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Journal of The Association of Physicians of India Vol.

64 August 2016 11

editorial

Management of Snake Bite in India


Shibendu Ghosh1, Prabuddha Mukhopadhyay2, Tanmoy Chatterjee3

Introduction Tarakeswar, Hooghly, West Bengal, Traditional remedies have NO


SRIHospitals, Betai, Nadia, West PROVEN benefit in treating

I ndia is a country known to


t h e we s t e r n p o p u l a t i o n a s a
country of snake charmersand
Bengal since 1987.

First Aid Treatment


snakebite.
T= Tell the Doctor of any systemic
symptoms that manifest on the way
s n a k e o ve r c e n t u r i e s . D e s p i t e Protocol of hospital.
generation after generations some
Much of the first aid currently Do not waste time for doing the
families in our country who play
c a r r i e d o u t i s i n e f f e c t i ve a n d first aid management.
with snakes(snake charmers), we
fail to protect the community from dangerous (Simpson, 2006). This method will get the victim
snake bite which requires atleast Recommended Method for India to the hospital quickly, without
education of the common people, recourse to traditional medical
Modified by our team in West
how to protect themselves from approaches which can dangerously
Bengal
snake bite as well as what to do delay effective treatment (Sharma et
after the bite has occurred. The The first aid being currently al, 2004), and will supply the doctor
estimated death in India is 50,000/ recommended is based around the with the best possible information
yr, an underestimate because mnemonic. on arrival.
of lack of proper registration C A R R Y N O R . I . G . H . T. I t Traditional Methods to Be
of snakebite. The persons or consists of the following: Discarded
population at risk of snakebite in CARRY = Do not allow victim to Diagnosis Phase
our country is around 50 million walk even for a short distance; just General assessment -> Depending
people which may occur any time carry him in any form, specially upon type of symptoms (Table 1).
in the life. There are large number when bite is at leg.
of conflicting protocolsfor dealing In addition some of the krait bite
No- Tourniquate (Shochoureki) doesnot respond
with first aid and treatment. In
2004,WHO established a snakebite No- Electrotherapy to ASV of Indian origin. In our
Treatment Group,whose role was to No- Cutting study none of the Russells Viper
develop recommendations toreduce presented with neurotoxicity.
No- Pressure immobilization
mortality according to international Diagnosis Phase: investigations
Nitric oxide donor (Nitrogesic
norms.A primary recommendation 20 Minute Whole Biood Clotting Test
ointment/ Nitrate Spray)
was to establish asingle protocol for (20WBCT)
both first-aid and treatmentwhich R.= Reassure the patient. 70%
of all snakebites are from non- Considered the most reliable
contained evidence based test of coagulation and shouldbe
procedures and was relevant to venomous species. Only 50% of
bites by venomous species actually carried out at the bedside by treating
the Indian context. In July 2006, physician. It can also be carried out
A National Snakebite Conference envenomate the patient
in the most basic settings.
was convened,including Indian and I = Immobilize in the same
International experts. Moreover way as a f r a c t u r e d limb. Use A few mililiter of fresh venous
publications issued by the WHO bandagesor cloth to hold the blood is placed in a new, clean and
RegionalOffice for South-East splints, not to block the blood dry, glass vessel and left at ambient
Asia, written and edited byDavid supply or apply pressure. Do not temperature for 20 minutes. The
A.Warrell in the year 2015 and apply any compression in the form vessel ideally should be a small glass
enduringefforts of the scientist and of tight ligatures, they dont work test tube. The use of plastic bottles,
doctors working indifferent regions and can be dangerous! tubes or syringes will give false,
of India is the back bone of this readings and should not be used.
GH= Get to Hospital Immediately.
Editorial.We have treated about The glass vessel should be left
10000 cases of snake bitepatients
in Medical College Hospitals, 1
Associate Professor, Department of Medicine, RIMS, Raipur, Chattisgarh; 2Assistant Professor, 3Associate
K o l k a t a , Ta r a k e s w e r R u r a l Professor, Vivekananda Institute of Medical Sciences, Kolkata, West Bengal
Hospitals andSeba NursingHome,
12 Journal of The Association of Physicians of India Vol. 64 August 2016

