handbook on treatment guidelines for snake bite and scorpion sting 2008 - tnhsp publication

HANDBOOK ON TREATMENT

GUIDELINES FOR SNAKE BITE AND

SCORPION STING

Tamil Nadu Health Systems Project

Health and Family Welfare Department

Government of Tamil Nadu, Chennai.

2008

INTRODUCTION

The Tamil Nadu Health Systems Project formed a snake bite task force in 2006

to try and understand the staggering Þ gures that were surfacing on snake bite and

scorpion sting cases in Tamil Nadu. During the effort, it was apparent that despite

morbidity and mortality, an evidence based handbook on treatment guidelines was not

available to medical ofÞ cers as a ready reckoner in dealing with affected persons.

A committee was then formed to prepare guidelines to treat snake bite and

scorpion sting with the assistance of the Health & Family Welfare department and in

particular the Poison Control, Training and Research Treatment Centre in Government

General Hospital, Chennai. The Committee has prepared this Handbook after several

rounds of discussion and has also subjected this document to a peer review.

This handbook will help to redeÞ ne patient care for those who suffer from

snake bite and scorpion sting and will be useful for health care providers, patients and

policy makers. Information provided in the following pages range from epidemiological

issues, clinical features, treatment modalities, management of complications, referral

aspects medical audit, research areas and so on.

With this handbook, we hope to ensure that a major information gap is

adequately plugged so as to ensure rational medical treatment and appropriate quality

of care for snake bite and scorpion sting victims.

November 2008

Chennai.

Dr. S. VIJAYA KUMAR I.A.S.,

Special Secretary to Government

Health & Family Welfare Dept.,

&

Project Director

Dr. S. VIJAYA KUMAR

Tamil Nadu Health Systems Project

7th Floor, DMS Building,

Chennai - 600 006.

Tel. Off : (91-44) 2434 5997

Fax : (91-44) 2434 5997

Email : [email protected]

iii

EDITORIAL COMMITTEE

Chair Person :

Thiru.Dr.S.Vijaya kumar, I.A.S.,

Project Director and

Special Secretary to Government,

Tamil Nadu Health Systems Project,

Chennai – 6.

Members:

Dr. (Capt.) M.Kamatchi,

Expert Advisor,

TamilNadu Health Systems Project (TNHSP),

Chennai.

Dr. P. Thirumalaikolundusubramanian,

Former Director, Professor and Head, Institute of Internal Medicine,

Madras Medical College and

Emeritus Professor, The Tamil Nadu Dr.M.G.R. Medical University, Chennai.

Mr. Ian D. Simpson, Consultant,

Member of Tamil Nadu Snake Bite Task Force and

Snake bite advisor to Pakistan Medical Research Council

Dr. C. Rajendiran, Director, Professor and Head, Institute of Internal Medicine,

Madras Medical College and

Physician i/c, IMCU & Poison Control, Training and Research Centre,

Government General Hospital, Chennai.

Dr. P. Ramachandran, Pediatrician, & Registrar,

Institute of Child Health & Hospital for Children,

Madras Medical College, Chennai.

Dr. C. Ravichandran, Asst. Professor,

Institute of Child Health & Hospital for Children,

Madras Medical College, Chennai.

Mrs. Beaula Indrani, Public Health Nurse,

Reproductive & Child Health, Chennai.

Dr. G. Sasikala, Editorial Assistant, TNHSP, Chennai.

iv

ACKNOWLEDGEMENT

Tamil Nadu snakebite task force team and staff Tamil Nadu Health Systems

Project (TNHSP), Chennai thank the Ministry of Health and Family Welfare, Health

& Family Welfare Department, State Government of Tamil Nadu, Chennai, India and

Madras Medical College, Chennai for making arrangements to prepare the treatment

guidelines for snakebite and scorpion sting; and also thank the Ministry of Health

& Family Welfare, Government of India, New Delhi, for considering the treatment

guidelines prepared from Tamil Nadu for Snake bite favourably.

The encouragement provided by Thiru .V.K. Subburaj, I.A.S., Principal

Secretary to Government, Health & Family Welfare Department, Government of

Tamil Nadu, Chennai; Ms. Supriya Sahu, I.A.S., former Additional Secretary, Tamil

Nadu Health Systems Project, Chennai; Thiru. P.W.C. Davidar, I.A.S., Former Project

Director & Special Secretary to Government, Tamil Nadu Health Systems Project,

Chennai; and Thiru. Muthiah Kalaivanan, I.A.S., former Project Director, Reproductive

and Child Health (RCH), Chennai, for the preparation of the treatment guidelines for

snakebite and scorpion sting is gratefully acknowledged.

The support provided by former Director of Medical Education, Dr. Vijayalakshmi,

former Director of Medical and Rural Health Services, Dr. N. Kalyanasundaram and

former Director of Public Health and Preventive Medicine, Dr. S.Murugan are duly

acknowledged.

The services rendered by Dr. P. Padmanabhan, Director of Public Health and

Preventive Medicine, Chennai; Dr.V.K. Rajamani, Professor of Medicine, and

Dr. Saradha Suresh, Director and Superintendent, Professor and Head of Pediatrics,

Madras Medical College, Chennai; Dr. S. Shivakumar, Professor and Head of

Medicine, Stanley Medical College, Chennai; Dr. A. Ayyappan, Professor and Head

of Medicine and Dr. M.L. Vasanthakumari, Professor of Pediatrics, Madurai Medical

College, Madurai; Dr. S. Muthukumaran, Professor and Head of Medicine, Thanjavur

Medical College, Thanjavur; Dr. Vasantha Elango, Professor and Head of Community

Medicine, and Dr. K.Umakanthan, Professor and Head of Medicine, Coimbatore

Medical College, Coimbatore; Dr. K. Sathyamoorthy, Professor and Head of Medicine,

Government M.K. Medical College, Salem; and Dr. R.A. Sankaramanian, Professor

of Pediatrics, Government Theni Medical College, Theni in reviewing the manuscript

and offering suggestions are greatly appreciated.

v

STATEMENTS

1. For private circulation, not for sale

2. Acknowledging the source permits copying or translating the material

3. This module is designed to give concise information for medical practitioners and

not intended to provide comprehensive scientiÞ c information

4. For detailed and up to date information as well as to know the current developments,

users are requested to go through the original articles, review papers, case reports,

related publications, websites etc.,

5. For administration of each drug, users are informed to go through the latest product

information leaß ets provided by the manufacturers

6. Users are reminded to recall the contraindications before using any drug.

7. Users have been motivated to make use of their experience and knowledge of

patients before deciding the dosage and treatment of each patient

8. The hand book has been revised as on November 2008

9. The publishers, Tamil Nadu Health Systems Project, Health and Family Welfare

Department, Chennai, Tamil Nadu, Funding agency, the contributors and reviewers

do not assume liability for any injury and / or any damage to persons or property

arising out of this publication

10. Readers are requested to submit their suggestions, views, feed back and

their experience on snakebite / scorpion sting to the following mail address

[[email protected]] which will be helpful for modifying / revising future editions.

vi

ABBREVIATIONS

AS – Anti Snake Venom •

AT – Antithrombin •

BP – Blood Pressure •

CT – Computerised Tomography •

DIC – Disseminated Intravascular Coagulation •

FFP – Fresh Frozen Plasma •

Hg – Mercury •

HR – Heart Rate •

HCL – Hydrochloride •

ICP – Intra Compartment Pressure •

IM – Intramuscular •

IV – Intravenous •

LAB – Laboratory •

PHC – Primary Health Centre •

PIM – Pressure Immobilisation Method •

PR – Pulse Rate •

RR – Respiratory Rate •

SD – Standard Deviation •

WBCT – Whole Blood Clotting Test •

WHO – World Health Organisation •

vii

List of Tables, Figures, Pictures and Plates

List of Tables

Table 1: Statistics on clinical aspects of snake bites and outcome

Table 2: Categorisation of snakes (W.H.O.1981)

Table 3: Snakes, clinical aspects and therapeutic response

Table 4: Details of local envenomation

Table 5: 20 Minutes Whole Blood Clotting Test (20WBCT)

Table 6: Currently recommended First aid

Table 7: Principles involved in the management

Table 8: Manifestations of immediate reactions to ASV

Table 9: Dosage of adrenaline for adults and children

Table 10: ASV – Risk and Wastage (Ian D.Simpson Model)

Table 11: Surgical issues: assessment and action required.

Table 12: Initial evaluation - No systemic envenomation

Table 13: Haemotoxic envenomation

Table 14: Neurotoxic envenomation

Table 15: Referral aspects for snake bite

Table 16: Distinguishing features of lethal and non-lethal scorpion

Table 17: Inß uencing factors for symptoms and signs

Table 18: Local effects at the site of sting.

Table 19: Systemic signs of scorpion sting.

Table 20: Non-neurological signs

Table 21: Measures to be adopted while using Prazosin

Table 22: Initial evaluation of scorpion sting without systemic envenomation

Table 23: Evaluation of scorpion sting with systemic envenomation

Table 24: Referral aspects for scorpion sting

Table 25: Responsibilities of health care providers

viii

Table 26: Levels of analysis

Table 27: Formula to calculate case fatality rate at different levels

Table 28: Snake bite cases reported and ASV vials used in secondary care hospitals

(district wise)

Table 29: Fluid requirement chart for children

Table 30: Normal Respiratory Rate (per minute) by age.

Table 31: Normal Heart Rate (per minute) by age

Table 32: Normal Blood Pressure in children by age

Table 33: Hypotension by systolic Blood Pressure and age

List of Figures

Figure 1: Grading of scorpion envenomation

Figure 2: Nervous system signs

List of Pictures

Picture No. 1: Snakes of Medical Importance in Tamil Nadu

Picture No. 2: Typical signs of local envenomation

Picture No. 3: Cellulitis with compartmental syndrome

Picture No. 4: Showing bilateral ptosis with overaction of frontalis

Picture No. 5: Showing ophthalmoplegia

List of Plates

Plate No. 1: Snake IdentiÞ cation

Plate No. 2: Important Venomous Snakes of India

Plate No. 3: Primary / Community Health Care Centre - Snake bite Treatment

Guidelines

Plate No. 4: Secondary Health Care Centre - Snake bite Treatment Guidelines

ix

CONTENTS

1. INTRODUCTION iii

2. EDITORIAL COMMITTEE iv

3. ACKNOWLEDGMENT v

4. STATEMENTS vi

5. ABBREVIATIONS vii

6. LIST OF TABLES, FIGURES, PICTURES AND PLATES viii

7. SECTION I: SNAKEBITE

8. SECTION II: SCORPION STING

9. SECTION III: MISCELLANEOUS

10. SECTION IV: ANNEXURES

Titles Page

1.1 General 1

Introduction •

Magnitude of the problem •

Epidemiology of snake bite •

Ecological aspects •

1.2 Classifi cation of snakes 4

Snakes of Medical Importance in Tamilnadu - •

Distinguishing features

1.3 Clinical aspects of snake bite 7

Pathophysiology •

Symptoms and signs •

Criteria for diagnosis •

Complications and outcome •

Investigations •

1.4 Treatment 14

First aid for snake bite •

Traditional methods followed for treating snake bite •

Newer methods - pressure pad or Monash technique •

Principles involved in the management •

Pharmacological aspects of Anti Snake Venom •

ASV Administration •

criteria

dosage

administration

Facts to be remembered before / while using Inj.ASV •

ASV reactions •

Prevention of ASV reaction(s) – prophylactic regimens •

SECTION - I

SNAKE BITE

Titles Page

Repeat doses of ASV in Anti haemostatic envenomation •

Recurrent envenomation •

Anti-hemostatic maximum ASV dosage •

Recovery phase •

ASV risk and wastage •

1.5 Clinical issues in Snakebite 29

Hypotension •

Persistent or severe bleeding •

Renal failure •

Surgical issues •

Use of Heparin and Botropase •

1.6 Snake Bite in special situations 32

Victims requiring life saving surgery •

Victims arriving late •

Snake bites again! •

Pregnancy and lactating women •

Others •

1.7 Management at Primary Health Care Centres and Block PHC 33

1.8 Referral aspects 36

1.9 Welfare measures 38

1.10 Occupational risk for snakebite 38

1.11 Preventive measures and health education 39

1.12 Resource material 39

Treatment Guidelines for Snakebite and Scorpion sting - 2008

Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai. 1

1.1 General

Introduction

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 Maharashtra and Goa the live snakes, rarely live cobras are brought

for worship. Snake charmers carry snakes especially cobra, door to door for worship.

