SECTION I: SNAKEBITE Titles

General: Introduction Snakes and snake bites: Epidemiology Ecological aspects Socio cultural aspects of snakes and snake bites Statistics on snakebites and ASV usage in Tamil Nadu Classification of snakes World snakes of Medical Importance Tamilnadu snakes of Medical Importance-Distinguishing features Clinical aspects of snake bite: Pathophysiology Symptoms and signs. Criteria for diagnosis Complications and outcome Investigations. Treatment: Principles involved in the treatment First aid for snake bite Traditional methods followed for treating snake bite. Newer methods- pressure pad or Monash technique. Pharmacological aspects of Anti snake venom ASV Administration- criteria ASV Administration- dosage Facts to be remember before/ while using Inj.ASV ASV reactions Prevention of ASV reaction prophylactic regimens Repeat doses: Neurotoxic Recovery phase Repeat doses: Anti haemostatic ASV risk and wastage Other supportive measures Clinical issues in snakebite 1. Hypotension
2. 3. 4.

Page

Persistent bleeding Renal failure Surgical issues

1

5.

Heparin and botropase

Snake Bite in special situations Victims requiring life saving surgery Victims arriving late Snake bites Again Pregnancy and lactating women. Others Management at PHC and Block PHC Referral aspects Welfare measures Occupational risk for snakebite Preventive measures and health education. References

SECTION I: SNAKEBITES
GENERAL: Introduction: Snake bites contribute to health problem in India and continue to be a major medical concern. In India approximately every minute one person is bitten by a Snake and every two hours one case of snakebite dies. As the facts are alarming, one has to take active steps. Actually an up-to-date National data, on the morbidity and mortality due to snakebite and the related are not available. The available statistics is incomplete and not systemically collected. In 1972, Dr. Sawai and Dr. Homma of the Japan Snake Institute selected about 10 hospitals in India and estimated the number of snake bite cases treated at the hospitals, and how many died there. They also estimated number of cases died outside the hospitals. But this of course could only be conjecture. The report concluded that about 10 per cent of deaths are of the victims who come to the hospital and about 90 per cent die outside, having gone for other remedies like mantra, magic, and so on. However things are very different now in different places after 35 years. An international expert on snakebite, the late Dr. Alistair Reid of the Liverpool School of Tropical Medicine found out that only 10 to 15 per cent of venomous bites end in death. The possibility of survival, even without treatment, is incredibly good in 80 to 90% of cases. There are many reasons for this. One is that many snakebites are by non-venomous snakes. Second, a large percentage of venomous snakebites are dry bites. That means, the snake does not always inject venom. Sometimes, it might inject only a tiny bit of venom. The snake can inject the quantity of venom it wants. This is an entirely voluntary process. Hence, you never know how much venom was injected into you except by the progress of the symptoms. In other words the success rate of recovery in snakebite without even treatment is greater. Every traditional healer to his / her advantage propagates his/ her own method to treat snakebite viz., herbal, "snakestone" or mantra, or plain soda water and most villagers would be happy to go to him.

Also, every one should remember that 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 another 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. 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 . Hence, the primary importance is the need to recommend the most effective first aid to the victims bitten by snakes.

It is gratifying to note that the traditional snake catcher in Tamil Nadu, the Irulas with their own sophisticated herbal medicine system, have now understood the position. They know that the snake injects venom which goes deep into the system and this can be neutralised only by injection Anti snake venom (ASV) and not by oral or locally applied remedies, no matter how famous. On an average, Government hospitals spends 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 in National Economy. So, there is an urgent need to take effective steps to contain these issues. Poisoning due to cobra and viper group are seen frequently in the state of Tamil Nadu. Very rarely sea snakebite cases are reported. Hence, in this hand book the focus has been made for the former two. Though the specific antidote is not available for sea snake, the same general principles for other snakebites are applicable here too.

Snakes and Snakebites: Epidemiology:

In India nearly over 4,00,000 persons are bitten by snakes per year. Envenomation happens approximately 82,000 and death occurs in 11,000 4

victims. Many deaths happen before the victim reachs the hospital. Snakebite is observed all over the country with a rural, urban ratio of 9:1, and more during monsoon and post monsoon season. Snakebites are seen often among agricultural workers than those going to the forest. Many of the susceptible populations are poor and living below poverty line. They live in rural areas with less access to health care. The ratio between male to female among the victims is approximately 3:2. Majority are young and their age is around 25 to 44 years. Majority of the bites (90 to 95%) are noticed on the extremities (limbs). The hospital stay vary from 2 to 30 days, with the median being 4 days. The inhospital mortality vary from 5 to 10% and the causes are acute renal failure, respiratory failure, sepsis, bleeding and others.

Ecological aspects:
By destroying forests and by 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 abnormal when compared to the natural population in the forest. Humans going into the field every morning and coming 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 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 bush 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.

