EMERGENCY

APPROACH FOR
SNAKE BITES
 What Are We Going To Cover Today????

1. What are the two main toxins and the bed

side tests to differentiate between the two?
2. How do you classify a snake bite?
3. What is the first-aid to be given when a
snake bites?
4. How quickly should medical attention be
given for a snake bite person?
5. What is the medical treatment and how is it
carried out?
6. How do you recognize a severe snake bite?
7. How do you avoid a snake bite?
• Remember, 70% of all snake bites are Non-
Venomous & 50% of Venomous bites are Dry
Bites.
• Snake bites can be classified into Poisonous &
Non-Poisonous Bites.
• Poisonous- Russell's Viper, Saw Scaled Viper,
Cobra & Krait.
• Non-Poisonous- Sand Boa, Red Boa, Rat Snake,
Checkered Back Water Snake, Tree Snake,
Bronze Back Tree Snake, Python, etc.
• Haematotoxic & Neurotoxic.
• Haematotoxic- Clotting Factors.
• Neurotoxic- Nervous System.
SAND BOA
Red Sand Boa
CHECKERED BACK WATER SNAKE
RAT SNAKE
KRAIT
RUSSELL’S VIPER
COBRA
What Snake Is This???
SAW SCALED RUSSELL’S VIPER
VIPER

KRAIT
 Biting Apparatus

Viper Phangs Cobra Phangs

 Characteristics Of Bite Marks

1. Saw Scaled Viper- Phang marks present

with blood clots. No active bleeding
seen.
2. Russell’s Viper- Active bleeding from
phang marks.
3. Cobra- Phang marks present with local
tissue destruction.
4. Krait- Phang marks absent and local
tissue destruction usually sets in very
late.
 First-Aid
 Do It “R.I.G.H.T”
 R- Reassurance.
 I- Immobilization.
 G&H- Go to Hospital. Ideally, within 4hrs.
 T- Tell the doctor what you have seen.

You do not do more than this and neither are you

expected to do more than this in the field!!!!!
 Treatment Protocol

 Patient Assessment Phase: On Arrival

1. ABC.
2. Evidence of a bite.

 Diagnosis Phase:
1. If possible identify the snake.
2. Observation for 24hrs.
3. Use of any traditional medicines.
4. Exact time of bite.

 Pain:
1. No! No! No! - NSAIDs & Aspirin.
2. Yes! Yes! Yes! – Tramadol & Paracetamol.
• Diagnosis Phase- Investigations
1. 20WBCT- Every 30min for 3hrs and then hourly after that
for 24hrs. If incoagulable blood is found, then the test is
performed 6hrly to check the need of ASV.
2. Hb, Plat., PT, APTT, D-Dimer
3. Urine- Proteinuria, Hemoglobinuria, Myoglobinuria, RBC.
4. Biochemistry- Urea, Creatinine and Potassium.
5. Vitals- BP,RR,PR & Oxygen Saturations.

• Diagnosis Phase- Symptoms

 RUSSELLS
COBRA KRAIT
FEATURES
SAW
VIPER SCALED
VIPER

Local Pain and Tissue Damage YES NO YES YES

Ptosis / Neurological Signs YES YES YES NO

Hemostatic Abnormalities NO NO YES YES

Renal Complications NO NO YES NO

Response to ASV YES YES YES YES

 General Signs & Symptoms Of Viperine
Envenomation
1. Swelling and local pain.
2. Tender enlargement of local L/N.
3. Bleeding.
4. Epistaxis.
5. Vomiting
6. Acute abdomen- GI / Retroperitoneal Bleeding.
7. Hypotension- Hypovolemic / Vasodilation.
8. Low back pain- Renal damage / Retroperitoneal Bleed.
9. Skin & Mucous Membrane- Petechiae, purpura &
ecchymosis.
10. Urine- Color / Out-Put
11. Lateralizing neurological symptoms and asymmetrical
pupils- Intracranial bleed.
12. Muscle pain- Rhabdomyolysis.
 General Signs & Symptoms Of
Elapid Envenomation.

