Hence, the community must be motivated to understand and adopt preventive
measures always.
Also, the people should be made aware of the first aid measures and adopt early •
health seeking behavior before complications set in.
Information and resource
Patients and care givers may be informed about the
1. Diagnosis
2. Number of cases referred
3. Number of cases expired at health centre
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 73
4. Number of cases brought dead
5. The available websites (Annexure XV) and on line resources on snake bites /
scorpion sting are given so that they can learn more about these aspects, if they
like to do.
Community should be informed on the national consensus on the management •
of snake bite / scorpion sting through local media uniformly in their respective
languages, so that they will not be carried away by any other means and different
systems of medicine, etc.,
3.6 What health care provider / professionals should know on snake
bite and scorpion sting?
Once community awareness on first aid measures and treatment modality of •
snake bite and scorpion sting increases, more number of such cases are likely
to attend the Health Centre / Hospital till the preventive measures are adopted
to reduce the problem.
The time interval between bite / sting and application of scientific treatment •
modalities should come down
As snake bite and scorpion sting patients are likely to get appropriate treatment •
early in the nearest Health Centre / Hospital, morbidity and mortality are likely
to come down
Health Centre / Hospital may require more materials to handle such cases. So •
the health care provider has to initiate efforts to maintain adequate stock and
replenish their requirements well in advance
If the treatment is initiated for snake bite at Health Centre / Hospital as per •
evidence based (standard treatment guidelines), the total anti snake venom
required per patient will come down and also the referral rate to higher centre
too.
Since the patients are getting treatment at peripheral Health Centre / Hospital, •
the patients may come to the hospital early without wasting time in other
traditional methods
Increased awareness of the welfare measures provided by the State Government •
of Tamil Nadu to the family members of the deceased victim, may result in
bringing the cases who died due to the bite / sting outside hospital for death
certificate. Under such circumstances the Medical Officer has to inform the
family members of the deceased victim, to shift the body to a centre where
postmortem could be carried out to ascertain the cause of death if they do not
have postmortem facilities in the respective Health Centre / Hospital.
Treatment Guidelines for Snakebite and Scorpion sting
74 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
3.7 Medical pitfalls (“14 Fs”)
Treating doctor should take adequate care to avoid medical pitfalls as these issues are
likely to come up during medical audit. Some of the issues are mentioned here.
F • ailure to provide first aid measures immediately when the victims of snake
bite / scorpion sting is brought to a health centre / hospital
F • ailure to admit the patient and document the findings properly
F • ailure to ask and assess the case in detail, and do the needful with the available
measures
F • ailure to monitor the case who are severely envenomed
F • ailure to stablise the airway and vital signs before specific intervention
F • ailure to treat the patient adequately, because of under-estimation of the
clinical status
F • ailure to observe anticipated complications while under medical care
F • ailure to warn the patient and / or the care givers of the potential complications
that could happen due to the envenomation and / or during treatment
F • ailure to obtain informed consent for interventional procedures
F • ailure to arrange for follow up care
F • ailure to refer to higher centre or to specialist[s] when such services are likely
to benefit the snake bite / scorpion sting victim.
F • ailure to provide adequate records / reports while discharging or demand
F • ailure to initiate treatment with ASV without adequate agents for managing
anaphylaxis or anaphylactoid reaction.
F • ailure to inform the patient / care giver(s) on the persistence of pain / lesion or
paresthesia at the site of bite / sting for days / weeks even after recovery from
the primary illness.
3.8 Medical audit for snake bite and scorpion sting
Medical audit for snake bite and scorpion sting is an attempt to review each case
who was brought alive or dead or died at the health care centre / hospital even after
treatment. In general “audit is a quality improvement process that seeks to improve
patient care and outcome through systematic review of case against explicit criteria
and the implementation of change” [www.nice.org]. The objectives, goals and vision
of medical audit are given below:
Objectives
To determine the probable reasons that might have contributed to death •
To find out the lapses and failures in the management •
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 75
To initiate the root cause analysis (RCA) •
To compare the case fatality on monthly basis at different levels •
Goals
To introduce remedial measures at all levels. •
To counsel and guide the affected victim and their family. •
To create awareness among the community. •
To implement preventive strategies so as to reduce mortality and morbidity. •
Vision
To provide appropriate care and support for snake bite and scorpion sting cases •
at all Health Centre / Hospital at all times.
Principles of audit:
Not to blame each other, but to improve •
Avoid reduplication of cases •
Refrain from false statement / data •
Find out the reasons for lapses / deficiencies •
Provide feed back to members at all levels •
Get suggestions from end users •
Find out ways for improvement and to implement them •
Place the data and resolutions / remedial measures on the web site •
Outcome of audit (“5 Es”):
E • licit the lacunae / limitations / variations at inter-regional and inter institutional
levels
E • numerate the needs for requirements
E • liminate the constraints
E • ducate the providers of health care and beneficiaries
E • ncourage health care providers to perform better
Treatment Guidelines for Snakebite and Scorpion sting
76 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Table No. 26: Levels of analysis
Level Place Reviewer Materials for analysis
I. Local
Health centre /
Hospital
Chief of the
Health centre /
hospital / unit
Details of snake bite and
scorpion sting treated /died /
brought dead to the respective
health centre / hospital and
health services
II. Health
Unit
Office of the
Health Unit of
respective health
districts
Chief of the
health unit
Details collected from all
hospitals [Government /
private], and death due to
snake bite and scorpion sting
collected from Panchayat /
Municipality, etc., and health
services
III. Revenue
district
level
Office of the J oint
Director of Health
Services
J oint Director of
Health Services
Details collected from the
health units under them and
death due to snake bite and
scorpion sting collected from
Panchayat / Municipality /
Corporation etc., and as well
as details of welfare measures
provided for such victims
family from the respective
Collectorate.