Socio-cultural aspects of snakes and snakebites:

5

In various religious system snakes have been described

under different

circumstances. 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 Maharastra and Goa the live snakes, rarely live cobras are brought for worship. Snake charmers carry snakes, cobra especially door to door for worship. At every house the snake's mouth is forced to open and some milk is poured down in its throat. Milk is not snake food. It is also believed that believe that snake bites people who harmed them in their previous birth. When snakes are killed people offer special prayers and bury them. People also 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 the non- scientific ideas on snakes and snakebites and display traditional treatment. Hence health department in a multi sectoral manner has to community. disseminate the scientific

aspects through Information, Education and Communication (IEC) to the

Statistics on snakebites and ASV usage

Government General hospital, Chennai, from January to December 2006 has treated 281 cases of snakebites. Among them, there were 182 males and 99 females. Of the 281, 94 were referred after treatment in different hospitals and 187 were brought to the hospital directly. Numbers survived were 274 (97.5%). Seven expired due to various complications of snakebite while they were in the hospital. The details on the type of snakes, distribution, clinical signs, complications, number referred, provided below (Table no.1). received supportive therapy and death are

Table No.1 : Statistics on clinical aspects of snake bites and outcome * 6

Type of snake

Numbe r treated

Local signs

Neuro Hemo. Toxici Toxicit ty y

Supportiv e

Numb er Expire d Fascioto my. 30 23 1 2 2 1

Mechnical ventilatio n Cobra Krait Russell' s viper Humpnosed viper Saw scaled viper Sea snake Non poisono us 118 82 42 80 42 118 51 82 42 90 60 6

16

16

16

3 16

3 6

* Government General hospital, Chennai (Jan Dec 2006). During 2005- 2006 a total of 19321 snake bite cases were admitted in the secondary care hospitals alone in Tamil Nadu. Out of which 85 persons expired at the hospitals. During 2006-2007 a total of 20677 patients were admitted and 75 persons expired. The total number of ASV vials used in this hospitals during the respective period were 94481 and 96800 respectively (Annexure I). The Government is spending a huge sum of money in procuring and supplying anti snake venom. Deaths due to snakebite can be prevented, if some simple first aid measures are under taken by the public and / or by the health care providers, when they come across snakebite cases. An equal or more number of snake bite cases were admitted and treated at Government Medical College Hospitals. Patients go to private hospitals mostly for first aid purposes. Very few get adequate treatment rarely at private health care. Over all analysis revealed that the snakebites and ASV usage in West, 7

North, East, Central, South zone of Tamil Nadu were 13, 17,24,20,26 and 13% respectively.

Classification of snakes:
There are more than 3000 species of snakes in the world. For the purpose of clinical practice, snakes are classified in to poisonous (venomous) and nonpoisonous (non venomous) snakes. Poisonous snakes are classified under three families and they are
1.

a) Cobra group [Elapidae]

b) Viper group [Viperidae] c) 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, a recent discovery that another species, the hump-nosed pit viper (Hypnale hypnale), is capable of causing lethal envenomation, and that this problem was being concealed by systematic misidentification of this species as the saw-scaled biper, has necessitated a review of the concept of the Big 4. The concept of the Big 4 snakes has failed to include all currently known snakes of medical significance in India, and its negative effects related to clinical management of snakebite and the development of effective snake anti venoms

World Snakes of Medical Importance

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 Four that are inaccurate and mislead doctors and more importantly ASV manufacturers that there are only four medically important species. Table No: 2: Categorisation of snakes (W.H.O. 1981) Class Details I II Commonly cause death or serious disability Uncommonly cause bites but are recorded to cause serious effects (death or local necrosis) Name of the snakes RUSSELLS VIPER/COBRA/SAW SCALED VIPER KRAIT/HUMP-NOSED PIT VIPER/KING COBRA/MOUNTAIN PITVIPER 8

III

Commonly cause bites but serious effects are very uncommon.

Tamil Nadu Snakes of Medical Importance - 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 data is that it concerned complex subjects such a scale counts and the identification of pre or post maxillary teeth which are not definitive and are 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 subject to major variation. What is important therefore is to focus on the key aspects of identification that enable the medical professional to rapidly identify the fact that they are dealing with a venomous species, and what that species might be.