Table 1: Clinical features Severe Current Local envenoming


Feature Cobra Kraits Russells viper Saw-scaled Humped-nose Severe current, local swelling
viper viper involving more than half of the
Local pain/tissue damage Yes No Yes Yes Yes bitten limb (in the absence of a
Ptosis, neurological sign Yes Yes No* No No tourniquet). In the case of severe
Hemostatic abnormality No May occour Yes Yes Yes swelling after bites on the digits
Renal complication No No Yes No Yes (toes and especially fingers)
Response to neostigmine Yes No No No after a bite from a known
Response to ASV Yes Yes Yes Yes No necrotic species.
undisturbed for 20 minutes and then be available. Rapid extension of swelling
gently tilted, not shaken. If the blood In India polyvalent ASV is only (for example beyond the waist
is still liquid then the patient has available, It is effective against all or ankle within a few hours
incoagulable blood. The must not the four common species; Russells of bites on the hands or feet).
be washed with detergent as this viper (Daboiarusselii), Common Swelling a number of hours old
will inhibit the contact element of Cobra (raja naja), Common Krait is not grounds for giving ASV.
the clotting mechanism. The test (Bungaruscaeruleus) and Saw Scaled Purely local swelling, even
should be carried out every. 30 viper (Echiscarinatus). if accompanied by bite mark
minutes from admission for three from an apparently venomous
There are known species
hours and then hourlyafter that. If snake, is not grounds for
such as the Hump-nosed
incoagulable blood is discovered, the administering ASV.
pitviper(Hypnalehypnale) where
6 hourly cycleis then be adopted to ASV Administration
polyvalent ASV is known to be
test for the requirement for repeat
i n e f f e c t i ve . I n a d d i t i o n , t h e r e Total required dose will be
doses of ASV.
are regionally specific species between 10 vials to 30 vials usually,
Management of Snake bite in general such as Sochureks Saw Scaled as each vial neutralizes 6mg of
Pain Viper (Echiscarinatussochureki) Russells Viper venom. Not all
Snakebite can often cause severe in Rajasthan, and Kalach in West victims will require 10 vials as
pain at the bite site; This can be Bengal where the effectiveness some may be injected with less than
treated with painkillers such as of polyvalent ASV may be 63mg. However, starting with 10
paracetamol. questionable. These species should vials ensures that there is sufficient
Handling Tourniquets be detected first and special neutralizingpower to neutralize the
measures to be taken for these bites. average amount of venom injected
Care must be taken when
ASV Administration Criteria and during the next 12 hours to
removing tight tourniquets which
ASV is a scarce, costly commodity neutralize any remaining free
most of the time used. Sudden
and should only be administered flowing venom, even in the large
removal can lead to a massive surge
when there are definite signs study from south India, the amount
of venom leading to neurological
of envenomation. Unbound, of ASV exceeded 50 vials in some
paralysis, h y p o t e n s i o n d u e t o
f r e e f l o w i n g ve n o m , c a n o n l y patients. So decision of the treating
vasodilatation etc.
be neutralised when it is in the physician is of utmost importance,
B e f o r e r e m o v a l o f t h e because the guidelines may not be
tourniquet, test for the bloodstream or tissue fluid. In
addition, Anti-Snake Venom carries useful for all patients.
presence of a pulse distal to
risks of anaphylactic reactions N o A sv t e s t d o s e m u s t b e
the tourniquet. If the pulse
and should not therefore be used administered
is absent ensure a doctor is
present before removal. unnecessarily. Test doses have been shown to
Systemic Envenoming have no predictive value in detecting
Be prepared to handle the
E v i d e n c e o f c o a g u l o p a t h y : anaphylactic or late serum reactions
complications such as sudden
Primarily detected by 20WBCT and should not be used (Warren et
respiratory distress or
or visible spontaneous systemic al 1999). These reactions are not
hypotension. If the tourniquet
bleeding. IgE mediated but Complement
has occluded the distal pulse,
a c t i va t e d , T h e y m a y a l s o p r e -
then a blood p r e s s u r e c u f f Evidence of neurotoxicity: ptosis,
sensitize the patient and thereby
can be applied to reduce the external ophthalmoplegia,
create greater risk.
pressure slowly. muscle paralysis, inability to
lift the head etc. ASV is Recommended to be
Anti Snake Venom (ASV)
Administered in the Following Initial
After assessing patient whenever Cardiovascular abnormalities: Dose
decision is taken for giving ASV, hypotension, shock,cardiac
Neurotoxic/ Anti Haemostatic 10 Vials
start ASV whatever dose is available arrhythmia, abnormal ECG.
in hand, do not wait for full dose to N.B. Children and pregnant
Persistent and severe vomiting
women receive the same ASV dosage
or abdominal pain.
Journal of The Association of Physicians of India Vol. 64 August 2016 13