At every house the snake’s mouth is forced open and some milk is poured down in

its throat though milk is not snake food. It is also believed that snakes bite people

who harmed them in their previous birth. When snakes are killed, people offer special

prayers and bury them. People also believe that 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 non-scientiÞ c ideas on

snakes and snakebites, and display traditional treatment. Hence, there is a need for

the health department to disseminate the scientiÞ c aspects related to snakebites to the

community.

Magnitude of the problem

Recently global burden of snake bite was assessed using available published data

and modeling technique. From that it is estimated that 4,21,000 envenomations and

20,000 deaths occur annually. These Þ gures may be as high as 18,41,000 envenomation

sand 94,000 deaths.

Snake bites contribute to health problem in India and continue to be a major

medical concern. India alone contributes to 81,000 envenomations and 11,000 deaths

annually. Based on the above statistics, it appears that every 10 seconds one individual

is envenomed and one among four dies due to snake bite. Many deaths occur before

the victim reaches the hospital. Actually up-to-date national data, on the morbidity

and mortality due to snakebite is not available. Moreover there is no national snake

bite registry in India. So the available statistics is incomplete and not systematically

collected. In 1972, Dr. Sawai and Dr. Homma of the Japan Snake Institute studied

snakebite in about 10 hospitals in India. They reported that about 10% of snakebite

deaths are among the victims who come to the hospital and about 90% die outside,

having gone for other remedies like mantra, magic, and so on. However things are

very different now, after 35 years.

Government General Hospital, Chennai, from January to December 2006 has

treated 281 cases of snakebites. Among them, there were 182 males and 99 females.

Treatment Guidelines for Snakebite and Scorpion sting

2 Tamil Nadu Health Systems Project, H&FW Dept, Govt of Tamil Nadu, Chennai.

94 were referred after treatment in different hospitals and 187 were brought to the

hospital directly. 274 (97.5%) survived and 7 died due to various complications of

snakebite while they were in the hospital. The details on the type of snakes, clinical

signs, complications, number referred, number who received supportive therapy and

death are provided below (Table no.1).

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

Type of

snake

Number

treated

Local

signs

Neuro

Toxicity

Hemo.

Toxicity

SupportiveNumber

ExpiredMechnical

ventilationHemo-

DialysisFasciotomy.

Cobra 118 80 118 - 90 - - 2

Krait 82 - 51 82 60 3 - 2

Russell’s

viper42 42 - 42 6 23 1 1

Hump-

nosed

viper

4 4 - 4 - 4 - 1

Saw

scaled

viper

16 16 - 16 - 3 - 1

Sea

snake 3 3 - - - - - -

Non

poisonous16 6 - - - - - -

*Government General Hospital, Chennai (Jan – Dec 2006).

An equal or more number of snake bite cases were admitted and treated at other

Government Medical College Hospitals. Patients go to private hospitals mostly for

Þ rst aid purposes. Very few get adequate treatment in these hospitals.

In Tamil Nadu the total number of snake bite cases admitted (and expired) in the

secondary care hospitals alone during 2005 - 2006 and 2006 -2007 were 19321(85)

and 20677(75) respectively. The total number of ASV vials used in these hospitals

during the respective periods were 94481 and 96800 (Annexure I). Over all analysis

revealed that the snakebites and ASV usage in West, North, East, Central, South zone

of Tamil Nadu were 13, 17, 20, 24 and 26% respectively.

The Government is spending a huge sum of money in procuring and supplying anti

snake venom. On an average, Government hospitals spend 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 on the national economy. Deaths due to snakebite can



be prevented, if some simple Þ rst aid measures are undertaken by the public and / or by

the health care providers. So, there is an urgent need to take effective steps to contain

these issues.

Many of the Þ rst 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. It is gratifying to note that the traditional snake catchers in

Tamil Nadu, the Irulas with their own sophisticated herbal medicine system, have now

understood the problems? They know that the snake injects venom which goes deep

into the system and this can be neutralised only by injection of Anti snake venom

(ASV) and not by oral or locally applied remedies, no matter how famous. But this

information needs to reach other communities also.

Hence, the need to recommend the most effective Þ rst aid to the victims bitten by

snakes and to recommend effective steps in the management of this problem. Poisoning

due to cobra and viper groups are seen frequently in the state of Tamil Nadu. Very

rarely sea snakebite cases are reported. Hence, this hand book focuses on the Þ rst two.

Though the speciÞ c antidote is not available for sea snake, the same general principles

for other snakebites are applicable here too.

Epidemiology of snakebite

Snakebite is observed all over the country with a rural / urban ratio of 9:1. They

are more common during monsoon and post monsoon seasons. Snakebites are seen

often among agricultural workers and among those going to the forest. Many of the

susceptible populations are poor living below poverty line, living in rural areas with

less access to health care. The male / female ratio among the victims is approximately

3:2. Majority are young and their age is between 25 to 44 years. Most of the bites (90

to 95%) are noticed on the extremities (limbs). The hospital stay varies from 2 to 30

days, with the median being 4 days. The in-hospital mortality varies from 5 to 10%,

and the causes are acute renal failure, respiratory failure, sepsis, bleeding and others.

Ecological aspects:

By destroying forests for creating agricultural land, the prey base of the snake

(that is frogs and rats) has increased. The rice Þ elds, which harbour millions of rats

attract a lot of snakes. The number of snakes per acre in a rice Þ eld is abnormally

high when compared to the natural population in the forest. Humans go into the Þ eld

every morning and come 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 ß ourish as long as there are rice Þ elds; 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 Þ elds because they like the plentiful small rodents such as the



Þ eld 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 bushes 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.

1.2 Classifi cation of Snakes:

There are more than 3000 species of snakes in the world. For the purpose of clinical

practice, snakes are classiÞ ed into poisonous (venomous) and non-poisonous (non

venomous) snakes. Poisonous snakes are classiÞ ed into three families and they are

Cobra group [Elapidae] •

Viper group [Viperidae] •

Sea snake group [Hydrophidae] •

For many decades, the concept of the “Big 4” snakes of medical importance has reß ected 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, recently another species, the Hump-nosed pit viper (Hypnale hypnale), has been found to be capable of causing lethal envenomation, and that this problem had been concealed by systematic misidentiÞ cation of this species as the saw-scaled viper. The concept of the “Big 4” snakes has failed to include all currently known snakes of medical signiÞ cance in India. This has a negative effects on clinical management of snakebite and the development of effective snake anti venoms

In 1981, the W.H.O. developed the following deÞ nition of snakes of medical importance (Table No.2). This model is more accurate and useful than deÞ nitions such as the ‘Big 4’ that are inaccurate and misleading to doctors and more importantly to ASV manufacturers.

Table No. 2: Categorisation of snakes (W.H.O. 1981)

Class Details Name of the snakes

I Commonly cause death or serious

disability

Russells viper / Cobra / Saw scaled

viper

II Uncommonly cause bites but are

recorded to cause serious effects

(death or local necrosis)

Krait / Hump-nosed pit viper /

King cobra / Mountain pitviper

III Commonly cause bites but serious

effects are very uncommon.

Water snakes, Green snake



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Snakes of Medical Importance in Tamil Nadu - Distinguishing

features

A great deal is written concerning the problem of how to identify medically

signiÞ cant species from non signiÞ cant 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 information is that it is complex (involves counting

of scales) and not deÞ nitive (the identiÞ cation of pre or post maxillary teeth) and 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 subjected to major variations. What is

important therefore is to focus on the key aspects of identiÞ cation that enable the

medical professional to rapidly identify whether they are dealing with a venomous

species, and what that species might be.

Picture No.1 Tamil Nadu Snakes of Medical Importance



There are six medically important species in Tamil Nadu shown above. Readers are

informed to get familiarised with the pictures given at the end of Hand-book. Further

details of some of the poisonous snake are provided in the ensuing paragraphs.

Russell’s Viper (Daboia russelii)

The Russell’s Viper is a stout bodied snake, the largest of which grows to

approximately 1.8 meters in length. Like all the vipers it is a nocturnal snake, but

unfortunately for humans, during the daytime 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 identiÞ cation features that are worth noting. The Þ rst is a series

of chain-like or black edged almond shaped marks along the snakes back and ß anks.

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)

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 identiÞ cation features of this species is the posture it adopts when

it is agitated. It moves its body into a Þ gure 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 its name of ‘Saw Scaled’. In addition, there are 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 bird’s foot.

The Hump-nosed Pit viper (Hypnale hypnale)

The Hump-nosed pit viper is one of India’s tiniest venomous snakes, its total length

ranging from 28.5 to 55cm. Its distinctive features include the presence of Þ ve 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, is probably India’s most well recognised snake. The hood

markings of the spectacle like mark, distinguishes this snake from other species, and

its habit of rearing up when alarmed makes it distinctive but not deÞ nitive as other



species do this, notably the Trinket Snake. The Cobras coloration may vary from pale

yellow 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 the day it

rests up in piles of bricks, rat burrows or other buildings. The Common Krait is the

most poisonous snake in India and its venom is pre-synaptic neurotoxic in nature.

There are a number of key identiÞ ers which are worth remembering. The Krait

is black, sometimes with a bluish tinge, with a white belly. Its 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 Snake’s 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 really useful if the dead snake

has been brought to the hospital and examined.

King Cobra (Ophiophagus hannah)

The King Cobra is the least medically signiÞ cant of the venomous snakes in India

in terms of both bites and fatalities. Hence, descriptive features of this are not provided

here.

1.3 Clinical aspects of Snake Bite

Pathophysiology:

Snake venom is mostly watery 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 on different

tissues of the body, and are grouped under neurotoxins, nephrotoxins, hemotoxins,

cardiotoxins, cytotoxins etc., resulting in organ dysfunction / destruction. Enormous

clinical and experimental works have been published on the pathophysiology of snake

bite in relation to different species of snakes.

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 also

variable, thus resulting in dissimilar features in different individuals. For example

hyaluronidase allows rapid spread of venom through subcutaneous tissues by disrupting

mucopolysaccharides, and phospholipase A2 has esterolytic effect on the red blood

cell membrane and causes hemolysis. It also promotes muscle necrosis. Thrombogenic



enzymes promote formation of weak Þ brin clot, which activates plasmin and results

in consumptive coagulopathy and hemorrhagic consequences. Venom of some snakes

causes neuromuscular blockade at pre or post synaptic level. In addition to above it

causes endothelial cell damage which results in increased vascular permeability. In

short, snake venom acts on various parts / systems / organs of the body. Venom also

causes endothelial cell damage which results in increased permeability.

Symptoms and signs:

An international expert on snakebite, the late Dr. Alistair Reid of the Liverpool

School of Tropical Medicine found out that only 10 to 15% of venomous bites end

in death. The possibility of survival, even without treatment, is incredibly good in

80-90% of cases. One of the reasons for this is that many snakebites are by non-

venomous snakes. Secondly, a large percentage of venomous snakebites are dry bites

i.e., the snake does not always inject venom. Sometimes, it might inject only a tiny

quantity of venom. The snake can inject the quantity of venom it wants. This is an

entirely voluntary process. Hence, one can never know how much venom was injected

except by observing the progression of the symptoms. In other words the recovery

in snakebite without even treatment is great. Every traditional healer uses this fact

to his / her advantage and propagates his / her own method to treat snakebite viz.,

herbal details, “snakestone” or mantra, or plain soda water and most villagers would

be happy to go to him.

Also, every one should remember 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 other 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.

The symptoms and signs of Viperine and Elapid envenomation as well as late-

onset envenomation are listed below.

General symptoms and signs of Viperine envenomation

Local effects

Swelling and local pain with or without erythema or discoloration at the site •

of bite

Tender enlargement of local lymphnodes as large molecular weight Viper •

venom molecules enter the system via the lymphatics.

Effects due to coagulopathy and hemorrhagic consequences •

Bleeding from the gingival sulci and other ori • Þ ces.



Epistaxis • .