Picture No. 1 Tamil Nadu Snakes of Medical Improtance There are six species of medically important species in Tamil Nadu shown above. Russell's Viper (Daboia russelii) The Russell's Viper is a stout bodied snake, the largest of which grows to approximately 1.8 metres in length. Like all the vipers it is a nocturnal snake, but unfortunately for humans, during the daytime hours 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)

10

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 it its name of Saw Scaled. In addition, there is 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 birds foot. Its venom is anti-haemostatic in nature and attacks the coagulation system. Unlike the Russells Viper, this particular viper does not cause renal failure. The Hump-nosed Pitviper (Hypnale hypnale) The Hump-nosed Pitviper is one of Indias tiniest venomous snakes, its total length ranging from 28.5-55.0cm. 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 it is probably India's most well recognised snake. The hood markings of the spectacle like mark, distinguish this snake from other species, and its habit of rearing up when alarmed make it distinctive but not definitive as other species do this, notably the Trinket Snake. The Cobras coloration is many and varied extending from pale yellow through 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 11

the day it rests up in piles of bricks, rat burrows or other buildings. The Common Krait is India's most toxic snake and its venom is pre-synaptic neurotoxic in nature. There are a number of key identifiers which are worth remembering. The Krait is a black, sometimes with a bluish tinge, snake with a white belly. It 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 Snakes 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 only really useful if the dead snake has been brought to the hospital and is under examinatio 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. Epidemiologically most bites occur among young men who represent India's growing population of snake catchers and try unsuccessfully to capture one.

CLINICAL ASPECTS OF SNAKE BITE:

Pathophysiology: Enormous clinical and experimental works have been published on the pathophysiology of snake bite in relation to different species of snakes earlier. Snake venom is mostly water 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 at different tissues of the body, and are grouped under neurotoxins, nephrotoxins, hemotoxins, cardiotoxins, cytotoxins etc., resulting in organ dysfunction / destruction.

12

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 variable, thus resulting in dissimilar features in different individuals. For example hyaluronidase allows rapid spread of venom through subcutaneous tissues by disrupting mucopolysacharides, and phopholipase A2 has a esterolytic effect on the Red blood cell membrane and cause hemolysis. Also, it promotes muscle necrosis. Thrombogenic enzymes promotes formation of weak fibrin clot, which activates plasmin and results in consumptive coagulopathy and hemorrhagic consequences. Apart from that some venom causes neuromuscular blockade at pre or post synaptic level. Over all, snake venom acts on various parts / system / organs of the body and produces damage if not recognized and supported earlier. In addition to above it causes endothelial cell damage which results in increased vascular permeability.

Symptoms and signs.

The symptoms and signs of Viperine and Elapid envenomation as well as Lateonset envenoming are provided below. General symptoms and signs of Viperine envenomation

Swelling and local pain with or without erythema or discloration at the site of bite Tender enlargement of local lymph nodes as large molecular weight Viper venom molecules enter the system via the lymphatics. Bleeding from the gingival sulci and other orifices. Epistaxis. The skin and mucous membranes may show evidence of petechiae, purpura 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 a early renal failure or retroperitoneal bleeding Muscle pain indicating rhabdomyolysis. Parotid swelling, conjunctival oedema, sub-conjunctival haemorrhage.

General symptoms and signs of Elapid envenomation 13

Swelling and local pain with or without erythema or discloration at the site of bite (Cobra). Local necrosis and/or blistering / bullae(Cobra) . 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 speeking Paralysis of jaw and tongue may lead to upper airway obstruction and aspiration of pooled secretions because of the patients 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 becoming paralysed is a frequent sign. Stomach pain which may sugget submucosal haemorrhages in the stomach (Krait). Krait bites often present in the early morning with paralysis that can be mistaken for a stroke. Eye pain and damage due to ejection of venom in to the eyes by spitting cobra(as observed in Africa)

Late-onset envenoming The patient should be kept under close observation for at leat 24 hours. Many species, particularly the Krait and the Hump-nosed pitviper 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. Juvenile snakes, 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 can also manifest neurotoxic symptoms. This can sometimes cause confusion and further work is necessary to establish how wide this might be. The neurotoxic symptoms in Russells Viper 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

Cobras Krait Russell Saw Hump

14

Feature Local Pain/ Tissue Damage Ptosis/ Neurological Signs Haemostatic abnormalities Renal Complications Response to Neostigmine Response to ASV YES YES NO NO YES YES

s NO YES NO! NO NO? YES

s Viper YES YES! YES YES NO? YES

Scaled Viper YES NO YES NO NO YES

Nosed Viper YES NO YES YES NO NO

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 but 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, regidity , renal failure, hyperkalemia and finally cardiac arrest.

Criteria for diagnosis

An approach to snakebite is provided in Annexure VIII and IX. The criteria to diagnose poisonous snakebite in a given clinical setting are: a) Systemic envenoming in the form of coagulopathy and neurotoxicity, (described vide supra) and b) Local envenoming (Table no: 4)

Table No :4 : Details of local envenomation Swelling is seen at the site of the bites on the digits (toes and especially fingers) also. Local swelling develops in more than half of the bitten limb immediately ( in the absence of the tourniquet). Rapid extension of swelling occurs beyond the site of bite (eg. beyond the wrist or ankle within a few hours of bites on the hands or feet) Development of an enlarged tender lymph node draining the bitten limb

Complications and Outcome

15

Complications in snake envenomation are due to the heterogenous composition

of the venom. In addition the quantity and quality response of the of the venom and the individual to the components of venom influence the clinical

course, complications and out come. The complications of venom are observed in 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 envenomation,bite to needle time,individuals response to envenomation,the complications that develop following snakebite and response to treatment.Till the patient is recovered,one can not predict the complications and outcome.