as adults. The ASV is targeted at final occasion but in the vast of ASV should continue on a 6 hourly
neutralizing the venom. Snakes majority of reactions, 2 doses of pattern until coagulation is restored
inject the same amount of venom adrenaline will be sufficient in or unless a species is identified as
into adults and children. children. one against whichpolyvalent ASV
ASV can be Administered in Two Ways If there is hypotension or is not effective.
Infusion: liquid or reconstituted hemodynamic instability, IV The repeat dose should be 10 vials
ASV in isotonic saline or fluids should be given. of ASV i.e. one full dose of the original
glucose, may be started without Once the patient has recovered, the amount. The most logical approach
any diluent fluid in volume ASV can be restarted slowly for 10-15 is to administer the same dose again,
overload patients. minutes, keeping the patient under as was administered initially. Some
close observation. Then the normal drip Indian doctors however, argue that
All ASV to be administered
rate should be resumed. since the amount of unbound venom
o ve r 1 h o u r a t c o n s t a n t s p e e d .
is declining, due to its continued
Local administration of ASV, near Late Serum sickness reactions can be
binding to tissue, and due to the
the bite site, has been proven to easily treated with an oral steroid such
wish to conserve scarce supplies
be ineffective, painful and raises as prednisolone, adults 5mg 6 hourly,
of ASV, there may be a case for
the intracompartmental pressure, paediatric dose 0.7mg/kg/day. Oral
administering a smaller second dose.
particularly in the digits, it should Antihistaminic provide additional
In the absence of good trial evidence
not be used . symptomatic relief.
to determine the objective position,
Snakebite in Pregnancy Neurotxic Envenomation a range of vials in the second dose
Pregnant women are treated in Neostigmine is an has been adopted.
exactly the same way as other victims. anticholinesterase that prolongs Repeat Dose: Haematotoxic
The same dosage of ASV is given. the life of acetylcholine and can
The normal guidelines are to
The victim should be referred to a therefore reverse respiratory
administer ASV every 6 hours until
gynecologist for assessment of any failure and neurotoxic symptoms.
coagulation has been restored.
impact on the foetus. It is particularly effective for post
However, what should the clinician
ASV Reactions synaptic neurotoxins such as those
do after say, 30 vials have been
Anaphylaxis can be rapid onset of the Cobra (Watt et al, 1986).
administered and the coagulation
and can deteriorate into a life- In the case of neurotoxic abnormality persists. A large study
threatening emergency very rapidly. envenomation where edrophonium recently done from south India
A d r e n a l i n e s h o u l d a l wa y s b e is not available Neostigmine Test ( K e r a l a ) s h o we d t h a t u p t o 5 0
immediately available. can bedone. The neostigmine dose vials (500 ml) has been given for
The patient should be monitored is 0.04 mg/kg IV and atropine/ Haemotoxic poisoning.
closely (Peshin et al, 1997) and glycopyrolate may be given by
It has been established that
at the first sign of any of the continuous infusion.
envenomation by the Hump-
following: The patient should be closely nosed Pitviper(Hypnalehypnale)
Urticaria, itching, fever, chills, observed for l hour to determine if does not respond to normal ASV.
nausea, vomiting, diarrhea, the neostigmine is effective. This may be a cause as, in the
abdominal cramps, tachycardia, Repeat Doses: Anti Haemostatic case of Hypnale, coagulopathy
hypotension, bronchospasm and In case of anti haemostatic can continue for up to 3 weeks.
angio-oedema envenomation, the ASV strategy Surgical Intervention
ASV to be discontinued will be based around a six hour time Whilst there is undoubtedly a
period. When the initial blood test place for a surgical debridement
Children are given 0.01mg/kg
reveals a coagulation abnormality, of necrotic tissue, the use of
body weight of adrenaline iv.
the initial ASV amount will be fasciotomy is highly questionable.
In elderly noradrenalin and given over 1 hour. The appearance of (Joseph, 2003):
nitroglycerin infusion when
No additional ASV will be given Fasciotomy is required if the
hypotension is corrected can
u n t i l t h e n e x t C l o t t i n g Te s t i s intracompartmental pressure is
be given to avoid adrenalin
carried out. This is due to the sufficiently high to cause blood
induced arrhythmia which is
inability of the liver to replace vessels to collapse and lead to
common in elderly.
clotting factors in under 6 hrs. ischemia.Now a days we are using
If after 10 to 15 minutes the
After 6 hours a further coagulation multiple puncture technique using
patients condition has not
test should be performed and a large bore needle.
improved or is worsening,
further dose should be administered What is important is that the
A second dose of 0.5 mg of in the event of continued coagulation intracompartmental pressure
adrenalin 1:1000 iv is given. This defect and in that case ASV to be given should be measured objectively
can be repeated for a third and over 1 hr. CT tests and repeat doses using saline manometers or newer
14 Journal of The Association of Physicians of India Vol. 64 August 2016