The skin and mucous membranes may show evidence of petechiae, purpura •

and 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 early renal failure or retroperitoneal bleeding. •

Other effects

Muscle pain indicating rhabdomyolysis. •

Parotid swelling, conjunctival oedema, sub-conjunctival haemorrhage. •

General symptoms and signs of Elapid envenomation

Local effects

Swelling and local pain with or without erythema or discoloration at the site of •

bite (Cobra).

Local necrosis and / or blistering / bullae (Cobra). •

Neurotoxic effects

Descending paralysis, initially of muscles innervated by the cranial nerves, •

commencing with ptosis, diplopia, or ophthalmoplegia. The patient complains

of difÞ culty in focusing and the eyelids feel heavy. There may be some

involvement of the senses of taste and smell.

Problems of vision, breathing and speech. •

Paralysis of jaw and tongue may lead to upper airway obstruction and aspiration •

of pooled secretions because of the patient’s 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 paralysis is a •

frequent sign.



Krait bites often present in early morning with paralysis that can be mistaken •

for a stroke. Stomach pain which may suggest submucosal haemorrhages in

the stomach.

Other effects

Stomach pain which may suggest submucosal haemorrhages in the stomach •

(Krait).

Eye pain and damage due to ejection of venom into the eyes by spitting cobra •

(as observed in Africa)

[If features of renal failure are noted search for other causes / mechanisms]

Late-onset envenomation

The patient should be kept under close observation for at least 24 hours. Many

species, particularly the Krait and the Hump-nosed pit viper 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 (young ones), 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 envenomation can also manifest with neurotoxic features. This can

sometimes cause confusion and further work is necessary to establish how wide this

might be. Development of neurotoxic features in Russells Viper bite 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

Feature Cobras KraitsRussells

Viper

Saw Scaled

Viper

Hump Nosed

Viper

Local Pain / Tissue

Damage

YES NO YES YES YES

Ptosis / Neurological

Signs

YES YES YES! NO NO

Haemostatic

abnormalities

NO NO! YES YES YES



Renal Complications NO* NO* YES NO* YES

Response to

Neostigmine

YES NO? NO? NOT

applicable

NOT

applicable

Response to ASV YES YES YES YES NO

[* If features of renal failure are noted search for other causes / mechanisms]

Sea snakes:

Sea snake bites are reported rarely among Þ shermen 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 insigniÞ cat which 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,

rigidity, renal failure, hyperkalemia and Þ nally cardiac arrest.

Criteria for diagnosis

An approach to snakebite is provided in Annexures VIII and IX. The criteria to

diagnose poisonous snakebite in a given clinical setting are:

a. Systemic envenomation in the form of coagulopathy and neurotoxicity.

b. Local envenomation (Table no: 4). Features of local envenomation - are grouped

under the mneumonic “PONDS”.

Table No :4 : Details of local envenomation

• Pain- pain at the site of bite, swelling and regional lymphnode

• Oozing- sero / sanguinous oozing from the site of bite

• Node- development of an enlarged tender lymphnode draining the bitten

limb

• Discoloration- discoloration at the site of bite

• Swelling – swelling is seen at the site of the bites on the digits (toes and

especially Þ ngers); local swelling develops in more than half of the bitten

limb immediately (in the absence of the tourniquet) and swelling extends

rapidly beyond the site of bite (eg. beyond the wrist or ankle within a few

hours of bites on the hands or feet)



%%

Complications and Outcome

Complications in snake envenomation are due to the heterogenous composition of

the venom. In addition the quantity and quality of the venom and the response of the

individual to the components of venom inß uence the clinical course, complications

and outcome. The complications of venom are observed in various systems viz., 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 amount of envenomation, bite to needle

time, individual’s response to envenomation, the complications that develop following

snakebite and response to treatment. Till the patient has recovered, one cannot predict

the complications and outcome.

Investigations

20 Minutes Whole Blood Clotting Test (20WBCT)

The 20 Minutes Whole Blood Clotting Test (20WBCT) is considered as the most

reliable test for coagulation and can be carried out at the bedside without specialised

training. It can also be carried out in the most basic settings. It is signiÞ cantly 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

Typical signs of local envenomation namely edema,

blister and joint swellingCellulitis with compartmental syndrome

Picture No.2 Picture No.3



Table No. 5: 20 Minutes Whole Blood Clotting Test (20WBCT)

Advantages Requirements Procedure

The most •

reliable test of

coagulation.

Can be carried •

out, at the

bedside.

Does not •

require

specialised

training.

Dry glass test tube •

(clean and new)

2ml disposable •

syringe

Cotton •

Antiseptic solution •

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)

Wash hands with soap and water. •

Wear the gloves •

Collect 2ml blood from the •

peripheral vein of the unaffected

limb

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 patient’s 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 of repeat doses of ASV. This is due to the inability of the

liver to replace clotting factors under 6 hrs.

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.

- Ocular fundus examination



1.4 Treatment

First aid for snake bite

The Þ rst 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 don’t work and can be dangerous!)

G. H. = Get to Hospital Immediately. •

(Traditional remedies have NO PROVEN beneÞ t 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.

Traditional fi rst aid methods followed for snakebite:

The traditional methods such as application of tourniquet, cutting (incision) and

suction, washing the wound, snake stone or other methods have adverse effects and

hence, they have to be discarded. The mneumonic used to recall some of the traditional

methods followed is “WHISTTLE” and these are described below.

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 ß ow of

venom into system by stimulating the lymphatic system.

Household remedies:

Various forms of household remedies are applied to the site of bite which may

enhance absorption of venom.



(Incision) 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.

Snake stone:

Snake stone is applied to the site of bite saying that it will absorb the venom and

falls once the venom is absorbed. This contributes to delay in seeking appropriate

health care.

Tourniquets:

Tight tourniquets made of rope, string and cloth, have been followed traditionally

to stop venom ß ow into the body following snakebite. The problems noticed with

tourniquets are :-

Risk of ischemia and loss of the limb •

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

Thermal methods:

Cautery treatment • is followed in some areas. It is injurious and not

beneÞ cial

Cryotherapy • involving the application of ice to the bite was proposed in the

1950’s. It was subsequently shown that this method had no beneÞ t and merely

increased the necrotic effect of the venom.

Local application of anti snake venom:

Local application of anti snake venom has not shown any beneÞ cial effects

Electrical Therapy:

Electric shock therapy for snakebite received a signiÞ cant amount of press

coverage in the 1980’s. 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 scientiÞ c papers. It has been demonstrated that the electric shock

has no beneÞ cial effect and hence, it has been abandoned as a method of Þ rst aid.

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 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 signiÞ cant snakes of India. In view of

the difÞ culties encountered at every level, Pressure Immobilisation Method cannot be

recommended for use at present.

Newer Methods

‘Pressure Pad or Monash Technique’

Initial research has suggested that a ‘Pressure Pad or Monash Technique’ may have

some beneÞ t in the Þ rst aid treatment of snakebite. This method should be subjected

to further research in India to assess its efÞ cacy. 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 Þ rst aid in difÞ cult geographic

settings where the need is great.

Treatment:

While dealing with a case of snake bite consider the mnemonic ‘RASI’.

Remember principles ( “12 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, •

management, outcome, welfare measures and follow up 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 “12 As”



Table No. 7: Principles involved in the management

Admit the victim immediately.1.

Ask effectively.2.

Assess quickly.3.

Act swiftly.4.

Administer medication meticulously.5.

Address to the wound properly.6.

Anticipate complications keenly.7.

Avoid errors carefully.8.

Ascertain the status repeatedly.9.

Amicable with patients and care givers and show empathy.10.

Advise on follow up accordingly.11.

Arrange for referral early.12.

1] Admit all victims of snake bite & Keep the victims under observation for 24 to 48

hours

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, 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] Airway, Breathing and Circulation

b] Vitals HR, RR, BP and oxygen saturation by Pulse oximetry (if required)

c] Chest expansion, and the ability to put out the tongue beyond incisors and

counting the numbers at the bed side.

d] Site of snake bite along with regional lymphadenitis clinically from head to

foot as well as back

e] For associated co-morbid illness[es]

f] For consuming any medication[s]

g] The status of envenomation - local systemic (neurotoxic, hemotoxic, myotoxic)

or a combination of them

4] Act swiftly

a] Support Airway, Breathing and Circulation

b] Start IV line [ß uid for children refer to Annexure II –Table No.29]



c] Provide supportive measures depending upon the requirements including blood

transfusion / components if required.

d] Connect to ventilator if there is a need

5] Administer medications meticulously

a] Tetanus Toxoid injection intramuscularly

b] Anti snake venum as IV drip if needed – described vide infra

(ASV is composed of large molecules (IgG or fragments) and are absorbed

slowly via lymphatics, making the bioavailability by this route poor as

compared to intravenous administration. Also, intramuscular injections

are not preferred as it could cause pain on injection and risk of hematoma

formation and sciatic nerve damage in patients with hemostatic abnormalities.

Intramuscular injections should only be given in settings where intravenous

access cannot be obtained and / or the victim cannot be transported to a hospital

immediately).

c] Ionotropics as IV drip if required

d] Antimicrobials if necessary

e] IV ß uids as per need [ß uid for children refer to Annexure II – Table No.29]

f] Other supportive medications including medicines to relieve pain (avoid

aspirin) 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 speciÞ c one. (Non-speciÞ c ulcers are deÞ ned as ulcers due to

infection of wounds, physical or chemical agents or due to local irritation).

d] 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 epithelialisation and to prevent contamination of the

wound.

Keep wounds clean and dry. •

Avoid soaking or scrubbing the wound. •

Teach & explain the care of wound to the patients. •

Educate on good personal hygiene and nutrition. •

Control diabetes if identiÞ ed. •

7] Anticipate complications keenly.

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 carefully while assessing the case, investigating the victims,

administering medications, following the case at hospital, undertaking any procedures,

referring to other specialists or hospital, communicating with patient / and care

givers, and planning for discharge as well as preparing reports, Þ lling 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 develop covert signs during hospital stay while on

treatment.

10] Amicable interaction with patient and care givers with empathy is essential 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 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.

Pharmacological aspects of Anti snake venom

The goals of pharmacotherapy with injection Anti snake venom (ASV) are to

neutralise the venom, reduce morbidity and mortality, and prevent complications.



Currently available Anti Snake Venom (ASV) 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 derived from horse serum and has a half-

life of over 90 hours. Though it is puriÞ ed, it still can be immunogenic.

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. Moreover it

is difÞ cult for the physician to determine which type of Monovalent ASV to employ

in treating the patient. In addition there are difÞ culties to prepare, supply and maintain

adequate stock of species speciÞ c 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

speciÞ c species such as Sochurek’s 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 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 years shelf life. Lyophilised ASV, in powder form, requires only to be kept

cool and hence, is useful in remote areas where power supply is inconsistent. The

details of pre hospital treatment and issues related to ASV may be recorded in the form

provided in Annexure IV.

ASV Administration

Criteria

ASV is prepared from animal and hence, it should only be administered when there

are deÞ nite signs of envenomation. Anti-Snake Venom carries risks of anaphylactic

reactions and should not therefore be used unnecessarily. Unbound, free ß owing

venom, can only be neutralised when it is in the bloodstream or tissue ß uid. Also it

is a scarce and costly commodity. Hence, ASV may be administered only if a patient

develops one or more of the following signs / symptoms.



Systemic envenoming

Evidence of coagulopathy primarily detected by 20 WBCT or visible •

spontaneous systemic bleeding, bleeding gums, etc., Further laboratory tests for

thrombocytopenia, Hb abnormalities, PCV, peripheral smear etc may provide

conÞ rmation, but 20 WBCT is paramount.

Evidence of neurotoxicity: 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. •

Local envenomation (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 administration of ASV may be justiÞ ed.

Dosage

In the absence of deÞ nitive data on the level of envenomation, symptomatology is

not a useful guide to the level of envenomation. Any ASV regimen adopted is at best

only an estimate. What is important is to establish a single guideline which could be

adhered to, in order to enable sensitization results to be reliably reviewed.

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 147mg.

One vial of ASV neutralises 6mg of Russells Viper venom. So, to neutralize

63mg of venom, 10 vials are needed. Not all victims will require 10 vials as some may

be injected with less than 63mg. However, starting with 10 vials ensures that there is

sufÞ cient neutralising power to neutralise the average amount of venom injected and

during the next 12 hours to neutralise any remaining free ß owing venom.