Investigations
20 Minute Whole Blood Clotting Test (20WBCT) The 20 Minute Whole Blood Clotting Test (20WBCT) is considered as the most reliable test of coagulation and can be carried out at the bedside without specialist 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 Table No . 5 : 20 Minutes Whole Blood Clotting Test (20WBCT) Advantages Requirements Procedure The most reliable Dry glass test Wash hands with test of tube soap and water. coagulation. (clean and new) Wear the gloves Can be carried 2ml disposable Collect 2 ml blood out, at the syringe from the bedside. Cotton peripheral vein of Dose not require Antiseptic the unaffected specialised solution limb 16

training.

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)

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 patients 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 for repeat doses of ASV.

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.

Treatment:
17

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 dont 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.

While dealing with a case of snake bite consider mnemonic RASI. Remember principles (Twelve 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 and outcome 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"12As

Table No: 7: Principles involved in the management.

Admit the victim immediately. Ask effectively. Asses quickly. Act swiftly Administer medication meticulously. Address to the wound properly. Anticipate complications carefully. Avoid errors keenly Ascertain the status repeatedly. Amicable with patients and care givers with 18

empathy. Advise on follow up accordingly. Arrange for referral early

1] Admit all victims of snake bite 24 to 48 hours

& Keep the victims under observation for

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, with 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] Assess the Airway, Breathing and Circulation B] Assess the vitals HR, RR, BP and Pulse oximetry (if required) C] Assess chest expansion, and the ability to put out the tongue beyond

incisors and counting the numbers at the bed side. D] Assess the site of snake bite along with regional lymphadenitis E] Assess clinically from head to foot as well as back F] Assess for associted co-morbid illness[es] G] Assess for consuming any medication[s] H] Assess the status of envenomation [ in view of neurotoxic, hemotoxic, myotoxic or a combination of them].

4] Act swiftly A] to support Airway, Breathing and Circulation B ] to start IV line C] to provide supportive measures depending upon the requirements including blood transfusion/components if required. D] to connect ventilator if there is a need 5] Administer medications meticulously 19

A] Tetanus Toxoid injection intramuscularly B] Anti snake venum as IV drip if needed described vide infra C] Inotropics as IV drip if required D] Antimicrobials if necessary E] I.V fluids as per need. E] Other supportive medications including medicines to relief pain 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] Wound heals under three phases(Three Rs) as described below. -Inflammatory phase (reactive) limits the damage and further injury to tissues -Proliferative phase (repair/regenerative phase) matrix synthesis, neovascularisation and reepithelialisation of the wound -Maturation phase (re-modeling) collagen cross-linking, shrinking and cross contraction of the wound takes place. E] 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. 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. 20

Teach & explain the care of wound to the patients Educate on good personal hygiene and nutrition. Control diabetes if identified.

7] Anticipate complications carefully. 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 keenly 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 Hospital, communicating with patient / and care givers and planning for discharge aswell 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 developed covert signs during hospital stay while on treatment. 10] Amicable with patient and care givers with empathy 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 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 of snake bite is provided vide infra in Table 15.

Traditional methods followed for treating snake bite.

The traditional methods such as application of tourniquet, cutting and suction, washing the wound, snake stone or other methods below. 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 tourniquet are provided below:

have

consequences and

hence, they have to be discarded. Some of the discarded methods are described

Risk of ischemia and loss of the limb 21

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

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. 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 the system by stimulating the lymphatic system. Electrical Therapy : Electric shock therapy for snakebite received a significant amount of press in the 1980s. The theory behind it stated that applying an electric current to 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. Cautery treatment : Cautery treatment is followed in some areas which is injurious and not beneficial Cryotherapy: Cryotherapy involving the application of ice to the bite was proposed in the 1950. It was subsequently shown that this method had no benefit and merely increased the necrotic effect of the venom. 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 22

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 can not be recommended for use at present.

Newer Methods Pressure Pad or Monash Technique

There has been some initial research that 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.

Pharmacological aspects of Anti snake venom

The goals of pharmacotherapy with injection Anti snake venom (ASV) are to neutralise the venom, reduce morbitity and privent comblications. Currently available Anti snake venom 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 and has a half-life of over 90 hours derived from horse serum. Though it is purified, it still can be immuinogenic. 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. More over 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 adquate 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 Sochureks 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 23

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 year shelf life. Lyophilised ASV, in powder form, requires only to be kept cool and hence, a useful one in remote areas where power supply is inconsistent. The details of pre hospital treatment and issues related to Inj.ASV may be recorded in the form provided in Annexure IV.