IV. State
level
Office of Director
of Public Health
and Preventive
Medicine
Director of
Public Health
and Preventive
Medicine
Data from all revenue
districts along with various
Directorates coming under
Health and Family Welfare
Department of Tamil Nadu,
Chennai
Role of reviewer
Adhere to reviewing of achievement of objectives, goals and vision •
Remember principles and outcome of audit •
Review the data with reference to responsibilities of health care providers/ •
professionals
Consider medical / social problems faced with each case •
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 77
Identify gains / setbacks in terms of man power • , skills, service, patient
satisfaction, maintenance of records, availability of drugs, drugs status
including expiry date, functional aspects of medical equipments, morbidity
pattern, referral issues and case fatality rate at different levels [for these use
formats given in Annexure IV to VII, XIII and IV].
1) Case fatality rate at different levels: Formula to calculate Case Fatality Rate
(CFR) at different levels is given in Table 27. CFR is mentioned in percentage.
Table No. 27: Formula to calculate case fatality rate at different levels
Case fatality rate for snake bite
/ scorpion sting at local health
centre / hospital for the particular
month =
Total number of death(s) due to snake bite /
scorpion sting for the particular month x 100
-------------------------------------------------------
Total number of cases (alive & dead) of snake
bite / scorpion sting brought to the health
centre / hospital for the particular month
Case fatality rate for snake bite /
scorpion sting at the level of health
unit for the particular month =
Total number of death(s) due to snake bite /
scorpion sting for the particular month in that
health unit area x 100
--------------------------------------------------
Total number of cases (alive & dead) of snake
bite / scorpion sting brought to the health
centres / hospitals of that health unit for the
particular month
Case fatality rate for snake bite /
scorpion sting at the level of
revenue district for the particular
month =
Total number of death(s) due to snake bite /
scorpion sting of that revenue district for the
particular month x 100
--------------------------------------------------
Total number of cases (alive & dead) of snake
bite / scorpion sting brought to the health
centres / hospitals and those applied for
welfare to the collectorate for the particular
month
Treatment Guidelines for Snakebite and Scorpion sting
78 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Case fatality rate for snake bite /
scorpion sting at the level of Tamil
Nadu state for the particular
month =
Total number of death(s) due to snake bite /
scorpion sting for the particular month in
different revenue districts x 100
--------------------------------------------------
Total number of cases (alive & dead) of
snake bite / scorpion sting brought to the
health centres / hospitals of different revenue
districts and data from collectorates for the
particular month
2) Ratio of time interval for treatment: In Tamil Nadu due to the available health
infrastructure, the maximum time required to reach the nearest health centre is
estimated to be 30 minutes. Hence the ratio of time interval for treatment is the
ratio of actual time taken to reach health centre / hospital to the estimated time
required [i.e., 30 minutes] and calculated as per the formula given in the box below.
The ratio should always be below one and infact it should be as low as possible. If
the ratio is one or more than one, it indicates delay in reaching the health centre /
hospital. Then elicit the probable reasons for each and try to rectify them. This has
to be reviewed at different levels. (details may be collected from Annexure IV)
Ratio of time interval
for treatment =
The time interval between actual time of snake bite /
scorpion sting and the time of arrival for scientific
treatment in minutes
----------------------------------------------------------------------
Estimated time required to reach the health centre /
hospital (30 minutes)
*Estimated time required to reach the health centre / hospital (30 minutes) is an
arbitrary one and the ratio of time interval for treatment is calculated to understand
the awareness and utilization of health care. However, the ratio should not be used as
a lone factor to assess or predict the clinical aspects, course and outcome, as these are
influenced by multiple factors.
3) Referral rate: Once the treatment is started early, it is expected that referral will
come down. This has to be analysed in relation to the reasons for referral (Annexure
XIV) and efforts to be taken to minimize the referral without compromising patient
care service. Moreover, referral rate has to be analysed at all levels like CFR and
measured in percentage.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 79
Referral rate =
Number of snake bite / scorpion sting referred x 100
----------------------------------------------------------------------
Total number of cases (alive & dead) of snake bite /
scorpion sting brought to the health centre / hospital for
the particular month
4) Availability of drugs and devices: Availability of drugs and devices have to be
analysed (Annexure VII) carefully and corrective efforts should be undertaken well
in advance so that non-availability should not be made as a reason for inadequate
treatment / referral.
5) Utilization of anti-snake venom:
Utilization of anti-snake venom has to be monitored in each and every health
centre / hospital which are providing treatment for snake bite victims. The details
given in the following box may be collected from each health centre / hospital of
the respective health and revenue district as well as at medical college hospitals and
discussed in the monthly medical audit meeting. The minutes of such meeting along
with problems encountered, suggestions for improvement, new clinical observations,
changing trends, recommendations and action taken for previous meeting should be
send to their respective directorates, which will then be consolidated at the office of
the Directorate of Public Health for further updating the modalities of treatment and
community participation.
Sl.No Subjects for discussion
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Bite to needle time
Delay in administration of ASV
Reactions to ASV
Reasons for repeated doses of ASV on case by case basis
Non-responders to ASV
Reasons for referral despite giving ASV
Status of availability of ASV
Deficiencies in the utilization of ASV
Root cause analysis for each
Review of action taken on previous meeting
Changing trends and limitation(s)
Any other. specify
3.9 Areas for research on Snake Bite / Scorpion sting
Areas for research on Snake Bite / Scorpion sting that could be undertaken
at health care institutions / organizations either alone or in collaboration with
Treatment Guidelines for Snakebite and Scorpion sting
80 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
sister specialties / and institutions are provided below. Interdisciplinary research
will bring out enormous information and help to improve the existing system.
Though titles are provided more on snake bite, similar areas may be considered
for scorpion sting also.
I. Arts and humanities
1. Myths related to snake bite.
2. Socio cultural aspects of snakes and snake bite.
3. Bibliometric studies on snakes, snake venom, anti snake venom and snake
bites from India.