Warrell et al based on their study have shown that test doses for ASV 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.

Administration

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 II)

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 of Anti Snake Venom (ASV)

1. ASV is available in a polyvalent form and marketed in liquid or lyophilised

preparations in 10ml vial / ampoule.

2. Remember to use and maintain cold chain systém 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.

4. Before administering ASV, health staff should read and check the status of vial or

ampoule containing ASV.

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

6. 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 prevented by test

dose.

8. ASV neutralises the unbound venom, hence give it early.

9. ASV administration should not be delayed or denied on the grounds of anaphylactic

reactions to a deserving case.

10. ASV is required only to those who show deÞ nite signs and symptoms of

envenomation.

11. ASV should not be pushed as IV bolus or IM directly. ASV has to be 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 intra-compartmental pressure, particularly in the digits.

Hence, it should not be adopted.



13. There is no prophylactic dose of ASV.

14. Total dose requirement cannot be decided on the basis of (WBCT) Whole blood

clotting test (or) clinical signs and symptoms.

15. Even if the patient develops reaction(s), the total dose required should be

administered slowly after the patient recovers from the reaction(s).

16. There is no other drug of choice other than ASV for the treatment of poisonous

snakebite.

17. The patient has to be closely monitored for manifestations of reactions to ASV for

atleast 2 hours continuously.

18. No interaction with ASV has been reported.

19. Fetal risk due to ASV has not been established or studied in humans.

20. Safety status for use of ASV during pregnancy has not been established.

21. Timely administration of ASV will not guarantee the recovery or protect the

individual from the venom induced toxicity or complications deÞ nitely.

ASV Reactions

* Reaction to ASV develop usually within 15 to 30 minutes or within 2 hours. So

monitor the case on ASV at 5min. interval for Þ rst 30min. and then at 15min.

interval for two hours. The details of pre hospital treatment and issues related

to ASV may be recorded in the form provided in Annexure IV.

* Some times, anaphylaxis (Type I) following 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

Itching (often over the scalp) •

Urticaria, even a single spot •

Nausea •

Vomiting •

Abdominal colic / pain •

Diarrhoea •

Tachycardia (PR >120/min) (for •

children refer age speciÞ c chart)

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) •

Anaphylaxis (Type I ) •



Treatment for ASV reactions

Discontinue ASV •

Maintain IV line •

Administer Inj. Adrenaline 0.5ml of 1:1000 IM, (Adults) / Inj. Adrenaline •

0.1ml/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 repeated for a third

and fi nal occasion but in the vast majority of reactions 2 doses of Adrenaline will

be suffi cient).

Studies have shown that adrenaline reaches necessary blood plasma levels in

8 minutes in the IM route, and in 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 slowly. 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 *Children (upto 25 kg)

Inject adrenaline 1:1000 intramuscularly:

Weighing < 50 kg give 0.25 ml •

Weighing 50 -100 kg give 0.50 ml •

Weighing >100 kg give 0.75 ml •

Inject adrenaline 1:10,000 dilute

1ampoule (1 ml) of adrenaline 1:1000

with 9ml water for injection or normal

saline.

Inject intramuscularly 1:10,000

adrenaline according to the guide

(approximates to 0.1ml/kg).

1 year (10 kg) give 1 ml •

3 years (15 kg) give 1.5ml •

5 years (20 kg) give 2ml •

8 years (25 kg) give 2.5ml •

Children > 25 kg as for small •

adults

Approximate body weight for children 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: Administer both H •1 receptor blockers Inj. Chlorpheniramine

maleate 10 - 20mg as IV / intramuscularly or Promethazine 0.5 - 1mg/kg

and H2 receptor blockers Inj.Ranitidine 1mg/kg or Famotidine 0.4mg/kg or

Cimetidine 4mg/kg slowly intravenously.

The dose for children is of Pheniramine 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

Chlorpheniramine maleate IV, and 2mg/kg of Hydrocortisone IV, antihistamine

use in pediatric cases must be deployed with caution.

Administer Corticosteroids intravenously: Hydrocortisone 2 - 6mg/kg or •

Dexamethasone 0.1 - 0.4mg/kg

Try nebulised Adrenaline (5ml 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 ß uids should be given for haemodynamic instability. •

Once the patient has recovered, the ASV can be restarted slowly for •

10 - 15minutes, 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 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. (Duration of treatment has to be

adjusted with case). Oral H1 Antihistamines provide additional symptomatic relief.

Prevention of ASV Reactions – Prophylactic Regimens

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 deÞ nitive trial evidence.



Two prophylactic regimens normally recommended are given below:

100mg of Hydrocortisone and H •1

antihistamine (10mg Chlorphenimarine

maleate; or 22.5mg IV Phenimarine maleate IV or 25mg Promethazine

hydrochloride IM) 5minutes 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.

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 of ASV in Neurotoxic Envenomation

The ASV regime relating to neurotoxic envenomation has caused considerable

confusion. If on reassessment after 1 - 2hrs the initial dose has been unsuccessful in

reducing the symptoms / if the symptoms have worsened / if the patient has gone into

respiratory failure then a further dose should be administered. 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 a patient 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 Þ rst few hours. After that the body recovers by using its own

mechanisms. Large doses of ASV, over long periods, have no beneÞ t in reversing

envenomation.

Confusion has arisen due to some medical text books 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 justiÞ cation for massive doses of 50+ vials in India, which usually results

in 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 are not necessary.



Repeat Doses of ASV in Anti Haemostatic envenomation

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 within 6 hours.

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 identiÞ ed

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 to 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.

Case of cobra snake bite in the recovery phase showing bilateral ptosis with

overaction of frontalis

Neuroparalysis recovering only showing

Ophthalmoplegia

Picture 4 Picture 5



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? 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. Coagulopathy can / may continue

for up to 3 weeks as in the case of Hypnale.

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 147mg, 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

180mg of neutralising capacity, this should certainly be enough to neutralise free

ß owing 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), cryoprecipitate

(Þ brinogen, factor VIII) fresh whole blood, thrombocytes or coagulation factors can

be considered, if available. Plasmapheresis has been used successfully under such

circumstances amidst controversies. More clinical trails are warranted in these areas.

Recovery Phase

If an adequate dose of antivenom has been administered, the following responses may

be seen:

a) Spontaneous systemic bleeding such as gum bleeding usually stops within

15 - 30 minutes.

b) Blood coagulability is usually restored in 6 hours. (Principal test is

20 WBCT).

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 reß ecting 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) Patients in shock blood pressure may increase after 30 minutes while on

treatment.



ASV risk and wastage

DeÞ nitive diagnosis and proper utilisation of ASV helps the patient. Otherwise

the patients are subjected to risk of receiving excessive / inadequate dosage of ASV.

More over the availability of ASV and doctors views and experience may inß uence the

utilisation of ASV for a given patient. Thus there is a possibility of Þ rst aid wastage of

ASV. The details of provided in Table No.10.

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

Low wastage High wastage

High risk ASV - Not available

- InsufÞ cient

administration

ASV – Too little supply and species

are different

Low risk Effective dose of ASV to

envenomed patients

Receive ASV when not required

Too much ASV when not required

Unnecessary ASV

1.5 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 are used for volume

expansion. However, there is no conclusive trial evidence to support a preference for

colloids or crystalloids.

In cases where increased 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 ß ow rate may be adjusted to

maintain blood pressure adequately. Rarely Russell’s Viper bites are known to cause

acute pituitary and / or adrenal insufÞ ciency. This condition may also contribute to

shock. Hence, this entity has to be remembered while dealing with hypotension in

snakebite as these cases require long term follow up.

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 appropriate treatment

should be considered. The major point to note is that clotting must be re-established

before additional measures are taken. Adding clotting factors, fresh frozen plasma



(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. Plasmapheresis has been used successfully in such situation.

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 Þ ngers •

Debridement of necrotic tissues •

Compartment syndrome and others •

Practitioner while dealing a case of snake bite with one or other surgical

issues has been informed to remember the following and keep the patient

and the care givers accordingly.

! 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.

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

Assess for internal and external •

surgical issues related to

envenomation carefully and observe

for the same 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

of the limb if any of the following

6 Ps. or a combination of them

appear.

Pain on passive stretching •

Pain out of proportion •

Pulselessness •

Pallor •

Paresthesia •

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.

Care of the wound •

- Apply appropriate topical agents

and dressing

- Maintain proper wound

environment

- 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

(normal <20mm Hg)

Monitor ICP every 30 to 120 •

minutes if required

Proceed with fasciotomy if the ICP •

exceeds 30 to 40mm of Hg.

Restore coagulation time before •

commencing the procedures.

Use of Heparin and Botropase in Viper Bites

Heparin has been proposed as a means of reducing Þ brin deposits in DIC. However,

heparin is contraindicated in Viper bites. Venom induced thrombin is resistant to

Heparin, the effects of heparin on antithrombin III (ATIII) are negated due to the

elimination of ATIII by the time Heparin is administered and hence, heparin can cause

bleeding by its own action. Clinical trial did not show any beneÞ cial 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. To conclude,

heparin and botropase have to be avoided.

1.6 Snake Bite in special situations

ASV Dosage in Victims Requiring Life Saving Surgery

In very rare case of snake bite 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

justiÞ ed (upto 25 vials) solely on the basis of guaranteeing 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 20 WBCT 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 having 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 patient requires respiratory support.

Snake bites Again!

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

Pregnancy and Lactating woman

There is very little deÞ nitive 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 re-assessed 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. ASV may be administered

to lactating woman if bitten by a poisonous snake and be treated like any other persons.

Breast feeding is not contraindicated.

Others:

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 ASV in the same manner like any other case of

poisonous snake bite.

1.7 Management in Primary Health Centre (PHC) 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 treat snakebite with conÞ dence.

Evidence suggests that doctors are not willing to make use of ASV and other

medications, even when equipped, due to lack of conÞ dence 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 Tables 12, 13 and 14

respectively.

Table No. 12: Initial evaluation – No Systemic Envenomation

ASSESS CLASSIFY TREATMENT

Vital signs

Pulse •

BP •

Respiration •

Vital signs (Adult)*

Pulse rate: 60-100/min •

BP 110 / 70 to 140/95 •

Respiratory r • ate <20/

min

Tab.Paracetamol

Inj.Tetanus Toxoid IM

Routine antimicrobials are

not necessary



Symptoms and signs

Bite marks •

Ptosis •

Double vision •

DifÞ culty in •

swallowing

Bleeding sites •

Reduced urine output •

Swelling and local •

pain

Local necrosis •

Descending paralysis •

Unconsciousness •

Regional •

lymphadenitis

Any other symptoms •

and signs noted down

Symptoms and signs

Local pain and/ or •

swelling+

Bite mark present, •

skin broken

No other symptoms •

and signs present

Laboratory test:

20 Minutes Whole Blood

Clotting Test - blood clot

formed

If above Þ ndings are there

at the time of assessment

classify as No systemic

envenomation

Monitor Pulse, Respiration

& BP every ½ hourly for 3

hours and every 4th hourly

for remaining 48 hours.

If normal send the

patient home

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

If the patient has any systemic manifestations refer to Table.13 and 14 for hemotoxic

and neurotoxic envenomation respectively. The details of local envenomation are

provided in Table 4.



Table No. 13: Haemotoxic envenomation


Vital signs

Pulse •

BP •

Respiration •

Symptoms and signs

Bite marks •

Ptosis •

Double vision •

DifÞ culty in •

swallowing

Bleeding sites •

Reduced urine output •


pain

Local necrosis •

Descending paralysis •

Unconsciousness •

Lymphadenitis •

Breathing difÞ culty •

Any other, note •

down


Pulse rate >120 per

minute, feeble (a

response to hypotension)

Respiratory rate > 20/min

Hypotension <

90/60 mmHg

Symptoms and signs

Swelling and local pain

or painful enlargement of

nearby lymphnodes

Bleeding from the

Gingival sulci •

Epistaxis •

Petechiae, purpura,

ecchymoses

Hematuria

Intracranial bleeding:

asymmetrical pupils •

unconsciousness •

convulsions •

Persistent and severe

vomiting or abdominal

pain

Low back pain

No urine output or

decreased urine output

Laboratory test:

20 Minutes Whole Blood

Clotting Test.

