1. TREATMENT PROTOCOL in VENOMOUS SNAKE BITE L F Hospital, Angamaly, Kerala
Dr Joseph K Joseph
Consultant Physician & Nephrologist
Little Flower Hospital,
Angamaly

2. SNAKEBITE TREATMENT PROTOCOL
PROTOCOL FOR DIAGNOSIS
TREATMENT PROTOCOL

3. Hemostatic & clinical markers suggesting envenomation
I. Deranged haemostatic profile, suggested by either or all of
-An abnormal WBCT
- PT above 1.5 times normal and a APTT showing 6 secs above control

4. 11 a. The presence of significant local inflammation
Tender enlarged lymph nodes
Recurrent nausea,vomiting and abdominal pain
Acute abdominal tenderness
Bleeding manifestations

5. 111. BLOOD PARAMETRES a) Crenated RBC in peripheral blood smear
b) Rise in serum creatinineof >30% of base line value
c )Proteinuria>2+
d)Raised D dimer value
e )Low platelet value<100000/mm3

6. Snake identification charts

7. Examination of the bitten part:
Fang marks
The extent of swelling
Palpate lymph nodes draining the limb
Limb girth

8. General examination
Measure the blood pressure (sitting up and lying to detect a postural drop indicative of hypovolaemia) and heart rate.
Examine the skin and mucous membranes for evidence of petechiae, purpura, discoid haemorrhages, ecchymoses and, in the conjunctivae, for haemorrhages and chemosis.
Thoroughly examine the gingival sulci, using a torch and tongue depressor, as these may show the earliest evidence of spontaneous systemic bleeding.
Examine the nose for epistaxis.

9. TREATMENT PROTOCOL Managing pain Handling Tourniquets
Anti snake Venom- dosage, administration,
side effects, managing anaphylaxis
Treating complications

10. Managing Pain Causes severe pain at bite site
Pain Killers-Paracetamol mg 6 hrly orally in adults, Pediatric dose- 10 mg /kg 4-6 hrly orally
Severe pain-Tramadol 50 mg orally
Tramadol IV if needed
No NSAID

11. HANDLING TOURNIQUETS Recommendation- No tourniquet to be applied
Current practice- see many victims reaching with tourniquets
Do not suddenly remove the tourniquet
Sudden removal-massive surge of venom causing neurological paralysis and hypotension due to vasodilatation

12. Indications Local envenoming:
Local swelling involving more than half of the bitten limb (in the absence of a tourniquet) Swelling after bites on the digits (toes and especially fingers)
Rapid extension of swelling (for example beyond the wrist or ankle within a few hours of bites on the hands/ feet)
Development of enlarged tender
lymph nodes draining the bitten
limb 12

13. Close Observation WBCT-½hrly – 3 hrs hrly - 3 hrs 2hrly – 6 hrs
Patients should be observed for a period of at least 24 hours
Krait & Hump-nosed pit viper – delayed envenoming (6-12hrs)
Monitor
Neurotoxic signs
20 min WBCT
WBCT-½hrly – 3 hrs hrly - 3 hrs
2hrly – 6 hrs
4hrly -12hrs

14. 20WBCT (20 minutes Whole Blood Clotting Test)
Place a few ml of freshly sampled venous blood in a new, clean, dry, small glass test tube vessel
Leave undisturbed for 20 min at ambient temperature
Tip the vessel once
If the blood is still liquid (unclotted) and runs out, the patient has hypofibrinogenaemia (incoagulable blood) as a result of venom induced consumption coagulopathy
If the vessel used for the test is not made of ordinary glass, or if it has been cleaned with detergent, its wall may not stimulate clotting ofthe blood sample (surface activation of factor XI – Hageman factor)and test will be invalid

15. Other Tests Hematological- Hb, PCV, TLC, DLC,
Peripheral Smear,Platelet count –repeated 6 hourly for the first 24 hours in viperidae bites
C T, B T , P T, APTT
DIC Workup- D-dimer,FDP,Fibrinogen, Repeated on the third day
Renal function tests-
Liver function tests- AST, ALT,Bilirubin, Total protein and albumin
Muscle enzymes,Blood sugar

16. Other Tests Urine – myoglobin, Hemoglobin and protein Blood group
Oxygen saturation
ABG
Tests repeated on daily basis- Hb, PCV, creatinine, platelets, and urine protein

17. Measuring intracompartmental pressure at LFH
If possible, intracompartmental pressure should be measured
Blood flow and patency of arteries and veins assessed (e.g. by doppler ultrasound).
Measuring intracompartmental pressure at LFH

18. Ventilatory capacity
Use a peak flow meter
Spirometer (FEV1 and FVC)

20. Initial management Tetanus toxoid Antibiotics Pain relief
Hydration –IV Fluids
Monitor Intake-Output
Respiratory rate
Mark the extent of local swelling
Measure the swollen limb

21. HAEMATOTOXIC ENVENOMATION
Russel viper injects on an average 63 mg of venom[5 to 147mg]
1ml ASV neutralise 0.6 mg of russel viper venom
1 vial-10 ml=6mg ASV
Total required dose wil be between 100ml[10 vial] to 250 ml[25 vial]
So starting with 10 vials ensures sufficient neutralising power

22. Recommended Dose of ASV
Haemotoxic Envenomation:
Treat the patient with Anti Snake Venom(ASV)
Start IV Normal Saline with wide bore needle
Begin with 10 vials of ASV in 100ml of NS and to start with drops per minute for 15 minutes & watch for reactions.
If the patient is not having signs and symptoms of anaphylactic shock continue the ASV drip in one hour period.
Continue to monitor the vital signs at five minutes interval for first 30 minutes and then at 15 minutes interval for two hours