4. Economical aspects of snake bite and regional variation.
5. Counseling and guidance to snake bite victims and their family.
6. J udicial aspects and activism related to snakes and snake bites in India
7. Snakes and snake bite in literature.
8. Snake and snake bite in cinema.
9. Snakes and snake bite in mythology.
10. Proverbs related to snakes and snake bite.
11. Interpretation of snakes and snake bite when appeared in dreams.
12. Ethical issues in snake bite.
13. Crime issue related to snake, snake venom and snakebite.
14. Snakes, snake venom and snakebite in lay press and other media.
15. Discussion on snakes, snake venom, anti snake venom and snake bite related
issues in Indian Parliament and Assembly in pre and post independent period.
16. Effects of global warming and climate change on the ecosystem of snakes,
behaviour of snakes, constituents of snake venom and snake bite.
17. Snakes in sculptures: what do they convey?
18. Religious aspects related to snakes, snake bite and recovery.
19. Astrological aspects of snakes, snake bite and recovery.
20. Social status and issues related to snake charmers / handlers.
21. Snakes and snake bite issues in philately.
22. Spatiotemporal variation in snakes and snake bites.
23. Demands, production and supply of anti snake venom.
24. Utilisation of anti snake venom in government and private sector.
II. Basic Sciences
1. Preparation of monovalent anti snake venom.
2. Bedside diagnostic kits to assess snake venom levels.
3. Nature and distribution of snakes in different areas in Tamil Nadu and India
a geographical study.
4. Use of snake venom in diagnostic and therapeutic purposes.
5. Heterogenecity of snake venom in relation to species and sub types.
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 81
6. Antioxidant status during snake bites.
7. Metabolic changes during envenomation.
8. Cytokine status during envenomation.
9. Biomarkers to assess envenomation, organ involvement and outcome.
10. Lipid profile during and after envenomation.
11. Trace element profile during envenomation and after recovery.
12. Mechanisms of thrombus formation and its consequences during snake
envenomation and management issues.
13. DNA fragmentation during and after envenomation.
14. Oxidative stress during envenomation.
15. Status of fibrinogen and fibrinogen degradation products in snake bite and its
applicability.
16. Influencing factors for changes in coagualation profile.
17. Anatomical site of bite and human behaviour.
18. Genetic basis for organ involvement in snake bites.
19. Microbial flora of snake oral cavity.
20. Microbial study of snake bite wound.
21. Serological studies while under envenomation.
22. Newer methods in the production of antisnake venom.
23. Postmortem studies in snake bite.
24. Histopathological changes in myocardium and other organs in snake bite
victims.
25. Complement profile during and after envenomation.
26. Immuno analytical studies following snake envenomation.
27. Immunisation against snake venom: experimental studies.
28. Kinetic studies on snake venom in clinical situations and experimental status
29. Humoral response following snake bite.
30. Early indicators of renal involvement in snake bite.
31. Preparation of anti snake venom for poisonous snake other than “Big 4”.
32. Isolation, identification and application of components of snake venom.
33. Application of nanotechnology in the diagnosis and management of snake bite.
III. Clinical aspects.
1. Epidemiology of snake bites.
2. Clinical aspects, management issues and outcome of sea snake bite.
3. Community survey on snake bites and outcome.
4. Circadian rhythms of snake bites.
5. Long term follow up of snake bite victims.
6. Challenges in the management of snake bite.
7. Clinical course and outcome of venomous and non-venomous snake bite other
than the “Big 4”.
Treatment Guidelines for Snakebite and Scorpion sting
82 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
8. Clinical course of ASV in patients with allergic disorder(s).
9. Adverse reactions to ASV.
10. Long term effects of ASV.
11. Newer modalities to treat snake bites.
12. Use of antioxidants in the treatment of snake bite.
13. Blood group pattern and blood / component requirements in the management
of snake bite.
14. Prophylactic schedule before ASV and its relevance.
15. Clinical and laboratory status of snake charmers / handlers.
16. Pattern of renal involvement in snake bites.
17. Cardiac involvement in snake bite.
18. ECG and Echo cardiographic assessment during envenomation.
19. EEG changes in snake bites before and after treatment.
20. Taste and smell in snake bite victims.
21. Neurological manifestations in snake bites.
22. Snake bite and pregnancy.
23. Snake bite in patients with coagulation disorders.
24. Hematological profile in snake bites.
25. Pulmonary manifestations in snake bite.
26. Effects of Inj.ASV in the unborn.
27. Ophthalmological aspects of snake bite.
28. ENT involvement in snake envenomation an analysis.
29. Endocrine complications following snake bite.
30. Involvement of Pancreas during snake bite.
31. Surgical aspects of snake bite.
32. Compartment syndrome in snake bite.
33. Pattern, clinical course and management of ulcers following snake bite.
34. Snake bite as an occupational hazard.
35. Addiction to snake venom: an emerging issue.
36. Clinical course and outcome of snake bite in tertiary care hospital after
implementation of treatment guidelines for snake bite.
37. Medical errors in the management of snake bite victims.
38. Failure of ASV: what, when, why and how?
39. Clinical and therapeutic aspects in patients who had second snake bite.
40. Effectiveness of ‘Pressure pad or Monash Technique’ in snakebite.
41. Role of insulin in preventing multi organ failure.
42. Plasmapheresis in the management of snake bite.
43. Obstetric and Gynecological aspects of snake bite.
IV. Community aspects:
1. Analysis of pre hospital treatment.
2. Case fatality rate in snake bite: Causes and concern.
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 83
3. Natural disasters: will those contribute to snakebite.
4. Global warming and behaviour of snakes.
5. Awarenesss programmes for community on snakes, snakebite: an analysis.
6. Comparison of bites and stings with non-communicable diseases.
7. KABP of personal protective measures against snake bite among victims of
snake bite and their family members.
8. Multisectoral approach to snake bite.
V. Managerial issues:
1. Analysis of welfare programmes: awareness and utilisation members of
deceased snake bite victims.
2. Utilization of facilities for snake bites at primary care level: problems and
solution.