1. Swelling and local pain- Cobra.

2. Local necrosis / Blistering- Cobra.
3. Descending Paralysis.
4. Hypoxia due to inadequate ventilation can
cause cyanosis, altered sensorium and coma.
5. Stomach pain which may suggest sub
mucosal hemorrhage in the stomach- Krait.
6. Krait bites often present in the early morning
with paralysis that can be mistaken for a
stroke.
PHYSIOLOGY BRUSH UP
PHYSIOLOGY BRUSH UP
 Local Signs Of Envenoming

Blistering & Early Necrosis after a Cobra Persistent Local Bleeding from
Bite Fang Marks of a Viper Bite

Fang Marks Without Bleeding

Blistering & Early Necrosis after a Cobra Characteristic of a Saw Scaled
Bite Viper
Ptosis Due to Neurotoxins & Conjunctival
Edema Due to Hemototoxins

Bilateral Conjunctival
Oedema
External Ophthalmoplegia with Bilateral
Ptosis

Subconjunctival Haemorrhages Bilateral Ptosis

 Bleeding & Clotting Disorders

Hemoptysis from TB Lung Cerebral Haemorrhage

Cavity

Cutaneous Discoid
Bleeding from Gingival Sulci Haemorrhages
Swelling, Blistering & Bruising Myoglobinuria

Following a Viper Bite

Viper Bite Cobra Bite

Tissue Necrosis Requiring Surgical Debridement
Chronic Physical Handicap Resulting from Necrotic Envenoming of a Viper Bite

Deformity & Dysfunction at the

Squamous Cell Carcinoma over
Bite Site with subsequent Calf
the Site of Chronic Skin Ulcer
Necrosis

Panhypopituitarism 3yrs after Severe Envenoming by a Russell's Viper. Secondary

to Haemorrhagic Infarction of the Anterior Pituitary Resulting in Sheehans- Like
Syndrome.
 Medical Management Of Snake Bite
 Non-Poisonous Snakes:
1. Wash the puncture site thoroughly with soap and water.
2. Take a Tetanus Shot.
3. Apply an Antiseptic Ointment.
4. If necessary, oral Antibiotics for 5 days.

 Poisonous Snakes:
1. Monovalent ASV.
2. Polyvalent ASV.

 Types Of ASV
1. Liquid ASV- Refrigeration required.
2. Lyophilized ASV- Refrigeration not required.
 ASV Administration Criteria
 Systemic Envenoming:
1. Evidence of Coagulopathy- 20WBCT / Spontaneous visible systemic
bleeding. Hb, Thrombocyte count & peripheral smear can also help
confirm.
2. Evidence of Neurotoxicity- Descending type- Ptosis, Ophthalmoplegia,
Muscle paralysis, Unable to lift head, etc.
3. Cardiovascular Abnormalities- Hypotension, Shock, Cardiac
Arrhythmia.
4. Persistent and severe vomiting or Abdominal pain.

 Local Envenoming:
1. Severe & locally spreading swelling from the bite site, involving more
than half of the involved limb. Development of blister.
2. Swelling present for a number of hours without local extension is not an
indication.
3. If swelling spreads 1hr after the removal of a tourniquet, is an
indication.
 Prevention Of ASV Reaction:
Prophylactic Regimes