specialised equipment such as the snake bite pose an important can be avoided. Most of the patients
Stryker Intracompartmental Pressure problem for transportation from a r e c o n s c i o u s t h o u g h t h e y r e
Monitoring Equipment. the site of bite to the hospital. A speechless and if theres no upper
Renal Failure in Snakebite well designed study from PGI airways paralysis, nasopharyngeal
Chandigarh shows that just putting (may be modified one) along with
The acute renal failure which
an airway tube and an AMBU bag non-invasive ventilation is a better
occurs due to snake bite are
decrease the morbidity to a great choice. However, if early intubation
multifactorial 1) Severe and
ex ten t. Mechanical vent ilat ion and early weaning principle is
persistent hypotension leading to
to be avoided as far as possible, m a i n t a i n e d , t h e n VA P c a n b e
acute tubular necrosis, 2) Hb and
as because most of the death in minimised, which may be the major
other cellular parts of RBC and others
ventilated snake bite patient is cause of mortality and morbidity
(myoglobin and rhabdomylysis 3)
Ventilator associated pneumonia. for altered mentation with or
part of DIC 4)vasculitis 5) acute
Early initiation and early weaning without bulbar paralysis. Theres
diffuse intersticial nephritis^)
from ventilator is the strategy, some physicians who think that
extra capillary proliferative
n o n i n va s i ve ve n t i l a t o r w i t h a ve n t i l a t o r y s u p p o r t s h o u l d b e
glomerulonephritis.
patent upper air way is better op the primary with very little or no
Most of the patients of acute tion. ASV particularly who came late (6
tubular necrosisrecovers by few hours or more), though this is not
Heparin and Botropase: No role
weeks, with the help of occational recommended still today
need of haemodialysis, but who Referral Criteria
develops cortical necrosis requires The primary consideration, in the References
reanal replacement therapy case of neurotoxic bites, is respiratory
on along term basis. It is the failure.Capasity of neck lifting is 1. Simpson ID. Management of Snakebite-
The National, API WB branch. Update in
hyperkalemia rather than elevated good predictor of requirement of
Medicine 2006; 88-93.
Urea, creatinine requires dialysis. ventilator support. Refer suchpatient
2. Narvencar K. Correlation between Timing
The hyperkalemia of snakebite AKI to the center equipped with invasive
of ASV Administration and Complication
is a hypermetabolichyperkalemia, ventilation. in Snake Bite. J Assoc Physicians India 2006;
which may kill the patient within In this issue of JAPI a study 54:717-719.
few minutes and Calcium gluconate from south India 9 involving more 3. Gudilines for the Clinical Management
and glucose insulin is mostly than 1000 patients has thrown of Snake Bites in South- East Asia Region
ineffective.Early urgent adequate light in the controversies in Written and edited by David AWarrell
treatment with ASV can reverse the m anag ement of snak e b it e published by WHO, 2005.
the whole process of deterioration victims. The study shows that early 4. Srimannaryan J, Dutta TK, Sahai Aet al.
of renal function which is far from diagnosis of envenomation by way Rational Use of Anti-Snake Venom(ASV):
our expectation in our country. Trial of Various Regimens in Hemotoxic
of clinical (history, bleeding and snake Envenomation. J Assoc Physicians
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complication of Russells Viper w i t h P T, A P T T a n d o b v i o u s l y 5. B awa s k a r H S . S n a k e Ve n o m s a n d
and Hump-nosed Pitviper bites WBCT and early institution Antivenoms: Critical Supply Issues. J Assoc
(Tin-Nu-Swe et a1,1993, Joseph et of anti-snake venom in adequate Physicians India 2004; 52:11-13.
al, 2006). The contributory factors dose,can reduce the development 6. Paul V, Pratibha S, Prahaald KA, et al.
a r e i n t r a va s c u l a r h a e m o l y s i s , of SAKI (snake bite induced acute High-Dose Anti- Snake Venom Versus Low-
DIC, direct nephrotoxicity and kidney injury).The study also used Dose Anti Snake Venom in the treatment
hypotension (Chugh et a1, 1975) ASV more than 50 vials or 500 ml of Poisonous Snake Bites- A Critical Study.
and rhabdomyolysis. (maximum) for haematological J Assoc Physicians India 2004; 52:14-17.

