1. Kaushik.H.M
080201388

2.  Rapid clinical assessment and resuscitation
 Detailed clinical assessment and species diagnosis
 Investigations/laboratory tests
 Specific treatment

3.  Attend to AIRWAY , BREATHING,
CIRCULATION
 Secure an IV line (wide bore).
 Booster dose of tetanus toxoid is
recommended.
 Identify the snake responsible

4.  All patients should be kept under
observation for a minimum period of 24 hrs.
 Determine the exact time of bite
 Bacterial Infections- Prophylactic course of
penicillin (or erythromycin for penicillin-
hypersensitive patients)and a single dose of
gentamicin or a course of chloramphenicol

5. •Care must be taken when removing tight tourniquets
tied by victim. Sudden removal can lead to massive
surge of venom leading to neurological paralysis,
hypotension.
•Pain-paracetamol/ 50 mg of tramadol maybe given.
NSAIDs and Aspirin are contraindicated.

6. Investigations
 20 minute whole blood clotting test -considered most
reliable test of coagulation.
 Platelet count : may be decreased – viper
 WBC cell count : Early neutrophil leucocytosis in systemic
envenoming from any species.
 Blood film : Fragmented RBC(“helmet cell”, schistocytes) are
seen in microangiopathic haemolysis.
 Plasma/serum : may be pink or brownish if there is gross
haemoglobinaemia or myoglobinaemia.

7.  Aminotransferases, creatine kinase, aldolase elevated if there
is severe local damage or, particularly generalised muscle
damage.
 Bilirubin is elevated following massive extravasation of blood.
 Creatinine, urea or blood urea nitrogen levels are raised in
the renal failure
 Early hyperkalaemia may be seen following extensive
rhabdomyolysis in sea snake bites. Bicarbonate will be low in
metabolic acidosis (eg renal failure).
 Arterial blood gases and pH may show evidence of respiratory
failure (neurotoxic envenoming) and acidaemia (respiratory
or metabolic acidosis).

8.  Urine for RBC – Viper Bite – Hematuria,
Proteinuria, Hemoglobinuria, Myoglobinuria
 ECG – Normal, Bradycardia with ST elevation or
depression, T inversion, QT prolongation.
 Chest X- ray – Normal or may show Pulmonary
Oedema, Intrapulmonary Hemorhages, Pleural
Effusion.

9. Monitor vital signs
 Observe every patient for minimum 24 hours. Monitor the
patient every 6 hours.
 Pulse, BP, Respiration
 Urine output
 Blood urea, Creatinine
 Bleeding tendency
 Local swelling
 Vomiting
 Diplopia, Ptosis, Muscle Weakness, Breathlessness

10. Anti Snake Venom
 Antivenom is immunoglobulin (usually the enzyme
refined F(ab)2 fragment of IgG) purified from the
serum or plasma of a horse or sheep that has been
immunised with the venoms of one or more species of
snake.
 It neutralises the free, unbound venom & to some
extent also dissociates the bound toxin
 ASV is manufactured in India by the Haffkine Central
Research Institute, Kasauli & Serum Institute of India,
Pune & both are POLYVALENT(neutralizes venom of
different species of snakes.)

11. 1 ml of ASV neutralises
 Cobra – 0.6 mg
 Common krait – 0.45mg
 Russels viper – 0.6 mg
 Saw scaled viper – 0.45 mg

12. Indications
 As per W.H.O Guidelines ONLY if a patient
develops one / more of the following
signs/symptoms ASV should be administered :
SYSTEMIC ENVENOMING
• Evidence of coagulopathy: detected by
20WBCT or visible spontaneous systemic
bleeding
• Evidence of neurotoxicity : ptosis,
ext.ophthalmoplegia

13. • CVS abnormalities : hypotension, shock,
arrhythmias
• Acute renal failure
• Hemoglobinuria / myoglobinuria
• Persistent severe vomiting / abdominal pain

14. LOCAL ENVENOMING
• Local swelling > ½ of involved limb
• Rapid extension of swelling
• Enlarged tender lymph nodes draining the bitten limb

15. ASV administration
 NO ASV TEST DOSE MUST BE ADMINISTERED .
 Recommended initial dosages are 100 ml( 10 vials) of
polyvalent ASV for adults & children based on
published research that russells viper injects on an
average of 63 mg of venom.
 Our initial dose must be calculated to neutralize the
average dose of venom injected.

16.  Range of venom injected = 5mg – 147 mg
 Suggested ASV dose = 100 -250 ml
 Initial dose of 100 ml must be diluted in 100 ml of NS &
given over 1 hour.
 Patient should be carefully monitored for 2 hrs.
 Local administration of ASV, near the bite site –
ineffective, painful, raises intracompartmental pressure.
– SHOULD NOT BE DONE

17. Victim who arrives late ?
 Often after several days , usually with acute renal failure.
 Are there any signs of current venom activity ?
 Perform 20WBCT & determine if any coagulopathy is
+, if + administer ASV. If - , treat ARF – dialysis
 Neurotoxic envenoming – look for ptosis, respiratory
failure , + administer 1 dose of ASV , respiratory support

18. ASV reactions
 Patient should be monitored closely
 First sign of any one of the following :
1. Utricaria 6. Vomiting 11.Bronchospasm
2. Itching 7. Diarrhoea 12.Angioedema
3. Fever 8. Abdominal cramps
4. Chills 9. Tachycardia
5. Nausea 10. Hypotension
 Discontinue ASV & give 0.5 mg of 1 :1000 adrenaline
IM/ IV diphenhydramine(antihistamines).

19. Repeat doses of ASV
 HEMATOTOXIC POISONING :
• 20 WBCT – abnormal – initial dose given over 1 hr.
• Repeat 20WBCT after 6 hrs
• Abnormal – another dose to be given. Repeat same
dose again.
• 20WBCT & Repeat doses of ASV – to be continued
on 6 hourly manner until coagulation is restored.

20.  NEUROTOXIC POISONING
• Assess the patient 1-2 hrs after the initial dose
• If symptoms persist / worsen , 2 nd dose which is
same as 1st dose is to be given & then ASV can be
discontinued

21. Role of Neostigmine in
Neurotoxic poisoning
 Anticholinestrase & prolongs life of Ach - which can
reverse resp.failure & neurotoxic symptoms ( post synaptic
)
 Neostigmine test : 1.5 -2.0 mg IM preceeded by 0.6 mg
atropine IV
• Observe for 1 hr
• If victim responds , continue 0.5 mg Neostigmine IM ½
hrly with 0.6 mg Atropine IV over 8 hrs
• If no improvement in symptoms after 1 hr , stop
Neostigmine

22. Supportive Therapy
 RESPIRATORY FAILURE :
• ABG
• Intubate & Ventilate
• Neostigmine & Atropine
 HYPOTENSION :
• Plasma expanders-crystalloids
• Dopamine 2.5 – 5 micrograms/Kg/min

23.  PERSISTANT / SEVERE BLEEDING :
• Majority – timely use of ASV will stop systemic bleed
• ASV + Blood Transfusion
 RENAL FAILURE
• Hemodialysis / peritoneal dialysis
 COMPARTMENT SYNDROME :
• Fasciotomy
 SURGICAL DEBRIDEMENT OF WOUND: Necrosis