ASV Administration Criteria

Inj.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 if a Patient develops one or more of the following signs / symptoms. Systemic envenoming Evidence of coagulopathy (vide supra) Primarily detected by 20WBCT or visible spontaneous systemic bleeding, gums etc., Further laboratory tests for thrombocytopenia, Hb abnormalities, PCV, peripheral smear etc may provide confirmation, but 20WBCT is paramount. Evidence of neurotoxicity (vide supra] : 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. Severe Local envenoming( 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 ASV may be applicable.

ASV Administration: Dosage

In the absence of definitive data on the level of envenomation, symptomology is not a useful guide to the level of envenomation. Any ASV regimen adopted is only a best estimate. What is important is that to establish a single guideline which could be adhered to, in order to enable results to be reliably reviewed.

24

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 147 mg. This suggests that the total required dose will be between 10 vials to 25 vials as each vial neutralises 6mg of Russells Viper venom. Not all victims will require 10 vials as some may be injected with less than 63mg. Not all victims will require 25 vials. 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 stated that test doses for ASV shown to 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 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, 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 2) 2. 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 injection of Anti Snake Venom( ASV)
1. 1.

The ASV is available in a polyvalent form and marketed in liquid or lyophilised manner in 10ml vial / ampoule. Hence,ascertain before buying/using it

Remember to use and maintain cold chain systm 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
2. 4.

Health staff before administering the ASV should read and check the status of vial or ampoule containing ASV.

25

5.

Elicit history of prior exposure to Inj.ASV. If a patient has received Inj.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 Inj.ASV, since he/ she has been sensitised.

Inj.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
6.

prevented by
8. 9.

test dose

ASV neutralize the unbound venom, hence give it early ASV administration should not be delayed or denied on the grounds of anaphylactic reactions to a deserving case is required only to those who show definite signs and symptoms of envenomation IV bolus or IM directly. ASV has to be should not be pushed as

10. ASV

11. ASV

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 intracompartmental pressure, particularly in the digits. Hence , it should not be adopted. 13. There is no prophylactic dose of ASV
1.

Total dose requirement cannot be decided on the basis of (WBCT) Whole blood clotting test (or) clinical signs and symptoms Even if the patient develops reaction(s), the total dose required should be administered slowly after the patient recovers from the reaction(s).

2.

16 . There is no other drug of choice other than ASV treatment of snake bite 17. The patient has to be closely monitored for manifestations of reactions to ASV for atleast 2 hours continuously. No interaction with Inj.ASV has been reported Fetal risk due to Inj. ASV has not been established or studied in humans 3. Safety status for use of Inj.ASV during pregnancy has not been established.
1. 2.

26

4.

Timely administration of Inj.ASV will not gurantee the recovery or protect the individual from the venom induced toxicity or complications definitely.

ASV Reactions Reaction to Inj.ASV develop usually within 15 to 30 minutes or with in 2 hours. So monitor the case on ASV at 5 min interval for first 30 min and then at 15 min interval for two hours. Some times, anaphylaxis(Type I) following Inj.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

tching (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) a 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).

Treatment for ASV reactions

Discontinue inj. ASV

Maintain IV line Administer Inj. Adrenaline 0.5ml of 1:1000 IM, ( Adults) / Inj.Adrenaline0.01ml/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

27

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, but up to 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. 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 Inject adrenaline 1:1000 intramuscularly:

*Children (up to 25 kg) Inject adrenaline 1:10 000 intramuscularly 0.1 ml per kg. dilute 1 ampoule (1 mL) of adrenaline 1:1000 with 9 mL water for injection or normal saline. Inject intramuscularly 1:10000 aadrenaline according to the guide (approximates to 0.1ml/kg).

Weighing <50 kg give 0.25 mL Weighing 50-100 kg give 0.50 mL Weighing >100 kg give 0.75 mL

1 year (10 kg) give 1 mL

3 years (15 kg) give 1.5 mL 5 years (20 kg) give 2 mL 8 years (25 kg) give 2.5 mL Children >25 kg as for small adults

* Approximate body weight may be calculated by the formula; 2 x Age + 9 = weight in kg.

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: 28

Administer both H1 receptor blockers Inj.Chlorpheniranine maleate 10 -20 mg as IV / intramuscularly or Promethazine 0.5-1 mg/kg and H2 receptor blockers ranitidine one mg/kg or famotidine 0.4 mg/kg or cimetidine 4 mg/kg slowly intravenously: The dose for children is of Phenimarine 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 chlorphenimarine maleate IV and 2mg/kg of hydrocortisone IV.Antihistamine use in pediatric cases must be deployed with caution. Administer corticosteroids intravenously: hydrocortisone 2-6 mg/kg or dexamethasone 0.1-0.4 mg/kg Try nebulised adrenaline (5 mL 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 hemodynamic instability, Once the patient has recovered, the ASV can be restarted slowly for 10-15 minutes, 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 Inj.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. Oral H1 Antihistamines provide additional symptomatic relief.