23. NEUROTOXIC ENVENOMATION- NEOSTIGMINE TEST
1.5 TO 2 mg NEOSTIGMINE IV +0.6mg ATROPINE iv IN AN ADULT&0.04mg/kg NEOSTIGMINE IV+0.05mg/kg ATROPINE IN CHILDREN
OBSERVE CLOSELY FOR 1 hr TO DECIDE THE EFFECT

24. NEOSTIGMINE TEST OBJECTIVE METHODS
Single breath count, mmof iris uncovered [amount covered by descending eyelid]
Inter incisor distance [distance between upper and lower incisors]
Length of time upward gaze can be maintained
FEV1 or FVC[ if available ]

25. Recommended Dose of ASV
Neurotoxic Envenomation:
Treat the patient with Antisnake venom (ASV) with the same dose for Haemotoxic Envenomation  plus
If Neostigmine test is +ve 0 .5 mg neostigmine at half hourly intervals for 5 injections followed by repeating the same dose at increasing intervals of hrs.
Each dose of neostigmine is preceeded by Inj. Atropine 0.6 mg as iv
Neostigmine is not useful in Krait bite

26. REPEAT DOSE IN HEAMATOTOXIC ENVENOMATION
Initial blood test reveals coagulation abnormality – 10 vials of ASV
No additional ASV untill next 6 hrs
[liver unable to replace clotting factors in under 6 hrs]
After 6 hrs another 20 WBCT
In continued coagulation disturbance another vials of ASV in 1 hr time
Rpt CT &Rpt ASV 6 hrly until coagulation is restored.

27. Repeat Dose- Neurotoxic
For Neurotoxic Envenomation: Initial dose 10 vials given and if symptoms persist or worsen / respiratory failure, rpt 10 vials after 1-2 hours as second dose and discontinue ASV
20 vials is the maximum dose of ASV
If the patient is in respiratory failure & has already received 20 vials & is on ventilator ASV therapy is to be stopped.

28. ASV in special situations
Victims requiring life saving surgery.
Victims who arrive late
Repeat snake bites
Snake bite in pregnancy and lactating women
Victims having other co morbid conditions – Autoimmune disorders, debilitating status, endocrine disorders, immuno supressed status, HIV AIDS, cancer, asthma and allergy disorders, etc.,

29. Treatment of Hypotension
Maintain C V P at 8cm of water
Maintain urine output at >30ml/hr
Normal saline if no renal failure
If Hb & PCV decreased [PCV<40]
FRESH BLOOD TRANSFUSION
If Hb & PCV increased, [PCV>50]
PLASMA EXPANDERS-FFP, Cryst- colloid
Evidence of DIC [Plat<50,000]FFP, Platelet transfusion
If Hypotension persists- DOPAMINE

30. SURGICAL INTERVENTION
Faciotomy - ICP>40mm
Clinical features-pain on passive stretching,pain out of proportion, absence of pulse,pallor, paraesthesia, paralysis
OBJECTIVE MEASUREMENT- saline manometers, STRYKER, Intracompartmental pressure monitoring equipment

31. Management of Allergic Reactions
If signs and symptoms of anaphylactic shock develop,
Stop the ASV drip temporarily and treat the shock with:
Inj Hydrocortisone 100 mg IV or
Inj.Phenaramine maleate 2ml IV
Inj,Adrenaline 1:1000 (0.5 ml)IM
Oxygen administration
IV.Normal saline as life line
As soon as the patient recovers, restart ASV infusion slowly with careful monitoring
Continue to monitor the vital signs at five minutes interval for first 30 minutes and then at 15 minutes interval for two hours
Stabilise the patient and refer to the higher institution – if needed

32. Treatment of early anaphylactic and pyrogenic reactions
Adrenaline should be kept loaded
Stop the ASV temporarily
Give adrenaline at the first sign of a reaction
0.5mg IM in adults
0.01mg/kg IM in children
Repeat every 5 to 10 mins

33. Immediate Management Airway and Breathing
Oxygenate with mask
Intubate and ventilate
if necessary

34. Early anaphylactic reactions
Dry cough
Fever
Nausea, vomiting, diarrhea
Abdominal colic and cramps
Rhinorrhea
Conjunctivitis
Lightheadedness

35. Adrenaline Infusion
Add 1 mg adrenaline to 500 ml of 5 % Dextrose (2 µg/ml).
Infuse at 1ml / min. Titrate upwards to 4 ml/min.
2 to 8 ug/min
Can cause life threatening arrhythmias
Cardiac monitoring

36. Treatment of Hypotension
Crystalloids NS bolus 1-2L
(10 to 20ml/kg in children)
SECOND- LINE THERAPY Corticosteroids
Hydrocortisone 200 – 500mg IV
(5-10mg/kg in children)
Methylprednisolone 125mg IV
(2mg/kg in children)
Prevents recurrent anaphylaxis

37. For allergic bronchospasm
Nebulization Salbutamol+ipratopium bromide
Nebulised adrenaline if required

38. Additional Treatment H1 antihistamine,
10mg chlorpheniramine maleate IV, (0.2mg/kg children) or
22.5mg pheniramine maleate IV or
25mg promethazine HCl IV
H2 antihistamines,
Ranitidine 50mg IV

39. When to restart the ASV after a reaction
Once the patient has stabilized
Once the BP is under control
Once the manifestations of the reaction have subsided
In severe reactions ASV can be restarted under cover of an adrenaline infusion
Rate of ASV infusion can be decreased initially
Patient should be under strict monitoring

40. CONCLUSION
There is need to maintain standard regimens
National snake bite trt protocol is an attempt to bring about uniformity in diagnosis and management.
Awareness among community about the proper first aid& early treatment
Better knowledge of ASV, its complications and treatment of complications

41. Thank you
Little Flower Hospital & Research centre,
Angamaly