Blood clot not •

formed

If above Þ ndings are

there at the time of

examination classify as

Haemotoxic

envenomation

Treat the patient with Anti

Snake Venom (ASV)

Start IV Normal Saline with •

wide bore needle

Begin with one vial of ASV •

in one point 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.Pheniramine maleate 2ml IV

Inj.Adrenaline 1:1000 (0.5ml)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 Þ ve minutes

interval for Þ rst 30 minutes

and then at 15 minutes

interval for two hours

Stabilise the patient and •

refer to the higher institution

Aspirin should not be used



Fluid requirements per day should be kept in mind while giving ASV. For children

readers are requested to see the ß uid requirement chart provided in Annexure II.

[Table No.29]

* Vital signs for children (see age speciÞ c chart) are provided in Annexure III.

[Table no.30 to 33].

Table No. 14: Neurotoxic envenomation


Symptoms and signs

Swelling and local pain •

Local necrosis •

Descending paralysis starting with •

ptosis, external ophthalmoplegia

Numbness around the lips and •

mouth progressing to pooling of

secretions, difÞ culty to talk and

respiratory failure

Paradoxical respiration •

Paralysis •

Abdominal pain •

Laboratory test:

20 Minutes WBCT - Blood clot formed

If above signs & symptoms are

present at the time of admission

classify as Neurotoxic envenomation

Treat the patient with ASV

as mentioned in Table 13

and add the following:

Inj.Neostigmine 1.5 mg

(Therapeutic Test dose) as

IM and

Inj.Atropine 0.6 mg (Test

dose) as IV

After that observe patient

for every Þ ve minutes for

30 minutes for signs of

response

1.8 Referral aspects

The medical ofÞ cer who is treating the cases of snake bite should take meticulous

care to look in to the patient’s status and provide Þ rst aid as well as supportive measures

before referring the case to higher centre / speciaslist. The details are furnished in

Table 15 below.

For local envenomation refer to Table 4.

For systemic envenomation refer to Tables 12 and 13



Table No. 15: Referral aspects for snakebite

Who needs? When to refer? Where to refer?

Patient requiring

Respiratory support •

Deteriorating •

neurologic

manifestations

Surgical •

intervention-Necrosis

/ Fasciotomy

Spontaneous •

persistent bleeding

Co-morbid diseases •

Acute impending •

kidney failure

Refer the patient •

after stabilising the

case and after giving

injection ASV (Refer

to Annexure VIII and

IX)

Refer to higher institution

having

Ventilator •

Dialysis facilities •

Measures to provide •

further supportive

treatment.

Referral Criteria for Haemotoxic envenomation

Once the ASV is Þ nished 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 hours rule ensures that a six hours

window is now available in which to transport the patient.

Referral Criteria for Neurotoxic envenomation

If after one hour from the end of the Þ rst dose of ASV, the patient’s 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 consider this case for referral to a

higher centre

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 •

Send the referral note with details of treatment given •

Instruct one staff to accompany the patient during transportation if required. •

Hand over the referral form with details regarding treatment given •

Mention the clinical status clearly in the referral form at the time of referral. •

1.9 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

certiÞ cate mentioning the cause of death as complications following snakebite in

a clear manner (as observed while on treatment). The amount varies from state to

state. Treating doctor should inform the family members of the deceased, and guide

them regarding the ways and means for getting the welfare measures provided by the

government.

1.10 Occupational risk for Snake bite

The normal perception is that rural agricultural workers are most at risk and the

bites occur Þ rst 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 signiÞ cant 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 grass-cutting •

colleagues.

Walking at night without a torch, barefooted or wearing sandals accounts for a •

signiÞ cant 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 non-venomous.

Cobras and other venomous species are good swimmers and may enter the

water to hunt.

Walking along the edge of waterways. •

Plucking ß owers in areas of ß ower cultivation •

Plucking hay / straw from bundle of hay / straw •

Persons involved in picking up dry Þ re wood, loose stones, heaps of paddy, •

sugar cane or jowar husk.

1.11 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 Þ rst. 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 Þ xed 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.

1.12 Resource materials

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2. Agarwal R. Singh AP, Agarwal AN. Pulmonary oedema complicating snake

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3. Ahmed SM, Ahmed M, Nadeem A, Mahajan J, Choudhary A, Pal J. Emergency

treatment of a snake bite: Pearls from literature. J Emerg Trauma Shock

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808.

6. Athappan G, Balaji MV, Navaneethan U, Thirumalikolundusubramanian P

Acute renal failure in snake envenomation: a large prospective study. Saudi J

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12-14, 2007 P.204

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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.

9. Banerjee RN, Sahni AL, Chacko KA. Neostygmine in the treatment of Elepidae

bites. Journal of Association of Physicians of India 1972; 20: 503-509.

10. Bawaskar HS, Bawaskar BH. ProÞ le of snake bites envenoming in western

Maharashtra, India. Trans Roy Soc Trop Med Hyg 2002; 96: 79-84.

11. 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.

12. Bawaskar HS, Bawaskar BH, Punde DP, Inamdar MK, Dongare RR, Phoite RR

ProÞ le of snakebite envenomation in rural Maharashtra. Journal of Association

of Physician of India 2008:56: 88 – 95

13. Bhat R.N., Viperine Snake Bite Poisoning in Jammu. JIMA 1974:63:383 – 392.

14. Chugh K.S. Snake Bite induced Acute Renal Failure. Kidney International

1989:35:891 – 90

15. Daga S, Biswas K, Roy K. Editorial: Medical record keeping- are we prepared?

J Indian Med Assoc 2008; 10: 145.

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the Clinical Management of Snake Bites in the South East Asian Region.

World Health Organization, Regional OfÞ ce for South East Asia, New Delhi

2005;PP67 + viii.



17. Ghosh S. Management of snake bite – an update. In: Bichille SK, Hasa NK,

Mehta SS. (Edrs). Medicine update. The association of physicians of india

2008; 18(chapter 90): 691-696.

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Government of Tamilnadu, Chennai, dated 19.01.2006.

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Department, State Government of Tamilnadu, Chennai, dated 02.11.2007.

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Department, State Government of Tamilnadu, Chennai, dated 09.01.08

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Chennai, Letter No. 637/P1/06-2 dated 27.01.06

22. 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.

23. Howarth DM, Southee AS, Whytw IM, Lymphatic ß ow rates and Þ rst aid

in simulated peripheral snake or spider envenomation. Medical Journal of

Australia 1994; 161: 695-700

24. 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.

25. 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

26. Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK,

Pathmeswaran A, etal. (2008) The global burden of snakebite; A literature

analysis and modeling based on regional estimates of envenoming and deaths,

PLoS Med 5(11): e218 doi:10.1371/journal.pmed.0050218

27. 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.

28. 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

29. Medical management of severe anaphylactoid and anaphylactic reactions.

www.australianprescriber.com/magazine/24/5/artid/546/ accessed on 08.02.08



30. Nayak KC, Jain AK, Sharda DP, Mishra SN. ProÞ le of cardiac complications

of snake bite. Indian Heart J. 1990 May-Jun;42(3):185-8

31. 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

32. Norris RL, Bite marks and the diagnosis of venomous snakebite. Journal of

Wilderness Medicine 1995; (6): 159-161

33. Pahlajani DB, Iya V, Tahiliani R, Shah VK, Khokhani RC. Sinus node

dysfunction following cobra bite:case reports. Indian Heart J. 1987:39:48-9

34. Pillay VV. (Edrs). Modern Medical Toxicology. Third Edition. Jaypee Brothers.

medical publication(P) Ltd., New Delhi 110 002. 2005; PP 499 + xviii

35. Rajendiran C, Simpson ID. Indian National Snake bites Protocol-2007

(OP-040). Abstract book of 6th annual conference of Asia PaciÞ c Association of

Medical Toxicology held at Bangkok, Thailand, December 12-14, 2007 P.104

36. Sarangi A, Jena I, Sahoo H, Das JP. A proÞ le of snake bite poisoning

with special reference to haematological, rental, neurological and

electrocardiographic abnormalities. J

37. Singh S, Dass A, Jain S, Varma S, Bannerjee AK, Sharma BK. Fatal

non-bacterial thrombotic endocarditis following viperine bite. Intern Med.

1998 Mar;37(3):342-4.

38. Senthilkumaran S. Cardiac complications among snake bite victims. Personal

communication

39. Simpson ID. The paediatric management of snake bite . The National Protocol.

Indian Pediatrics 2007,44:173-176

40. 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

41. Simpson ID. Snake bite management in India, the Þ rst few hours: a guide for

primary care physicians. Journal Indian Medical Association 2007;105: 324,

326, 328, 330, 332, 334 & 335.

42. Simpson ID. Indian National Snake bite Protocol. www.indianwildlifeclub.

com/blog/topic.asp?id_top=10 accessed on 28.01.08

43. Sharma S, Chappins F, Jha N, Bovier PA, Loutan I, Koriala S. Impacts of snake

bites determinants of fatal outcomes in Southern Nepal. Amer J Trop Med Hyg

2004; 71(2):234-38



44. Srivastava RK. Director General, OfÞ ce of the Directorate General of Health

Services, Nirman Bhawan, New Delhi – 110011. Letter D.O.No.D.32020/3/2008

– EMR, Dated 5th February, 2008.

45. Training module Poison First aid and Treatment Centre (BEmONC, PHC),

State Health Mission Health and Family Welfare Government of Tamil Nadu,

Chennai. 2008.

46 Thirumalaikolundusubramanian P, Areas for research on Snake Bite / Scorpion

Sting, Personal records.

47. Thirumalaikolundusubramanian P, Rajendiran C. Medical audit for snake bite

and scorpion sting. Unpublished records

48. Tun Pe, Tin-Nu-Swe, Myint-Lwin, Warrell DA, Than-Win, The efÞ cacy of

tourniquets as a Þ rst aid measure for Russells Viper bites in Burma Trans. R

Soc Trop Med Hyg 1987; 81:403-405

49. Tun P, Khin Aung Cho. Amount of venom injected by Russells Viper (Vipera

russelli) Toxicon 1986; 24(7): 730-733

50. Veerapandian R. [Edrs]. Guidelines for common surgical interventions in

the elderly. Developed under WHO – Government of India collaborative

programme 2006-07. August 2007.

51. Visweswaran RK, George J. Snake bite induced acute ranal failure. Indian J

Nephrol 1999; 9(4): 156-159.

52. Warrell, D.A. (Edrs). 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.

53. 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.

54. 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

55. When a cobra strikes. The Hindu (Online edition of India’s National newspaper)

June 13,2004. www.thehindu.com accessed on 30th June 2008.

56. Yildirim C, Bayraktaroglu Z, Gunay N, Bozkurt S, Kose A, Yilmaz M. The

use of therapeutic plasmapheresis in the treatment of poisoned and snake bite

victims: an academic emergency department’s experiences. Journal of Clinical

Apheresis 2006;21(4):219-23.

Titles Page

2.1 General 45

Introduction •

Epidemiology •

Eco-biological aspects of scorpion •

Distribution of various species of scorpions •

Socio cultural aspects •

2.2 Clinical aspects 47

Components of venom and mechanisms of action •

Pathophysiology •

Symptoms and signs. •

Criteria for diagnosis •

Differential diagnosis •

Investigations •

Clinical course •

Complications •

2.3 Treatment 54

First aid measures •

Traditional methods •

Principles involved in the management •

Pharmacological aspects of Prazosin •

2.4 Scorpion sting in special situations 60

2.5 Management at PHC and Block PHC 60

2.6 Referral aspects 62

2.7 Occupational risk, patient education and prevention 63

2.8 Prognosis 64

2.9 Resource Material 64

SECTION - II

SCORPION STING



2.1 General

Introduction

Scorpion sting is a life threatening medical emergency. The effect of envenomation

is greatest among children below 5 years of age. Adults too can succumb to scorpion

sting. Many social and environmental factors contribute to scorpion sting. Hence, it

becomes an important public health problem. The epidemiology, presenting features,

clinical course, complications, therapeutic response and outcome are variable in

different series. However, early recognition and appropriate intervention inß uence the

outcome. Hence, scorpion sting deserves special attention and cases should never be

taken lightly.