Prevention of ASV Reactions Prophylactic Regimens

There is no statistical trial evidence of sufficient statistical power to show that prophylactic regimens are effective in the prevention of ASV Reactions. 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. Two prophylactic regimens normally recommended as given below: 100mg of hydrocortisone and H1antihistamine (10mg chlorphenimarine maleate; 22.5mg IV phenimarine maleate IV or 25mg promethazine hydrochloride IM ) 5 minutes 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.

29

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: Neurotoxic

The ASV regime relating to neurotoxic envenomation has caused considerable confusion. If the initial dose has been unsuccessful in reducing the symptoms or if the symptoms have worsened or if the patient has gone into respiratory failure then a further dose should be administered, after 1-2 hours. At this point the patient should be re-assessed. If the symptoms have worsened or have not improved, a second dose of ASV should be given. 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 the patient is 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 textbooks 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 result from 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 is not necessary.

Recovery Phase
If an adequate dose of appropriate antivenom has been administered, the following responses may be seen: a) Spontaneous systemic bleeding such as gum bleeding usually stops within 1530 minutes. b) Blood coagulability is usually restored in 6 hours. (Principal test is 20WBCT) 30

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) In shocked patients, blood pressure may increase after 30 minutes while on treatment

Repeat Doses: Anti Haemostatic

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 in under 6 hrs. 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 sto 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.

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? 31

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. This may be a cause as, in the case of Hypnale, coagulopathy can continue for up to 3 weeks! 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 147 mg, 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 180 mg 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) or factors can be considered, if available.

ASV risk and wastage

Definitive diagnosis and proper utilisation of Inj.ASV help the patient . Otherwise the patients are subjected to risk of receiving excessive/inadequate dosage of Inj.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 Inj.ASV . The details of provided in Table No.10.

Table No: 10 ASV Risk and Wastage ( Ian D.Simpson Model )

Low wastage High risk Inj.ASV -Not available - Insufficient administratio n Low risk High wastage Inj.ASV Too little supply Species are different

Effective dose of Receive Inj.ASV Inj.ASV when not required to envenomed patients Too much Inj.ASV when not required Unnecessary Inj. ASV

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 32

are used for volume expansion. However, there is no conclusive trial evidence to support a preference for colloids or crystalloids. In cases where generalised capillary permeability has been established a vasoconstrictor such as dopamine can be used. dose being is 5- 10 /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

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 treatment with appropriate should be considered. The major point to note is that clotting must have been re-established before additional measures are taken. Adding clotting factors, 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.

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 The details and approach to some of the surgical issues are provided in Table no. 11. Table No: 11: Surgical issues: Assessment and action required. Assessment Action required * Assess for internal and external * Care of the wound surgical issues related to envenomation - Apply appropriate topical agents carefully and observe for the same and dressing 33

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 if any of the following 6 Ps. or a combination of them appear. Pain on passive stretching Pain out of proportion Pulselessness Pallor Parasthesia 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.

- Maintain proper wound enviroment - 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 * Monitor ICP every 30 to 120 minutes if required * Proceed with fasciotomy if the ICP exceeds greater than 30 to 40 mm of Hg. * Restore coagulation time before commencing the procedures.

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.

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(AT) are negated due to the elimination of ATIII by the time Heparin is administered and heparin can cause bleeding by its own action. Clinical trial did not show any beneficial effect 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.

Snake Bite in special situations ASV Dosage in Victims Requiring Life Saving Surgery
34

In very rare cases, symptoms may develop which indicate that 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 (up to 25 vials) solely on the basis on guaranteeing a 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 20WBCT 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 evidencing 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 respiratory support or normal recovery will be the outcome.

Snake bites Again !

If a patient has been bitten by a poisonous snake and received Inj.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 Inj.ASV, since he/ she has been sensitised.

Snake bite in Pregnancy

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 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 reassessed 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.

Others:

35

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 Inj.ASV in the same manner like any other case of poisonous snake bite.

Management in Primary Health Care Centres 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 to 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 the 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 table 12, 13 and 14 respectively.

Table 12 : Initial evaluation - No Systemic Envenomation ASSESS CLASSIFY Vital signs Vital signs (Adult)* 1. -Pulse 15. Pulse rate: 60-100/min 2. -BP 16. BP 110 / 70 to 140/95 3. -Respiration 17. Respiratory rate SYMPTOMS AND SIGNS <20/min 4. Bite marks SYMPTOMS AND SIGNS 5. Ptosis 18. Local pain and/ or 6. Double vision swelling 7. Difficulty in swallowing 19. Bite mark present, skin 8. Bleeding sites broken 9. Reduced urine output 20. No other symptoms and 10. Swelling and local pain signs 11. Local necrosis Laboratory test: 12. Descending paralysis 20 Minute Whole blood 13. Unconsciousness Clotting Test -Blood clot 14. Any other notedown formed If above findings are there at the time of assessment classify as No systemic envenomation

TREATMENT Tab.Paracetamol Inj.Tetanus Toxoid IM Routine antimicrobials are not necessary Monitor Pulse, Respiration & BP every hourly for 3 hours and every 4 hourly for remaining 48 hours. If normal send the patient home

*Vital signs for children (see age specific chart) are provided in Annexure II.