3. Influencing factors for utilisation of ASV.
4. Production and utilization of ASV in India.
5. Managerial issues in the treatment of snake bite.
6. Analysis of referral status of snake bite.
7. Outcome of snake bite in ralation to transport modalities adopted.
8. Utilisation and issues related to ambulance services for snake bite victims.
9. Medical audit of snake bite records.
10. Public private partnership in the management of snake bite.
11. Utilisation of NGOs in snake bite management.
12. Welfare policies for snakebite victims and their families in different union
territories / states of India.
13. Inter-regional variations on outcome of snake bite.
14. Designing and developing a software for documentation and analysis.
VI. Indigenous medical system related:
1. Traditional treatment for snake bite: an analysis.
2. KABP of alternative medical practitioners on snakes and snake bite.
3. Snakes and snake bite in complementary and alternative medical system.
4. KABP of Traditional Medical practitioners on snakes, snake venom and snake
bite management.
5. Educational modules and training aspects on snakes and snake bite to
traditional medical practitioners.
VII. Educational aspects:
1. KABP of modern medical practitioners and nurses on snakes and snake bite.
2. Analysis of current medical education and training programme on snakes,
snake venom and snakebite management.
Treatment Guidelines for Snakebite and Scorpion sting
84 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
3. Inconsistencies and controversies on the diagnosis and management of snakes,
snake venom and snake bite management in the text books used by medical
and nursing students.
4. Educational and training programmes on snake bite for practitioners of
alternative medicines.
5. Academic audit on teaching and training aspects of snakes, snake venom and
snakebite management.
6. Assessement of skills of trainee students of health sciences on snake bite
management by OSPE and OSCE methods.
7. Assessement of skills on snake bite management among medical practitioners
and nurses.
8. Curriculum on snakes, snake venom and snake bite management in science
education at schools and teacher training programme.
9. Analysis of snakes and snake bite management in first aid training
programme.
3.10 Key points for snakebite and scorpion sting:
* Clinical
Assess every case thoroughly. •
Treat them confidently and observe vigilantly (at health centre / hospital). •
Detect the status and note down the changes, and act accordingly. •
Anticipate complications and treat them immediately. •
Provide care and support with empathy. •
Create confidence among patients, public and care givers continuously. •
Bring down morbidity and mortality. •
Explain the available welfare measures to the family members of the deceased •
victims clearly.
Arrange for follow up programs regularly. •
* Community Aspects
Conduct health education programme so as to promote immediate seeking of •
health care.
Eliminate the barriers that cause delay in health care seeking. •
* Educational & Research
Organise teaching and training programs for health care workers. •
Undertake research activities in a planned manner. •
* Administrative Issues
Arrange for required amount of drugs and devices in health centres / hospitals •
regularly.
Maintain records and reports safely. •
Monitor the activities at all levels periodically. •
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 85
3.11 Conclusions:
The ultimate goal is to provide appropriate first aid and treatment at the nearest
health centre / hospital at the earliest. Complicated cases have to be referred to higher
centre after first aid and supportive measures. Community should receive health
education on preventive and curative aspects of snakebite and scorpion sting. Each
health centre / hospital irrespective of the status should maintain a registry for snake
bite / scorpion sting and initiate research activities in a trans-disciplinary manner.
All these joint efforts will bring down the morbidity and mortality. In addition health
care institutions should undertake research activities on various aspects of snake bite /
scorpion sting, and share the knowledge and experience with others in order to advance
further in health care delivery.
Titles Page
I Snake bite cases reported in secondary care hospitals 87
II. Fluid requirement chart for children 88
III. Vital signs reference table for pediatric age group 88
IV. Pre hospital treatment for snake bite and issues related to ASV 91
V. Reporting / referral form for snake bite / scorpion sting 93
VI. Snake bite and scorpion sting monthly reporting format 94
VII. List of drugs and devices 95
VIII. Algorithmic approach to bite / sting 96
IX. Algorithmic approach to snake bite 97
X. Algorithmic approach to scorpion sting 98
XI. Frequently asked questions / self assessment queries 99
XII. Snakebite and scorpion sting in Tamil literature 100
XIII. Form to assess the quality of services 104
XIV. Form to analyse and audit the statistics on snake bite /
scorpion sting 105
XV. Useful Websites 106
SECTION - IV
ANNEXURES
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Annexure : I
Table No. 28: Snake bite cases & deaths reported and ASV vials used in
secondary care hospitals in Tamil Nadu (District wise)
Sl.
No.
District
April 2005- March 2006 April 2006- March 2007
Cases Deaths
ASV
Vials
Used
Cases Deaths
ASV
Vials
Used
1 Coimbatore 1107 2 12236 1109 0 16195
2 Cuddalore 1380 1 11779 2169 2 6898
3 Dharmapuri 679 1 2261 1076 0 3374
4 Dindigul 807 12 3041 972 13 3741
5 Erode 1277 10 11129 1607 6 7237
6 Kancheepuram 670 0 890 714 5 1598
7 Kanyakumari 3 0 3 11 0 5
8 Karur 228 3 1405 286 2 2242
9 Krishnagiri 432 0 1170 453 6 1271
10 Madurai 982 0 1801 677 0 2861
11 Nagapattinam 445 0 2565 420 0 2229
12 Namakkal 804 1 4565 1147 1 5959
13 Perambalur 576 0 3209 475 1 5746
14 Pudukkottai 683 3
2475
581 2 1865
15 Ramanathapuram 428 4 2377 373 3 2485
16 Salem 1175 5 3180 1331 1 4007
17 Sivagangai 328 2 1739 367 3 2023
18 Thanjavur 325 5 3213 514 5 3275
19 The nilgiris 69 0 31 49 1 0
20 Theni 486 0 2179 553 3 2391
21 Thiruvallur 766 0 1254 604 2 1305
22 Thiruvarur 160 2 866 142 9 715
23 Thoothukudi 351 1 1819 381 2 2056
24 Tirunelveli 671 3 2783 540 3 2814
25 Tiruvannamalai 894 5 3776 808 1 5074
Treatment Guidelines for Snakebite and Scorpion sting
88 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
26 Trichy 193 6 837 183 0 714
27 Vellore 1098 9 2650 708 2 2164
28 Villupuram 1109 9 5791 1084 2 2861
29 Virudhunagar 1195 1 3457 1343 0 3695
Total 19321 85 94481 20677 75 96800
ASV vials used in secondary care hospitals (District wise)
ASV - Anti snake venom (each vial contains 10ml)
Annexure II: Fluid requirement chart for children
Table No. 29: Fluid requirement chart for children
Weight Fluid requirement
Upto 10 kg 4 ml / kg / hour
11 kg to 20 kg 40 ml +2 ml / kg / hour
21 kg & above 60 ml +2ml / kg / hour
Example:
8 kg child with snake bite is admitted – add the vials to 2 hours of fluid.