Though the research on scorpion venom and knowledge on treatment of scorpion

sting have advanced, these newer ideas are yet to reach the health care provider and

the community. In this context, it is worthwhile to remember Dr.H.S.Bawaskar, a

private practitioner from Maharashtra who for the Þ rst time in world has introduced

the usefulness of alpha blocker in scorpion sting nearly 25 years ago. This has been

accepted globally now in the treatment of scorpion sting.

Epidemiology

In general for every case of snakebite, there may be 10 or more numbers of scorpion

stings. If that is the case, the number of cases of scorpion sting may run to millions.

There is no reliable statistics on the scorpion sting in India. Scorpion sting is under-

reported. Published reports are institution based, hence include only serious cases of

scorpion sting treated in such institutions. As most of the cases of scorpion sting have

mild symptoms, the general practitioners or family physicians or a traditional medical

practitioners provide treatment and they never appear in health statistics.

In Mexico, 1000 deaths due to scorpion sting occur per year whereas in USA four

deaths were reported in 11 years. Of the 13,000 stings reported in USA, majority was

due to non lethal scorpions. Most deaths occur during the Þ rst 24 hours of the scorpion

sting and are secondary to respiratory and cardiovascular failure. Children and elderly

are at great risk of death due to their decreased physiological reserve. Death due to

scorpion sting occurs in 25% of children below 5 years, if not treated, whereas only

1% of scorpion stings are lethal to adults.

In India too, deaths due to scorpion sting occurs across the country but do not get

due attention. Larger the scorpion population, greater is the number of scorpion sting

cases. Scorpion stings are reported more from rural areas and the rural to urban ratio

is approximately 3:1. Mostly stings occur between 6 P.M. to mid-night and between

6 A.M. to 12 Noon, which correlate very well with human activity. Scorpion sting

occur more in temperate and tropical zones, and more during summer than winter.



The Institute of child health, Madras Medical College, Chennai, has recorded nearly

1900 cases between 1980 and 1999 and the death rate varied from 4 to 7%. Of the 727

cases of scorpion stings treated during the period of 2000-2007 which included 406

males and 321 females [M: F= 4:3]; the death among them were 11 and 8 respectively.

The death rate in children due to scorpion sting was 2% which has come down from

4 to 7% earlier.

In general, male to female ratio of scorpion sting is approximately 2:1 but females

suffer more due to lower body weight. There is no racial predilection but clinical

symptoms, course, and outcome vary because of individual’s genetic constitution and

other factors [vide infra]. Human stinging occurs accidentally, when scorpions are

touched, threatened, cornered or disturbed (stepped upon) while in their hiding places.

So, people involved in handling construction materials, carpentry works, clearing

bushes or house cleaning as well as children playing nearby these areas are susceptible

to scorpion sting.

Eco- biological aspects of scorpion

Scorpions are shy creatures and not aggressive by and large. These are nocturnal

creatures and hunt for their prey at night. Scorpions hide normally in crevices and

burrows during daytime to avoid light. Scorpions are found elsewhere outside the

environmental range. eg., accidentally crawl into luggage, boxes, containers, or shoes,

pile of bricks, wooden materials, Þ rewood, etc. They may also be transported in

traveller’s luggage and cargo.

There are about 1500 scorpion species of which 50 are dangerous. In India 86

species of scorpion have been identiÞ ed. Among them, Mesobuthus tamulus and

Palamneus swammer-dami are important medically. Except Hemiscorpius species,

all lethal scorpions belong to the family called the Buthidae. The lethal members

of Buthidae family include the genera of Buthus, Parabuthus, Mesobuthus, Tityus,

Leiurus, Andractonus and Centruroides. Among the 30 scorpion species found in USA,

only one of them is dangerous to human beings.

Scorpions live in temperate and tropical regions especially between the latitudes of

50o north and 50o south of equator. The distinguishing features between lethal and non

lethal scorpions are provided in Table 16 given below.

Table No. 16: Distinguishing features of lethal and non-lethal scorpion

Structure Lethal Scorpion Non lethal scorpion

Sternum Shape • Triangular Pentagonal

Pincers • Weak looking Strong and Heavy

Body • Thin in a empathetic manner. Thick

Tail • Thick Thin



Scorpions use their pincers to grasp the prey. It arches its tail over its body and

stings into its prey. Thus it injects its venom, sometimes more than once. The venom

glands are situated in the tail. The striated muscles in the stings regulate the amount of

venom injected. When entire venom is used, it takes several days to replenish venom.

Scorpion with large venom sacs such as Parabuthus species can even squirt their

venom.

Distribution of various species of scorpions

Buthus is found in Mediterranean area, Parabuths in Western andSouthern Africa,

Mesobuthus in Asia, Tityus in Central and South America, and Caribbean, Leiurus

in Northern Africa and Middle East, Andractanus in Northern Africa to Southeast

Asia, and Centruroides in South West USA, Mexico and Central America.

Socio cultural aspects

For scorpion sting also, patients are taken for magico religious treatment where

mantras are chanted, herbal medicines are applied externally and / or given orally. Since

the scorpion sting has mild effects in many, most of them improve with local practices.

Hence the community has conÞ dence on the local / traditional practitioner or priest. If

the pain continues or symptoms get aggravated or general condition deteriorates and

in children if crying or restlessness continues, the patients are brought to the hospital.

Thus local practices contribute to delay in health seeking.

2.2 Clinical Aspects

Components of Venom and Mechanisms of action

The components of venom are cardiotoxin, hemotoxin, nephrotoxin, neurotoxin,

hyaluronidases, phosphodiesterases, phopholipases, glycosaminoglycans, histamine,

serotonin, tryptophan and cytokine releasers. Among all, the most potent is the

neurotoxin. There are two classes of neurotoxins (long chain & short chain polypeptide)

which are heat stable, have a low molecular weight and are responsible for causing cell

impairment in nerves, muscles, and the heart by altering sodium and potassium channel

permeability. The long chain polypeptide neurotoxin induces continuous, prolonged,

repetitive Þ ring of somatic, sympathetic and parasympathetic neurons which results

in autonomic, and neuromuscular over excitation symptoms. It also prevents normal

nerve impulse transmissions. Further, it results in release of neurotransmitters viz.,

epinephrine, nor-epinephrine, acetylcholine, glutamate, and aspartate excessively. The

short chain polypeptide neurotoxin blocks the potassium channels.



Pathophysiology

The venom is produced by columnar cells of the venom glands. Scorpion venom

is water soluble, antigenic and positively charged. It is a heterogenous mixture and

this can be easily demonstrated by electrophoresis method. Also, the heterogenisity of

the venom explains the variable response to venom as observed in different people.

Normally injected venom is between 0.1 to 0.6mg. Generally most lethal scorpions

have a lethal dose (LD50) below 1.5mg. The potency varies with species causing mild

ß u to death with in an hour. Humans are much more sensitive than mice.

Once the venom is injected, it is distributed rapidly into the tissues. If the venom

is deposited into a vein, the symptoms develop within 4 to 7 minutes after injection,

with a peak concentration in 30 minutes. The half life of venom varies from 4.2 to 13.4

hours.

Symptoms and signs

Symptoms and signs are inß uenced by factors related to “3 Ss” viz., scorpion, sting

and the status of the patient.

Table No. 17: Infl uencing factors for symptoms and signs

Scorpion Sting Status of the patient

Species •

Age, size and •

nutritional status •

Stinging apparatus •

(telson)

Time of sting •

Number of stings •

Quantity of venom •

injected (low dose –

adrenergic, high dose

– cholinergic)

Depth of the sting •

penetration

Site of sting IV/SC/IM •

Components of venom •

Age of the patient •

Health status •

Comorbid conditions •

Weight of the victim •

Physiological response •

of the individual

Sensitivity of •

the systém to the

neurotransmitters and

toxins

Usual signs of scorpion sting are as follows

Mydriasis •

Nystagmus •

Hyper salivation •

Dysphagia •

Restlessness •



Usual mode of death is via

Respiratory failure secondary to •

Anaphylaxis

Broncho constriction

Bronchorrhoea

Pharyngeal secretion

Pulmonary edema

Diaphragmatic paralysis

Venom induced multi organ failure •

In view of the numerous toxins and enzymes released from the scorpion venom,

the clinical signs and symptoms of envenomation may vary at local and at systemic

level. The local signs are provided in Table 18. Grading of scorpion envenomation is

based on neurological and non neurological predominance as shown in Figure 1. The

local signs and systemic signs are provided in Table 18, 19 and 20 respectively.

Figure 1: Grading of scorpion envenomation

(83%) (10%) (5%)

Local signs at the site of sting are further classiÞ ed into non-lethal local effects as well

as neurotoxic and cytotoxic local effects. The details are provided in Table No: 18.



Table No. 18: Local effects at the site of sting

Nonlethal local

effects

Neurotoxic local signs at

the site of sting

Cytotoxic local signs at the

site of sting

Pain •

Erythema •

Induration •

Wheal •

(due to activation

of kinins and

slow releasing

substances of

venom)

Local effect of sting •

minimal or absent •

Tissue necrosis (rare) •

Sharp burning pain •

Erythema •

Local tissue swelling •

Ascending hyperasthesia •

(paresthesia persists for

several weeks and the

last symptom to resolve)

Appearance of a macule •

or papule within Þ rst

hour

Diameter of the lesion •

vary with quantity of

venom injected

Progress of the lesion to •

a purpuric plaque which

will necrose and ulcerate

Nonlethal local

effects

Neurotoxic local signs at

the site of sting

Cytotoxic local signs at the

site of sting

Positive “Tap test”- •

(Paresthesia worsens

with gentle tapping at the

site of sting)

Hypersensitive to touch •

and temperature

Lymphangitis (if the •

venom is transferred

through lymphatics)

Systemic signs are grouped into neurologic signs and non-neurologic signs, and a brief

description of the same is provided in Table 19.

Table No. 19: Systemic signs of scorpion sting

Neurologic signs [refer Figure No.2]Non neurologic sytemic signs [refer

Table 20]

Central nervous system signs •

Autonomic nervous system signs •

Sympathetic signs

Parasympathetic signs

Somatic signs

Cranial nerve signs •

Peripheral nervous systém signs •

Cardiovascular signs •

Respiratory signs •

Gastro intestinal signs •

Hematological signs •

Metabolic signs •

Genitourinary signs •

Allergic signs •

Pregnancy signs •



Figure 2: Nervous system signs

Non-neurologic systemic signs:

The scorpion venom affects all systems and details of non neurological signs are

depicted in Table 20. However, the commonly observed were local, respiratory,

cardiovascular and neurologic manifestations.



Table No. 20: Non-neurological signs

* Cardiovascular signs

Hypotension •

Hypertension •

Tachycardia (bradycardia at •

times)

Cardiac dysrhythmia •

Transient apical pansystolic •

murmur

Cardiovascular collapse •

Cardiogenic shock •

Cardiac dysfunction •

* Respiratory Signs

Tachypnoea •

Pulmonary edema •

Respiratory failure •

* Gastro intestinal Signs

Dysphagia •

Excessive salivation •

Nausea and vomiting •

Gastric hyperdistension •

Increases gastric acid out put •

and gastric ulcer

Acute pancreatitis •

Liver glycogenolysis •

Toxic hepatitis •

* Hematologic Signs

Platelet aggregation •

Disseminated intra vascular •

coagulation (DIVC)

* Metabolic Signs

Hyperglycemia •

Increased lactic acidosis •

Electrolyte imbalance •

* Genitourinary Signs

Acute renal failure •

Rhabdomyolysis •

Priapism •

* Allergic Signs

Urticaria •

Angioedema •

Bronchospasm •

Anaphylaxis •

* Pregnancy Signs

Toxin induced uterine contraction •

Criteria for diagnosis

Defi nite confi rmatory signs

Witnessed sting •

A dead scorpion •

Evidence at the site of sting - single puncture mark •

Local pain – positive tap sign •

Local and systemic manifestations •

(Absence of pain or manifestations does not rule out scorpion sting)



Probable scorpion sting

Local edema •

Pin hole bleeding •

Profuse sweating – Local or generalised •

Differential diagnosis

Botulism •

Tetanus •

Organophosphorus toxicity •

Less common conditions for differential diagnosis

Myasthenia gravis •

Guillain barre syndrome •

Neuroleptic syndrome •

Sympathomimetic over dose •

Envenomation due to snake •

Investigations

Haematology

- Complete Blood Count (CBC)

- Leukocytosis

- Hemolysis (variable)

- Coagulation proÞ le

- DeÞ brination [if required]

Blood Chemistry

- Blood sugar

- Serum creatinine

- Serum creatine kinase

- Serum amylase / lipase

- Serum aspartate / alanine amino transferase

- Arterial blood gas (ABG) analysis [if required]

Imaging studies

Chest x – ray •

Other investigations

Electro cardiogram & serial ECG (monitor ST, T & others) during follow up. •



Special investigations [if required]

Echocardiogram / and repeat for follow up studies •

Color-ß ow doppler •

Pulmonary artery catheterisation studies •

Serial spirometry to measure pulmonary functions •

Hormone studies •

Estimation of different cytokines •

Serum venom level •

Clinical Course

Clinical course of scorpion sting is usually less alarming but in some cases it

may progress to maximum severity in about 5 hours to 12 hours and starts subsiding

within a day or two. Even if the patient has features of autonomic nervous system

manifestations, it may start subsiding by 12 hours after initiating treatment. Tachycardia

usually subsides within 24 to 48 hours. Hypertension may last for 4 to 8 hours.