 Two Regimes:
1. Inj. Hydrocortisone 100mg + Inj. Avil 22.5mg (Adults)
Inj. Hydrocortisone 2mg/kg + Inj. Avil 0.1- 0.3mg/kg
OR
2. Inj. Adrenaline 0.25-0.3mg s/c (1:1000 dilution)
 ASV Administration: Dosage
 A snake bite usually injects approximately around 60mg of Venom.
Each ASV Vial has the capability to neutralize around 6mg of Venom.
 Approx. around 10-25 vials are required, since the range of venom
injected is around 5mg-147mg.
 Usually 8-10 vials are more than sufficient to neutralize an average
bite.
 Adults and Children receive the same dose. ANY IDEA WHY????
 Infusion- Reconstituted ASV is diluted in 5-10ml/kg of NS / Glucose
and infused over 1hr.
 Pregnant women are given the same dosage.
 Victims who come after few days with renal failure, perform
20WBCT. If coagulopathy present, give ASV. If not present, Renal
Failure to be treated with Dialysis. If present with Neurotoxicity, it is
wise to administer 8-10vials of ASV. At this stage, it is likely that all
the venom is bound and either respiratory support or normal
recovery will be the out come.
 ASV Reaction:
1. Stop the infusion immediately.
2. Administer 0.5mg Adrenaline IM. Children-
0.01mg/kg IM.
3. In order to provide long term protection from
anaphylactoid reaction, Hydrocortisone & Avil
are administered.
4. If after 10-15min symptoms don’t come down,
another dose of Adrenaline is given to a max of 3
doses.
 Repeat Doses: Anti Haemostatic
 After the first dose, a 20WBCT is performed after 6hrs. If it
shows coagulopathy, repeat an other 5-10vials infusion for 1hr.
 20WBCT should be repeated after the 2nd infusion after waiting
for another 6hrs. Why waiting for 6hrs?????
 A max. of 30 vials could be required to neutralize
Haematotoxic Venom.

Repeat Doses: Neurotoxic

• If the persons condition deteriorates after the initial dose, a
second dose should be administered after 1-2hrs.
• A max. of 2 doses containing of 20 vials should be given.
Anything more than that is of no use.
• Once the patient is in respiratory failure, has received 20vials
and on ventilator support, further ASV therapy should be
stopped. The idea behind this is, all the circulating venom has
been neutralized by this stage and the body has to recover by
itself.
 Additional Treatment for Neurotoxic Envenomation
 Inj. Neostigmine can be used.
 It’s an Anticholinesterase, that prolongs the life of Ach at the Neuromuscular Junction.

 It’s especially useful in Cobra Bites, since it’s a post-synaptic neurotoxin.

 A “NEOSTIGMINE TEST” is administered. Observed for 1hr.

Inj. Neostigmine 1.5-2.0mg IM + Inj. Atropine 0.6mg IV

Inj. Neostigmine 0.04mg/kg IM + Inj. Atropine 0.05mg/kg IV (Pediatrics)
 Objective methods to assess the effect of the TEST:

1.Single breath count.

2.Mm of iris uncovered.

3.Inter incisor distance. Recorded every 10min

4.Length of time upper gaze can be maintained.

5.FEV1.
 Average blood plasma levels of Neostigmine is around 20min. So improvements should be seen

within 30min
 If improvements are seen, Neostigmine 0.5mg IM every 30min+Atropine

0.6mg IV over 8hrs. If no improvement in 1hr, stop the treatment.

 Other Complications &
Management
1. HYPOTENSION:
 Start Crystalloid infusion.
 No response, then start Noradrenaline infusion @ 0.1-1mcg/kg/min.
2. RENAL FAILURE & ASV:
 Renal failure can start very early in Russell’s Viper bite. Even if ASV
was administered within 1-2hrs, there are incidences which have lead
to renal failure.
 Management is Hemodialysis.
 Indications for renal failure:
1. Decreased or no urine output.
2. S. Creatinine more the 5mg/dl.
3. Urea more than 200mg/dl.
4. Potassium more than 5.6mmol/l
5. Metabolic Acidosis.
 Surgical Intervention
 Surgical intervention does not reduce the venom!!
 Fasciotomy is done if the intracompartmental pressure is
sufficiently high to cause blood vessels to collapse and
ischemia to set in.
 Criteria for increased intracompartmental pressure are:
1. Pain on passive stretching.
2. Pain out of proportion.
3. Absence of pulse.
4. Pallor.
5. Parasthesia
6. Paralysis.
7. Intracompartmental pressure > 40mmHg.
 How Do You Recognize A
Severe Snake Bite

1. Snake identified is a very venomous

one?
2. Rapid early extension of local swelling
from the bite site.
3. Early enlargement of L/N.
4. Early systemic symptoms.
5. Early spontaneous bleeding.
6. Passage of dark brown urine.
THANK YOU ALL FOR YOUR
PATIENCE.

ANY QEUSTIONS?????