8 kg requirement = 4 ml / kg / hour
= 4 ml / 8 kg / 2 hour =64 ml
So mix the vials in 65 ml to 75 ml of IV fluid and run it for 2 hours as given in the
treatment column.
Annexure: III: Vital signs reference table for paediatric age group
Respiratory rate
Normal spontaneous ventilation is accomplished with minimal work, resulting in
quiet breathing with easy inspiration and passive expiration. The normal respiratory
rate is inversely related to age. It is rapid in the neonate, then decreases in older infants
and children. A respiratory rate consistently greater than 60 breaths per minute in a
child of any age is abnormal and is a “red flag”.
Table No. 30: Normal Respiratory Rate by Age
Age Breaths per Minutes
Infants (<1 year) less than 2months
2months - less than one year
40 to 60
30 - 50
Toddler (1 to 3 years) 24 to 40
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 89
Preschooler (4 to 5 years) 22 to 34
School age ( 6 to 12 years) 18 to 30
Adolescent (13 to 18 years) 12 to 16
Heart Rate
Heart rate should be appropriate for the child’s age, level of activity and clinical
condition (Table 2). Note that there is a wide range for normal heart rate and that it
varies in a sleeping and awake child.
Table No. 31: Normal Heart Rate (Per Minute) by Age
Age Awake Rate Sleeping Rate
Neonate 100 to 180 80 to 160
Infant 100 to 160 75 to 160
Toddler 80 to 110 60 to 90
Preschool 70 to 110 60 to 90
School age child 65 to 110 60 to 90
Adolescent 60 to 90 50 to 90
References :
Hazinski.M. Children are different In:Hazinski M, ed. Manual of Pediatric •
Critical care. St.Louis, MO: Mosby year book ; 1999. Chapter 1,5-6.
Allen HD, Driscoll DJ , Shaddy RE, Feltes TF (Edrs). Moss and Adams’ Heart •
Disease in Infants Children and Adolescents Including the Fetus and Young
Adult. Lippin cott, Williams and Wilkins, Baltimore, MD, USA, 2007.
Blood Pressure
Normal blood pressure values for children by age is provided in Table 32. This
table summarizes the range from the 33
rd
to 67
th
percentile in the first year of life and
from the 5
th
to 95
th
percentile for systolic and diastolic blood pressure according to age
and gender and assuming the 50
th
percentile for height for children of one year of age
and older. Like heart rate, there is a wide range of values within the normal range.
Treatment Guidelines for Snakebite and Scorpion sting
90 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Table No. 32: Normal Blood Pressure in Children by Age
Age
Systolic BP (mm Hg) Diastolic BP (mm Hg)
Female Male Female Male
Neonate (1
st
day) 60 to 74 60 to 74 31 to 45 30 to 44
Neonate (4
th
day) 67 to 83 68 to 84 37 to 53 35 to 53
Infant (1 month) 73 to 91 74 to 94 36 to 56 37 to 55
Infant (3 months) 78 to 100 81 to 103 44 to 64 45 to 65
Infant (6 months) 82 to 102 87 to 105 46 to 66 48 to 68
Infant (1 year) 68 to 104 67 to 103 22 to 60 20 to 58
Child (2 years) 71 to 105 70 to 106 27 to 65 25 to 63
Child (7 years) 79 to 113 79 to 115 39 to 77 38 to 78
Adolescent
(15 years)
93 to 127 95 to 131 47 to 85 45 to 85
Blood Pressure ranges taken from the following source:
“Neonate, Infant (1 to 6 months) 8; Infant (1 year) Child, Adolescent”. •
Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood •
Pressure in Children and Adolescents: NHLBI, USA May 2004
Hypotension
Hypotension is defined by the following thresholds of systolic blood pressure
Table No. 33: Hypotension by Systolic Blood Pressure and Age
Age Systolic Blood Pressure (mm Hg)
Term Neonates (0 to 28 days) <60
Infants (1 to 12 months) <70
Children 1 to 10 years 5
th
BP percentile <70 +(age in years x 2)
Children >10 years <90
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 91
Annexure IV: Pre hospital treatment for Snake bite and issues
related to ASV
(one for each case)
1. Name: S.No: Date:
2. Age:
3. Medical unit: IP NO:
4. Gender: Male / Female:
5. Hospital:
Details about the snakebite:
6. Time of snake bite ________ am / pm
7. Victim walked home - yes / no
8. Shifted home manually - yes / no
9. If yes, state poisonous / non-poisonous
10. Nature of snake specify - Viper (type)...../ Cobra / Krait / Sea snake / others...
11. Nature of snake specify - Viper............./ Cobra / Krait......./ Sea snake group
Pre hospital treatment:
12. Household medicines given to the patient – yes / no
If yes, specify_____________
13. Taken to the traditional healer – yes / no. If yes, specify_____________
14. Taken to the Local Medical Practitioner – yes / no. If yes, Nature of the first aid
given-
15. Other traditional practices followed:
tourniquet - yes / no
cutting and letting the blood out – yes / no
applying traditional substances externally -yes / no
any other, specify_________________
Anatomical site of the bite:
16. Upper limb / lower limb
17. Right side / left side / bilateral
18. Other areas in the body ........ specify____________
19. Multiple sites ....... specify____________
Treatment Guidelines for Snakebite and Scorpion sting
92 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
ASV related:
20. ASV administered – yes / no
21. If yes, Time of starting ASV___________ am / pm
22. Time interval between snakebite to time at which ASV started (21 - 7)......
23. Probable reason for delay in bite to needle time
a. Travel related
b. Beliefs and practices of traditional medicine
c. Failure to recognize symptoms
d. Sub optimal family support systems
e. Financial constraints
f. Any other, specify______________
24. Test dose for ASV given – yes / no
25 If yes, mention the details of reaction(s):...................
26 Mention if any prophylactic medications given - yes / no
27 If yes, mention the details of drugs given ....................
28. Reaction(s) while on ASV – yes / no
If yes, describe the nature of reaction to ASV and details of
management...............
29. Time taken to complete first dose of ASV...............
30. Time interval between starting and completing first dose of ASV
(29 - 21)......
31. Form of ASV used - Lyophilized / liquid form
32. Name of the manufacturer of ASV________________ Lot No.__________
Batch No._______________ Date of Expiry_____________
33. Mention if any repeat dose of ASV given -yes / no
If yes, reasons for repeat dose .........................................
34. Total quantity of ASV given (in ml)
35. Any others (specify) …..........
Medical Officer Name / Signature / Designation / Seal / Date
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 93
Annexure V: Reporting / Referral form for Snake bite / Scorpion sting
(One for referral, second for reporting & third to be retained)
1. O.P NO................................. / I.P.NO..................................
2. Date on which snake bite / scorpion sting case attended:
3. Time at which snake bite / scorpion sting case reported to Health Center:
4. Name of the Patient:
5. Address: Father / Mother / Husband / Wife / Son / Daughter of
Door No: Street/ Lane / Ward:
Village: Nearest Town / Post Office:
Pincode: Taluk:
District: Phone/Mobile No:
6. Sex: Male / Female
7. Age:
8. Nature of snake bite / scorpion sting (describe what type of snake / scorpion):
9. Describe the condition of the patient on arrival
Pulse....../min; Respiration......./ min; BP............mm of Mercury
Clinical status of envenomation
10. Describe the nature of first aid and treatment given:
11. Name and designation of the person who gave first aid:
12. If referred, to other hospital:
a. Referral time and date
b. Details of the hospital to which referred
c. Staff accompanied - yes / no, if yes details................
d. Status of the patient at the time of referral
e. Others
13. Any other remarks – mention:
14. Follow up action & outcome:
Medical Officer Name / Signature / Designation / Seal / Date
Treatment Guidelines for Snakebite and Scorpion sting
94 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Annexure VI: Snake bite / Scorpion sting monthly reporting format
(age & gender wise)
(Use separate tables for snake bite and scorpion sting would be helpful because we can
get rates for each eg. M/F, deaths, referrals etc...)
Name of the Health Centre ………………
Address: …..........
Sl.
No.
Details
Reporting Month..............Year 200...
Total
Below
5 yrs
6-9
yrs
10-14
yrs
15-24
yrs
25-44
yrs
45-64
yrs
65 and
above
M F M F M F M F M F M F M F
I a. Snake bite
/Scorpion
sting
Total cases
treated
II Out come of
the treatment
1. No.
Recovered
2. No.
referred
3. No.
Expired
at health
centre
III No. of cases
brought dead
Medical Officer Name / Signature / Designation / Seal / Date
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 95
Annexure VII: List of drugs and devices to be stocked at
health centre
Name of the Agent / Material Available as Numbers
Tab.Prazosin (plain) 1mg 20
Inj. Antisnake venom (ASV) 10ml/vial 20 vials
Inj. Atropine (0.6mg / amp) 2ml/amp 100 ampoules
Inj. Adrenaline 1ml/amp 15 ampoules
Inj. Chlorpheneramine maleate 2ml/amp 15 ampoules
Inj. Neostigmine 0.5mg/ml 20 ampoules
Inj. Lignocaine without adrenaline 30ml/vial 2 Vials
Inj. Hydrocortisone 100mg 5 ampoules / vials
Inj. Dexamethasone 4mg/ml 5 ampoules / vials
Inj. Ranitidine 50mg/2ml 20 ampoules
Inj. Diazepam 10mg/2ml 10 ampoules
Inj. Dobutamine 10 ml/ampoule 5 ampoules
Intravenous fluids
35 bottles
a. Normal saline 500ml 15 bottles
b. Dextrose saline 500ml 20 bottles
IV Set 20 sets
Intravenous Cannula (Venflon)

18 Size – Green 5
20 Size – Pink 5
22 Size – Blue 5
24 Size – Yellow 5
Nasogastric tube (different size) 10 each
Airway (different size) 5 each
Ambu bag (Adult) / (Pediatric) One each
Laryngoscope set (Adult) 1
Endotracheal tube (different size) 5
Glass test tube (5 or 10 ml) 20
Laryngeal Mask Airway
Others if any..............
2
Treatment Guidelines for Snakebite and Scorpion sting
96 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Drugs to be indented based on the requirement
Check for the expiry date and change accordingly
Other items that should be available in the emergency tray:
Sterile Glass syringes, Splint (to support the limb / hand), Compression bandage
linen cloth, Laryngeal mask airway, Gloves, Suction Apparatus [Electrically and or
manually operated], Thermometer, Torch Light (2 cells) and other item as per need.
Annexure VIII: Algorithmic approach to bite / sting at primary level

2
prazosin
C
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 97
symptoms
R
I
G
T
H
for
2
&
f
x
Annexure IX: Algorithmic approach to Snake bite
Treatment Guidelines for Snakebite and Scorpion sting
98 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
NGT - Nasogastric Tube; IV - Intravenous; NS – Normal Saline;
RL - Ringer Lactate; NG – Nitroglycerine; SNP - Sodium Nitroprusside
Annexure X: Algorithmic approach to scorpion sting
S
persists
x
Paresthesia
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Annexure XI: Frequently asked questions / self assessment queries.