Renal damage can develop very and 30 vials for neurotoxic 7. Indian National snake bite Protocol 2008

early in cases of Russells Viper bite poisoning (maximum) and which 8. Guideline for management of snake bite in
and even when the patient arrives I fully endorse from my personal south east Asia countries by David Warrel

at hospital soon after the bite, the experience. 9. Menon JC, Joseph JK, Jose MP, et al. Clinical
Profile and Laboratory Parameters in 1051
damage may already have been Another study from North
Victims of Snakebite from a Single Centre in
done. Studies have shown that India 10 in this issue of JAPI has Kerala, South India. J Assoc Physicians India
even when ASV is administered shown that usual or low dose ASV 2016; 63:22-29.
within 1-2 hours after the bite, it (100 ml of two doses) is sufficient 10. Pandey PC, Bajaj S, Srivastava A. A Clinico-
was incapable of preventing ARF along with early ventilatory Epidemiological Profile of Neuroparalytic
(Myint-Iewin et al, 1985). support. However, I personally Snake Bite: Using Low Dose ASV in a
Neurological Manifestation in think that if invasive ventilation Tertiary Care Centre from North India. J
Snakebite can be avoided, incidence of Assoc Physicians India 2016; 63:16-20.

Neurological manifestation of ventilator-associated pneumonia

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