36

If the patient has any systemic manifestations refer to Table.13 and 14 for Heamotoxic and Neurotoxic envenomation respectively. The details of local envenomation is provided in Table 4.

Table 13 : Heamotoxic envenomation

ASSESS
Vital signs

CLASSIFY
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 or painful enlargement of nearby lymph nodes Bleeding from the Gingival sulsi urine Epistaxis Petechiae, purpura, ecchymoses Heamaturia Intracranial bleeding: -asymmetrical pupils -unconciousness - convulsions Persistent and severe vomiting or abdominal pain Low back pain No urine output decreased urine output Laboratory test: 20 Minute Whole Clotting Test -Blood clot not formed If above findings are there at the time of examination classify as Heamotoxic envenomation blood or

TREATMENT
Treat the patient with Anti Snake Venom(ASV) - Start IV Normal Saline with wide bore needle - Begin with one Vial of ASV in one pint 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.Phenaramine maleate 2ml IV Inj,Adrenaline 1:1000 (0.5 ml)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

Pulse BP

Respiration SYMPTOMS AND SIGNS Bite marks No Ptosis Double vision Difficulty in swallowing Bleeding sites Reduced output Swelling pain and

local

Local necrosis Descending paralysis Unconsciousness Any down other note

- Stabilise the patient and refer to the higher institution Aspirin should not be used

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Fluid requirements per day should be kept in mind while giving ASV. For children readers are requested to seethe fluid requirement chart provided in Annexure II. *Vital signs for children (see age specific chart) are provided in Annexure III.

Table 14 : Neurotoxic envenomation: ASSESS -As mentioned in Table 13 CLASSIFY SYMPTOMS AND SIGNS -Swelling and local pain -Local necrosis -Descending paralysis starting from ptosis, external ophthalmoplegia -Numbness around the lips and mouth progressing to pooling of secretions, difficulty to talk and respiratory failure -Paradoxical respiration -Paralysis -Belly pain Lab.test: 20 Minute Whole Blood Clotting Test (WBCT) -Blood clot formed If above signs & symptoms are present at the time of admission classify as Neurotoxic envenomation TREATMENT Treat the patient with Antisnake venom (ASV) as mentioned in Table 7 and add the following: Inj.Neostigmine 1.5 mg (Test dose) as I.M and Inj.Atropine 0.6 mg(Test dose) as I.V After that observe patients for every five minutes for 30 minutes for signs of response

Patients have to be assessed for features of local evenomation as described in table 4

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 cases to higher centre/speciaslist. The details are furnished in Table 15 below. 38

Table No :15 : Referral aspects for snakebite Who needs Patient requiring Respiratory support Surgical interventionNecrosis / Fasciotomy Spontaneous persistent bleeding Co-morbid diseases Acute impending kidney failure When W here Refer the patient Refer to higher after stabilising the institution having case and after Ventilator giving injection ASV 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 hour rule ensures that a six hour 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 patients 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, a second dose of ASV is given over 1 hour. Again ASV is now completed for this patient.

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 Continue life supporting measures Provide airway support with the help of an accompanying staff 39

Send the referral note with details of treatment given Instruct one staff to accompany the patient during transportation if required. Hand over the referral slip with details regarding treatment given Mention the clinical status clearly in the referralat the time of referral.

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 vary from state to state. Treating doctor should inform the family members of the deceased, and guide them the ways and means for getting the welfare measures downtrodden. provided by the Government to the poor and

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 grasscutting colleagues. Walking at night without a torch barefooted or wearing sandals accounts for a significant number of bites. 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

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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 jowhar husk.

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.

References
1.

2.

Agarwal P.N., Agarwal A.N., Gupta. D., Behera.D., Prabhakar. S., Jindal. S.K. Management of Respiratory Failure in Severe Neuroparalytic Snake Envenomation. Neuro India 2001: 49: 25 28. Alvares R. (Goanet) Myths and Snake bites.
http://lists/whatwg.org/goanet-goanet.org/2004september/017828.html accessed on 28.01.08.

3.

Amarel CFS, Campllina D, Dias MB, Bleno CM, Razende NA. Tourniquet ineffectiveness to reduce the severity of envenoming after crotalus durissus snakebite in Belo
41

4.

5.

6.

7.

8.

9.