1. Mention the poisonous snakes / scorpions noticed in Tamil Nadu.
2. Mention the predisposing factors for snake bite / scorpion sting.
3. What are the implications of snake bite / scorpion sting?
4. Mention the various clinical symptoms and signs of snake bite / scorpion sting
5. Describe the local effect of snake bite / scorpion sting.
6. Mention the reasons why the presenting features, clinical course, complications
and outcome vary from case to case in snake bite / scorpion sting.
7. What is late onset envenomation in scorpion sting and mention the
mechanisms?
8. Mention the various risks involved in tourniquet.
9. What is pressure pad technique and how is it used for snake bite cases?
10. Criteria for the diagnosis of snake bite / scorpion sting at the bed side.
11. What are the laboratory investigation required for snake bite / scorpion sting?
12. Mention the details of 20WBCT - the procedures, the advantages, the
requirements and the interpretation.
13. What are the additional investigations and care that should be adopted while
treating a case of pregnant women with snake bite / scorpion sting.
14. What are the principles involved in the treatment of snake bite / scorpion
sting?
15. What are the prognostic features for a better outcome in snake bite / scorpion
sting?
16. What are the long term complications of snake bite / scorpion sting?
17. How do you monitor the cases of snake bite / scorpion sting in resource limited
setting?
18. Describe the various complications observed in acute snake bite / scorpion
sting.
19. What are the first aid methods to be adopted for snake bite / scorpion sting?
20. Describe the methods to take care of the site of bite / sting.
21. Describe the management of snake bite / scorpion sting in special situation.
22. What are the precautions to be adopted while managing a case of snake bite /
scorpion sting in a patient who has one or other co-morbid illness or taking any
other medication?
23. Can a patient on ASV therapy for a poisonous snake bite undergo dental
procedure?
24. What are the prophylactic medications to be used, to avoid reactions to ASV?
25. Why is prazosin tablet preferred for scorpion sting?
26. What are the alternative for Tab.prazosin in scorpion sting?
27. Why should antihistamines not be given while a patient is getting treated for
scorpion sting?
28. Do we have anti snake venom for each and every snake individually?
29. Narrate the pharmacological aspects of ASV.
Treatment Guidelines for Snakebite and Scorpion sting
100 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
30. Describe the methods adopted to administer ASV.
31. Is there any concept called prophylactic medication for ASV?
32. What are the immediate reactions that follow after ASV?
33. Mention briefly the treatment a modalities adopted to tackle reactions to ASV.
34. Describe clearly the guidelines to be adopted while planning to repeat ASV.
35. What are the measures to be adopted to tackle a case of snake bite for which no
anti-venom is available?
36. What will you do if a patient treated for snake bite with ASV comes back with
poisonous snake bite again?
37. What is the role of Heparin / botropase in snake bite?
38. What are the reasons for referring a case of snake bite / scorpion sting to higher
centre / specialist?
39. Discuss the measures you would like to adopt to prevent snake bite / scorpion
sting?
40. What are the components of competency of a health care provider / doctor?
41. What are the quality care indicators used to assess the management of snake
bite / scorpion sting?
42. What facts should patients and care givers know about snake bite / scorpion
sting?
43. What should Health Care Providers (HCP) know about snake bite / scorpion
sting?
44. What are the medical pitfalls associated with snake bite / scorpion sting?
45. How can HCP help the family members of deceased victim?
46. Why should narcotics not be used in scorpion sting?
47. Describe the late serum sickness reaction and treatment of the same.
48. What are the various unusual complications of snake bite / scorpion sting?
49. What are the various surgical issues related to snake bite / scorpion sting?
50. What are the various uses of venom?
Annexure XII: Snake bite and scorpion sting in Tamil Literature.
Tamil language is an ancient language. The poems and proverbs of the Tamil •
language describe the status of living at that time, highlight their knowledge,
express talents, reflect cultures, bring out tradition and reveal their beliefs and
practices, though the place of origin may not be available clearly. One can
also appreciate the changes that had happened over a period of time through
literature. Based on the circumstantial evidences the time of origin has been
calculated.
Communicating to a group of persons in their own language using the poems, •
proverbs and the procedures adopted in that region, will help to win their
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Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 101
confidence. Thereafter changing them and bringing them into the scientific
arena is easier. Once a community gets convinced, it is easy to convey health
messages and they get adapted to newer methods which will be of immense use
for their health and welfare.
Good amount of information is available in Tamil Literature and Tamil medicine •
on symptoms, clinical course and outcome of it. Infact the descriptions are
better than what is available today. Their knowledge on types of snakes and
scorpions are simply astonishing. This can be used to educate the community
and make them realize the usefulness of modern medical treatment for better
outcome.
Proverbs irrespective of the language help to explain or convey messages within •
and outside a community. Historically collected proverbs of Tamil literature is
displayed as early as 5 A.D. one each under one poem of “Pathinen keezh
kanakku Nool”. Tamil being an advanced language with high level of grammer,
it has given criteria / guidelines for poems and proverbs and these are made
available in Tholkappiam (poem 177) and Agananooru (poem No.101: 2 – 2
and 66 : 5-6)
Most of the proverbs are thought provoking, contain rich information and are •
unique to the language. Also, these proverbs help to transfer relevant facts with
beauty and brevity between the speaker and the audience or readers. Moreover
poems and proverbs act as a bridge between health care professional and the
patients or the public to convey health messages convincingly, clearly, and
confidentially within few minutes.
When a speaker uses an apt poem or proverb or both to convey a message to •
the community, their understanding is greater, ability to accept is better and
the capacity to transfer the message in real life is superior. Keeping all these
in mind efforts are made to bring / provide Tamil proverbs and certain aspects
of Tamil medical practices in relation to snake bite and scorpion sting is given
below.