Hypotension and bradycardia are encountered usually within 2 hours. Once treatment

is started, the signs of recovery begins within 48 or 72 hours. In some cases pulmonary

edema may develop within 30 minutes to 3 hours, usually secondary to myocardial

dysfunction. Unfortunately some cases of scorpion sting may die within 30 minutes

and this may be related to ventricular arrhythmias or non cardiac pulmonary edema

due to ARDS [often reported from Brazil]. Central nervous system manifestations with

or without convulsions may occur within one to two hours in fatal cases.

Complications

Various complication of scorpion sting are:

Respiratory failure •

Multi organ failure •

Dilated cardio myopathy •

Rhabdomyolysis •

Persistent paresthesia •

Anti venom anaphylaxis and serum sickness •

Ankylosis of small joints if sting occurs at a joint •

Iatrogenic high dose sedative hypnotic respiratory arrest •

2.3 Treatment

The Þ rst aid currently recommended is based around the mnemonic ‘R.I.G.H.T’. The

details provided earlier in Table no.6 is again furnished below for easy reading.



Table No. 6: Currently recommended First aid

R = Reassure the patient. •

I = Immobilisation of the limb in the same way as a fractural limb helps to •

prevent rapid absorption of the venom into the circulation. (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 don’t work and can be dangerous!).

G. H. = Get to Hospital Immediately. (Traditional remedies have NO PROVEN •

beneÞ t in treating scorpion sting).

T = Tell the doctor all that happened from the time of scorpion sting along •

with symptoms that developed till reaching (or arrival) the hospital.

This method will get the victim to the hospital quickly, without recourse to

traditional medical approaches which can delay effective treatment.

Traditional methods

The traditional methods such as application of counter irritants, herbal materials

or paste over the site of sting or tight tourniquet (it may intensify local effects of

venom), or hot fomentation should be avoided as they may enhance the effects of

venom. Also avoid cutting and suction (oral extraction of venom from the site), or

cutting and letting out the blood, or washing the wound with chemicals or alcohol or

other methods as they facilitate the absorption of toxin. In view of the consequences

noticed, these traditional methods have to be discarded.

However, local application of ice bags (one of the traditional methods) to reduce

the pain is acceptable for some time if not contraindicated. This method slows down

the absorption of venom via vasoconstriction. This is the most effective one during the

Þ rst 2 hours following the scorpion sting. One should not cause freezing injury, while

using ice cubes / bag.

While dealing a case of scorpion sting consider mnemonic ‘RASI’.

R • emember principles

A • ddress the problems – clinical and social

S • eek help from others when required and

I • nform the patient and / or care givers on the status of illness, clinical course,

management, outcome, welfare measures and follow up clearly with empathy.



Principles involved in the management of scorpion sting

The principles envisaged to treat scorpion sting at all Health Centres / Hospitals

irrespective of the status (Government or Private) are given below (the same given

under snake bite) under “12 As”.

Table No. 7: Principles involved in the management

1. Admit the victim immediately.

2. Ask effectively.

3. Assess quickly.

4. Act swiftly.

5. Administer medication meticulously.

6. Address to the wound properly.

7. Anticipate complications keenly.

8. Avoid errors carefully.

9. Ascertain the status repeatedly.

10. Amicable with patients and care givers and show empathy.

11. Advise on follow up accordingly.

12. Arrange for referral early.

1) Admit all victims of scorpion sting & keep the victims under observation for

24 to 48 hrs. (If scorpion is brought try to identify the colour and size of it).

2) a) Ask for the details of scorpion sting and never be carried away with the sting

marks either for diagnosis or for assessment of severity.

Time of sting •

Number of stings •

Nature of the incident •

Depth of the sting •

Site of envenomation-close to head & torso [results in quicker venom •

absorption & onset of symptoms in the former]

b] Ask for the time interval between the sting and arrival at the hospital.

c] 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.

d] Ask for clinical symptoms and correlate with the progression of symptoms and

signs due to scorpion sting [provided in page vide supra]

3] Assess the following quickly.

a] Airway, Breathing and Circulation

b] Vitals HR, RR, BP and Pulse oximetry (if required)



c] Site of sting and the probable route of envenomation - (Intravenous have

immediate effects, while subcutaneous and intramuscular routes take several

minutes to hours to cause effect)

d] Chest expansion

e] Clinically from head to foot as well as back

f] For associted co-morbid illness[es]

g] For consuming any medication[s]

h] Status of envenomation – mild, moderate and severe

[in view of neurotoxic, cardiotoxic, hemotoxic, myotoxic or a combination of them]

4] Act swiftly

a] To support Airway, Breathing and Circulation

b] To start IV line [ß uid for children - refer Annexure II Table No.29]

c] To provide supportive measures depending upon the requirements

d] To connect ventilator if there is a need

5] Administer medication meticulously

a] Tetanus Toxoid injection intramuscularly

b] Topical anaestetic agent to the site of sting to decrease paraesthesia.

c] Injection lignocaine 1% without adrenaline; 2ml as local inÞ ltration

(after test dose for lignocaine) (0.1 to 0.2mg/kg body weight for children)

d] Oral rehydration solution to hydrate the patient if not contraindicted.

e] Tab. Paracetamol 10mg/kg body weight to reduce pain

f] Tab. Prazosin [plain 1mg]

Pharmacological aspects of Prazosin

Prazosin is an alpha blocker. It counteracts scorpion induced adrenergic

cardiovascular effects and reduces pulmonary edema through vasodilatory effect,

Usually it is started with small dose using plain tablet but not exceeding 5mg/day.

For children the dose preferred is 30 microgram / kg body weight. Though pediatric

requirement has not been established, it is started with small dose. Prazosin can be

given irrespective of blood pressure, provided there is no hypovolemia

It should be avoided, if the patient is hypersensitive to prazosin. Always exercise

caution if patient has renal insufÞ ciency and hypertension. Users must remember that

it interacts with beta blocker and causes hypotension. Also, verapamil may increase

serum levels of prazosin and increase patient’s sensitivity to prazosin and cause

postural hypotension. Interestingly, prazosin decreases the anti hypertensive effect of

clonidine. Safety in pregnancy has not been established. Also, users are informed to

follow standard measures while using prazosin (Refer Table No.21).



Table No. 21: Measures to be adopted while using Prazosin

Prazosin should not be given as prophylactic dose when pain is the only •

symptom.

Give Prazosin through nasogastric tube, if baby has vomiting. •

Keep the patient in lying posture for about 3 hours (even while examining •

the case) in order to prevent ‘Þ rst dose phenomenon’ (hypotension) due to

Prazosin.

Monitor pulse, BP, and respiration every 30 minutes for 3 hours. •

Reassess for warmth and return of pain at the site of sting. •

Continue monitoring of pulse, BP, and respiration every 60 minutes for next •

6 hours.

Recheck the same every 4 hours till improvement is visible. •

Repeat Tab. Prazosin in the same dose at the end of 3 hours according to •

clinical response and later every 6 hours till extremities are warm, dry and

peripheral veins are visible easily.

* Alternative to Tab. Prazosin is NiÞ dipine, Nitroprusside, Nitroglycerine, Isosorbide

di-nitrate, Hydralazine or Angiotensin converting enzyme inhibitors (ACEIs).

However, users have to remember the constraints while prescribing such drugs.

g] Beta-blockers in small doses along with alpha blockers if needed and if not

contraindicated.

h] Nitrates if patient has hypertension and myocardial ischemia

i] Ionotropics such as digitalis (has little effect), or dobutamine (refer snake bite

section for details). Avoid Dopamine as it aggravates the myocardial damage.

j] Nor-epinephrine as IV drip to correct hypotension refractory to ß uid therapy.

k] Antimicrobials if infection is suspected

l] Inj. Atropine (required at times) to counter venom induced parasympathetic

effects.

m] Inj. Insulin has been shown to prevent multiorgan failure (especially cardio-

pulmonary) in animal experiments.

n] Barbiturate and / or benzodiazepine as continuous infusion for severe /

excessive motor activity

o] Steroids to decrease shock and edema is of unproven beneÞ t.

p] Antivenom for scorpion sting is not used commonly in India (as species speciÞ c

antivenom is not available and usage has not demonstrated any beneÞ t)

q] Vaccine – not available (tried in experimental animals).

r] IV fl uids as per need [ß uid for children- refer Annexure II Table No.29].



s] Other supportive medications such as sodium nitroprusside (0.3 –0.5 mcg/

kg/min with upward titration), or nitroglycerine as per need (usually in

pulmonary edema)

Though Inj. Morphine is used as a standard therapy for pulmonary edema, it should

be avoided in scorpion sting since narcotics worsen dysrhythmias in children

6] Address to the wound properly

The details of wound care are provided below. However, one should also remember

the other surgical issues described vide Table 11 in the snake bite section.

a] Wound following scorpion sting may show sting marks with or without local

manifestations.

b] Sometimes venom may penetrate deep and hence deeper tissues may be

damaged which may not be visible during initial examination (rare).

c] At the site of the sting a bleb or vesicle may develop and end in the form of non

speciÞ c ulcer. (Non-speciÞ c ulcers are deÞ ned as ulcers due to infection of

wounds, physical or chemical agents or due to local irritation).

d] Consider the following while managing the wound / ulcer (uncommon in

scorpion sting).

Minimize unnecessary blood loss. •

Initiate adequate cleaning with normal saline or tap water, 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. •

Teach & explain the care of wound to the patients and / or care givers. •

Educate on good personal hygiene and nutrition. •

Control diabetes if identiÞ ed. •



7] Anticipate complications keenly.

a] Examine the victims at regular intervals for alterations in symptoms and signs

b] Anticipate dysrhythmias during the Þ rst 24 to 48 hours after sting

c] Start tapering prazosin after the clinical improvement begins to manifest

d] Observe for drug related systemic changes and drug toxicity, and treat them

accordingly.

8] Avoid errors carefully 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 hospitals, communicating

with patients / and care givers, planning for discharge, preparing reports, Þ lling up

the forms, reviewing the data and conducting the audit.

9] Ascertain the status repeatedly and provide supportive measures, as these cases

may develop covert signs during hospital stay while on treatment.

10] Amicably interact with patient and care givers and show empathy to them in

view of the socio clinical aspects related to scorpion sting.

11] Advise on follow up accordingly in view of the systemic toxicity. Patients may

also be 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

are provided in Table 24.

2.4 Scorpion sting in special situations

If patients already suffering from one or other illness(es) with or without medications

for the underlying illness, suffers from scorpion sting, these patients have to be treated

like any other case of scorpion sting. However, treating doctor has to exercise caution

while prescribing and using medications, consider drug interaction, contraindications,

absorption, and excretion of the drugs used so as to avoid toxicity.

Also, one has to carefully monitor the status of underlying illness. Pregnant women

and lactating women with scorpion sting have to be treated like any other women.

Remember to consider the baby in utero by clinical and technological means.

2.5 Management in Primary Health Centres (PHC) and Block PHC

The key objective of this guideline is to enable even the doctors working in Primary

Care Institutions as well as private practitioners to treat scorpion sting with conÞ dence.