Horizonte, Minas Gerasis, Brazil. Toxicon 1998, 36(5): 805808. 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 6th annual conference of Asia Pacific Association of Medical Toxicology held at Bangkok, Thailand December 12-14, 2007 P.204 Bambery P.snakebites and arthopod envenomation. In: Shah SN, etal. [Edrs]API text book of Medicine 8th edition. The Association of Physicians of India, Mumbai 400 011. 2008; Volume 2: section 24, chapter 11 : 1517-20. Banerjee RN, Sahni AL, Chacko KA. Neostygmine in the treatmetn of Elepidae bites. Journal of Association of Physicians of India 1972; 20: 503-509. Bawaskar HS,Bawaskar BH. Profile of snake bites envenoming in western Maharashtra , India. Trans Roy Soc Trop Med Hyg 2002; 96: 79-84. 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. Bawaskar HS,Bawaskar BH,Punde DP,Inamdar MK,Dongare RR,Phoite RR Profile of snakebite envomation in rural Maharastra.Journal of Association of Physician of India 2008:56: 88 95 Bhat R.N., Viperine Snake Bite Poisoning in Jammu. JIMA 1974:63:383 392. Chugh K.S. Snake Bite induced Acute Renal Failure. Kidney International 1989:35:891 90 Daga S, Biswas K, Roy K. Editorial: Medical record keeping- are we prepared?. J Indian Med Assoc 2008; 10: 145. Dutta T.K., Mukta V. Snake Bite. JIMA 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. Ghosh S. Management of snake bite an update. In: Bichille SK, Hasa NK, Mehta SS.(Eds). Medicine update . The association of physicians of india 2008; 18(chapter 90): 691696. Government Order (D) No.46, Health and Family Welfare Department, State Government of Tamilnadu, Chennai, dated 19.01.2006.

.
10. 11. 12. 13.

14.

15.

42

16.

17.

18.

19.

Government Order (2D) No.125, Health and Family Welfare (EAP 1/1) Department, State Government of Tamilnadu, Chennai, dated 02.11.2007. Government Order (MS) No.10, Health and Family Welfare (MCA 1) Department, State Government of Tamilnadu, Chennai, dated 09.01.08 Health and Family welfare (P1.) Department, State Government of Tamilnadu, Chennai, Letter No. 637/P1/06-2 dated 27.01.06 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.

Howarth DM, Southee AS, Whytw IM, Lymphatic flow rates and first aid in simulated peripheral snake or spider envenomation. Medical Journal of Australia 1994; 161: 695-700 21. 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. 22. Kalantri S, Singh A, Joshi 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
20. 23.

24.

25.

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. 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 Medical management of severe anaphylactoid and anaphylactic reactions*

www.australianprescriber.com/magazine/24/5/artid/546/ accessed on 08.02.08 26. 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 27. Norris RL, Bite marks and the diagnosis of venomous snakebite. Journal of Wilderness Medicine 1995; (6): 159-161 28. Pillay VV.(Edr). Modern medical Toxicology. Third Edition. Jaypee Brothers. medical publication(P) Ltd., New Delhi 110 002. 2005; PP 499 + xviii
29.

Rajendiran C, simpson ID. Indian National Snake bites Protocol-2007(OP-040). Abstract book of 6th annual conference of Asia Pacific Association of Medical Toxicology held at Bangkok, Thailand December 12-14, 2007 P.104
43

30. 31.

32.

33.

34.

35.

Simson ID. The paediatric management of snake bite . The National Protocol. Indian Pediatrics 2007,44:173-176 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 Simpson ID. Snake bite management in India, the first few hours: a guide for primary care physicians. Journal Indian Medical Association 2007;105: 324,326, 328,330,332,334 & 335. Simpson ID. Indian National Snake bite Protocol. www.indianwildlifeclub.com/blog/topic.asp?id_top=10 accessed on 28.01.08 Srivastava RK. Director General, Office of the Directorate Generallll of Health Services, Nirman Bhawan, New Delhi 110011. Letter D.O.No.D.32020/3/2008 EMR, Dated 5th February,2008. Training module Poison First aid and Treatment Centre (BEmONC , PHC),State Health Mission Health and Family Welfare Government of Tamil Nadu, Chennai. 2008.
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 Tun P, Khin Aung Cho. Amount of venom injected by Russells Viper (Vipera russelli) Toxicon 1986; 24(7): 730-733 Veerapandian R.[Edr]. Guidelines for common surgical interventions in the elderly. Developed under WHO Government of India collaborative programme 2006-07. August 2007. Warrell, D.A. (Ed). 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. 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. Wen Fan H, Marcopito LF, Cardoso JLC, 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

36.

37. 38.

39.

40.

41.

42.

When a cobra strikes. The Hindu (Online edition of India's National newspaper) June 13,2004. www.thehindu.com th accessed on 30 June 2008.

44

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