The health care professions involved in patient care and community education •
programme are informed to make use of the information provided. When the
professionals use the literary phrases / poems available in their own language,
community acceptance the greater. Hence changes will occur which can be
measured quantitatively. Health care providers can make use of the proverbs
and collect more proverbs and poems related to snakebite and scorpion sting,
and forward to us which will be of great use to subsequent editions.
Treatment Guidelines for Snakebite and Scorpion sting
102 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Tamil proverbs related to Snake bite and Scorpion sting
ešthœÎ fšéæš fyªJiuahl gh«ò k‰W« njŸ r«gªj¥g£l
gHbkhêfŸ
1. mut¤ij f©lhš Ñç éLkh? (mšyJ) muit¡f©lhš Ñç éLkh?
2. Ïo nf£l ehf« nghy
3. Ïiu ‹w gh«ò nghy
4. fUlid¡ f©l gh«ò nghy
5. fiwah‹ ò‰W gh«ò¡F cjλwJ
6. fiwah‹ ò‰bwL¡f¡ fUehf« FoòFªjJ nghy
7. fiwah‹ ò‰¿š mut« Fobfh©lJ nghy
8. vè ÏU¡»w Ïl¤Âš gh«ò ÏU¡F«
9. gl« vL¤jhš jh‹ gh«ò
10. gukÁt‹ fG¤ÂèU¡F« gh«ò nghy
11. fhiy R‰¿a gh«ò fo¡fhkš élhJ
12. gh«Ã‹ fhš gh«g¿Í«
13. gh«ÃY«, gh«ò F£o¡F éõK«, ÅçaK« mÂf«
14. gh«Ã‰F gšèš k£L« jh‹ éõ« Mdhš ghéfS¡F clš KGtJ« éõ«
15. gh«Ã‹ F£o gh«ò, mj‹ F£o e£Lth¡fèah?
16. gh«ò v‹whš gilÍ« eL§F«
17. gh«ò Mæu«, gid Mæu«, gh«Ã‹ fhš Mæu«
18. gh«ò¡F gif fUl‹
19. gh«ò¡F _¥ò Ïšiy
20. gh«ò j‹ gÁia ãid¡F«, njiunah j‹ éÂia ãid¡F«
21. gh«ò §»w CU¡F nghdhš eL¡f©l« ek¡F
22. gh«ò ò‰Wf©L, m§F »zW bt£L
23. gh«ò gif, njhš cwth?
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 103
24. ghé¡F gh«ò f©
25. ghé¡F gh«ò bré
26. é Koªjtid éça‹ fo¡F«
27. éça‹ fo¤jhš é KoÍ«
28. Ñç¡F« gh«ò¡F« Ôuh¥gif
29. ÑçÍ« gh«ò« nghy
30. Ú®¥gh«ò fo¤jhY« Ïurg£o MF«
31. bg£o gh«ghf ml§»dh‹
32. njS¡F kâa« bfhL¤jhš, rhk¤J¡F (bghGJ éoÍ« k£L« ãäl¤J¡F ãäl«)
bfh£L«
33. njS¡F éõ« bfhL¡»ny, gh«ò¡F éõ« gšèny
34. bfh£odhš njŸ, bfh£lhé£lhš ßisó¢Áah?
35. njiu ‹w gh«ò fo¤jhš Ïw¥ò ã¢ra«.
gh£L
f©lJ gh«ò
fo¤jJ fU¡F
‹wJ kUªJ
bfh‹wJ kU¤Jt‹
Treatment Guidelines for Snakebite and Scorpion sting
104 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Annexure XIII: Form to assess the quality of services rendered to snake bite /
scorpion sting for the month of ……….200…/ for the quarter ending March /
June / September / December200........
Name of the Health Centre / Hospital …………………………Code No……….
Sl.
No
Quality of services
Observations /
Problems /
Complaints
Remarks
1.
Clinical matters
Admission •
Assessment & Administration of •
appropriate drugs
Observation on adverse reactions to •
ASV and / other drugs
Lapses in clinical care •
Referral of cases •
Morbidity status for the reporting •
month
Mortality •
Sharing of experiences with others •
Guiding on welfare programme •
Others –specify •
2.
Preventive aspects
Organising awareness programmes •
Reduction in the time interval •
between bite / sting to
hospitalisation
Immobilisation of the victim •
Avoidance of traditional practices •
Any other – specify •
3.
Administrative issues
Availability of medications •
Submission of report to higher •
authorities
Monitoring and review of •
a. Patient care
b. Preventive aspects
Any other – specify •
Name, Designation, Signature, Date and Office seal of Medical Officer
Treatment Guidelines for Snakebite and Scorpion sting - 2008
Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 105
Annexure XIV: Form to analyse and audit the statistics on snake bite /
scorpion sting for the month of ……….200…../ for the quarter ending
March / June / September / December 200…
Name of the Health Centre / Hospital ………………….....Code No……
Name, Designation, Signature, Date and Office seal of Medical Officer
b
1.
2.
3.
4.
5.
6.
7.
8.
9.
.
Treatment Guidelines for Snakebite and Scorpion sting
106 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.
Annexure XV: Useful Websites:
http:// • www.globalcrisis.info/poisonandvenomemergency.html
http:// • www.whosea.org/bct/snake/5htm
http:// • www.whosea.org/bct/snake/2introB.htm
http://www • .whosea.org/bct/snake/5f.html
http://www.fda.gov/Fdac/features/995_snakes.htm • l
http://www.emedicine.com/MED/topic2143.ht • m
http://www.emedicinehealth.com/snakebite/article_em.htm •
http://www.lfsru.org/firstaid.ht • m
http://www.healthcentral.com/ency/408/000031.htm • l
http://www.umm.edu/non_trauma/snake.htm •
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Treatment Guidelines for Snakebite and Scorpion sting
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Guidelines
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Treatment Guidelines for Snakebite and Scorpion sting
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Treatment Guidelines for Snakebite and Scorpion sting
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