Evidences suggest that doctors are not willing to make use of the medications and

devices, even when available, due to lack the conÞ dence and guidelines. The present

handbook provides guidelines to meet their needs, and outlines how they should proceed



within their context and setting. The principles envisaged to treat scorpion sting at all Health Centres / Hospitals irrespective of the status (Government or Private) are given in Table no: 7 (vide supra under treatment) The initial evaluation and systemic manifestations following scorpion envenomation (described in Table 18, 19 and 20, and Figure 1 and 2), and treatment aspects are provided in detail vide supra. However, a format for quick assessment is provided in Table 22 and 23 (refer Annexure VIII and X).

Table No. 22: Initial evaluation of scorpion sting without

Systemic Envenomation


Vital signs

Pulse •

BP •

Respiration •

SYMPTOMS AND

SIGNS

Local effects (Table 18)

Sting marks and site •


painPain, erythema & •

whealInduration, macule/ •

papuleProgress to purpuric •

plaqueLocal necrosis •

Lymphangitis •

Ascending •

hyperesthesiaPositive “Tap test” •

Conscious level •

Any other systemic •

effects


Pulse rate: 60-100/ •

min

BP 110 / 70 to 140/95 •

Respiratory rate <20/ •

min

SYMPTOMS AND

SIGNS

Local pain and/ or •

swelling

Sting mark present •

No other symptoms •

and signs

If the patient has

above Þ ndings at the

time of assessment,

classify as No systemic

envenomation

Tab.Paracetamol

Inj.Tetanus Toxoid IM

Routine antimicrobials are

not necessary

Monitor Pulse, Respiration

& BP every ½ hourly for 3

hours and every 4 hourly for

remaining 48 hours.

If normal send the

patient home

If the patient develops one or

other systemic manifestations

as described in Table 18, 19

and 20, and Figure 1 and 2,

proceed to treat as given in

Table 23.

*Vital signs for children (see age speciÞ c chart) are provided in Annexure III

(Table No.30 to 33). If the patient has any systemic manifestations as described in

Table 19 and 20, and Figure 1 & 2, proceed to manage as described in Table 23. The

details of local envenomation is provided in Table 18.



Table No. 23: Evaluation of scorpion sting with Systemic Envenomation


Vital signs

Pulse •

BP •

Respiration •

SYMPTOMS

AND SIGNS

In addition to

those described in

Table 22, look for

those mentioned

in Table 19 and 20

as well as Þ gure

1 and 2 for one

or other systemic

manifestations as

described in Table

19 and 20, and

Figure 1 and 2.


Pulse rate >120 per

minute, feeble (a

response to hypotension)

Respiratory rate > 20/min

Hypotension < 90/60

SYMPTOMS AND

SIGNS

Swelling and local pain

If systemic Þ ndings

are there at the time of

examination, classify as

systemic envenomation

Oxygen administration if •

required

Follow various principles •

described vide supra

Start IV Normal Saline with •

wide bore needle as life line

Treat the patient with Tab. •

Prazosin (Plain)

Continue to monitor the vital •

signs at Þ ve minutes interval

for Þ rst 30 minutes and then

at 15 minutes interval for two

hours.

For further details while using •

Prazosin follow the details

provided in Table No.21.

Stabilise the patient and •

refer to the higher institution

keeping the patient in lying

posture.

Fluid requirements per day should be kept in mind while managing the case.

For children readers are requested to see the ß uid requirement chart provided in

Annexure II.

* Vital signs for children (see age speciÞ c chart) provided in Annexure III.

2.6 Referral aspects

The medical ofÞ cer who is treating the cases of scorpion sting should take meticulous

care to look into the patient’s status and provide Þ rst aid as well as supportive measures

before referring the cases to higher centre / specialist(s). The details are furnished in

Table 24 below.



Table No. 24: Referral aspects for scorpion sting

Who needs When to refer Where to refer

Patient requiring

Respiratory support •

Cardiac failure/shock •

Surgical intervention •

Spontaneous •

persistent bleeding

Co-morbid diseases •

Acute impending •

kidney failure

Multi-system •

involvement

Refer the patient after •

stabilising the case and

after giving Tab.Prazosin

and other supportive

measures (refer to

Annexure VIII and X)

Refer to higher institution

having ventilator and other

measures to provide

further supportive

treatment.

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 •

Arrange for an ambulance •

Transfer in a vehicle to Secondary Care Hospital or Tertiary Care Hospital •

where facilities are available for further management

Continue life support measures •

Provide airway support with the help of an accompanying staff •

Send the referral note with details of treatment given •

Instruct one staff to accompany the patient during transportation if required •

Hand over the referral form (Annexure V) with details regarding treatment •

given

Mention the clinical status at the time of referral clearly in the referral form •

2.7 Occupational risk, Patient Education and Prevention

Occupational risk for scorpion sting is noticed frequently among those handling •

building materials, Þ re wood, etc., where scorpions hide.

Educate the patients and community on how to avoid scorpion and scorpion •

sting.

To check shoes, gloves, clothing and package before use. •

To keep yards free of debris, which serve as places for scorpions to hide. •

To prevent entry of scorpion into home (make sure windows and doors Þ t •

tightly).

Avoid walking barefoot especially at night. •



Encourage biological methods to control scorpion by introducing chicken, •

ducks, owls etc.,

Use chemicals such as (organo-phosphates, pyrethrum and chlorinated •

hydro carbons) which help to control.

2.8 Prognosis

Prognosis is related to species of scorpion, the venom injected (amount and •

components), physiological response of the individual to the venom, and

individual’s response to pharmaco therapy as well as supporting measures.

Symptoms generally persist for 24 – 48 hours, if the patient survives without •

severe toxic effects on cardio respiratory or neurologic systems or multi organ

failure.

Greater the systemic symptoms and poorer the response to therapy, worse is •

the prognosis.

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Titles Page

3.1 Quality of Care 69

3.2 Responsibilities of health care providers / professionals 69

3.3 Maintenance of records and reports 70

3.4 Utilisation of Information, Education and Communication

(IEC) materials 70

3.5 What patients and care givers should know about

snake bite / scorpion sting? 70

3.6 What health care providers / professionals should know

on snake bite and scorpion sting? 73

3.7 Medical pitfalls 74

3.8 Medical audit for snake bite and scorpion sting 74

3.9 Areas for research on snake bite / scorpion sting 79

3.10 Key points for snake bite and scorpion sting 84

3.11 Conclusions 85

SECTION - III

MISCELLANEOUS



3.1 Quality of Care

The Medical OfÞ cer of a Health Centre / Hospital should be competent enough to

manage cases of snake bite and scorpion sting. For all practical purposes competency is

deÞ ned as the point at which the doctor or a health care provider – knows the principles /

steps involved in the treatment of cases, has acquired skills [cognitive, psychomotor

and affective] to manage the cases conÞ dently with available resources and materials,

and refers the deserving cases to higher centre or specialist[s] in time when required.

Quality of care has to be assessed by objective means for the purpose of approving

health centre / hospital for health care services, accreditation, third party payment,

upgrading the status, research, etc., Some of yardsticks to measure the services are

provided below:

1. Case fatality rate for snake bite / scorpion sting,

2. Ratio of time interval for treatment,

3. Referral rate, and

4. Availability of drugs and devices

5. Utilization of Anti-snake venom

3.2 Responsibilities of health care providers / professionals

The responsibilities of health care provider with reference to quality of care have

been narrated under “10 Rs” provided in Table 25 below.

Table No. 25: Responsibilities of health care providers / professionals

1. Recognise the case and distinguish it from other conditions.

2. Remember the principles of management.

3. Resuscitate if required.

4. Reassure patients in an empathetic manner.

5. Reassess to estimate the clinical status and complications.

6. Refer to higher centre or specialist[s] in time if required.

7. Review the health services and effectiveness of health education with health

care team.

8. Retrain the health care team to raise their standard and quality of service.

9. Reeducate the community for empowerment in terms of prevention, control

and welfare as well as in the treatment and follow up.

10. Revise the strategies for constant availability of drugs and devices all through

the year.



3.3 Maintenance of records and reports:

Medical record (MR) is systematic documentation of sequential events of patients’

medical history and health care. Medical records serve multi-dimentional roles viz.,

serve as educational material, provide data for research works, act as material for

medical audit, safe guard physician / practitioner from legal wrath, help medical

insurance / third party, help authorities for the purpose of accreditation or approval,

assist patients for follow-up and to know the status of illness, act as a source to assess

quality of care and guide health care planners. Medical council act gives clear directions

on maintenance of medical records. So, in the context of snakebite and scorpion sting,

the medical ofÞ cers have to maintain the treatment records of the victims and send

the reports periodically to higher authorities for further monitoring and surveillance.

The model forms are provided in Annexure IV, V, VI, XIII and XIV. List of drugs

and devices required at health centres to provide Þ rst aid treatment for snakebite and

scorpion sting are provided in Annexure VII.

3.4 Utilisation of Information, Education and Communication (IEC)

materials:

The medical ofÞ cers and public health staff should make use of the information,

education and communication (IEC) materials, and disseminate the correct knowledge

on snakebite / scorpion sting management and prevention to the community in order

to reduce morbidity and mortality. For this purpose, one has to organise programmes

with clear direction. The steps involved are:

1] Identify goals

2] Set objectives

3] Analyse the details required

4] Review the health needs

5] Determine key issues

6] Find out the areas that need change

7] Conduct IEC programmes

8] Reassess the status

9] Provide feed back and

10] Continue the programme with necessary modiÞ cations.

3.5 What patients and care givers should know about snake bite /

scorpion sting?

Snake and Scorpion

Snakes move • frequently in agricultural area to catch its prey

Krait bite is more fatal than bite from other three of the “Big 4” •



Scorpions are shy creatures, which hide in crevices and burrows, and sting if •

cornered, disturbed or threatened

Destruction of snake / scorpion will not have any effect on mortality •

Venom variation has been identiÞ ed among the subsets of snakes / scorpions •

Venomous snakes / scorpions do not inject venom sometimes or inject only •

small quantity of venom

Bite and Sting

All venomous bites / stings do not end in death or complications. •

Farmers encounter snakebite more than people in forests •

Children encounter scorpion sting more than adults •

Snake / scorpion never runs out of venom •

Bites / stings due to venomous snake / scorpion may be insigniÞ cant at times •

Antivenom

Separate ASV is not available for individual venomous snakebites in India. •

Antivenom made for Indian Russell’s Viper, may not be effective for Russell’s •

Viper bite of Srilanka

Anti venom is effective but not without side / adverse effects •

Adverse effects have to be observed and tackled immediately •

Clinical course, complications and outcome: Preventive measures

and health education:

Symptoms, signs, clinical course, complications, therapeutic response and •

outcome may vary from patient to patient bitten by the same species of the

snakebite / scorpion sting.

Consider whether poisoning due to snake bite / scorpion sting is of different •

species, if the clinical course and complications are different or the patient is

not responding to treatment.

At any point of time, clinical course, complications and outcome cannot be •

categorically predicted in a given case despite available drugs and devices.

Early arrival and treatment may help to improve outcome. •

Recovery is a natural process and treatment is an adjuvant to assist the process •

of recovery.

Complications can be minimized and avoided to some extent but can neither be •

predicted nor avoided totally.



Co-morbid status / preexisting illness[es] and medication[s] of any sort may •

inß uence the response to venom as well as treatment and outcome.

Each case is different from another in one or other aspects. •

Follow up

Follow-up checks are required for assessment of long term effects on different •

organs / systems and appropriate management has to be instituted wherever

required / needed.

Limitation

Laboratory investigations are of little value in the diagnosis of severity of •

envenomation or the sub-type of snake due to biological variations, but assist

for intervention

Currently available treatment modalities and supportive care attempt to reduce •

morbidity, alter the clinical course, enhance natural process of recovery and

minimize mortality.

Welfare measures

More deaths occur following snake bite / scorpion sting outside the hospitals, •

and at times deaths occur inside the hospital despite treatment, because of the

patients’ biological characteristics

Many state governments in India provide solatium to the family members of •

the deceased snake bite victims.

Prevention

At present no effective vaccine is available against snake bite and scorpion sting. •

Hence, the community must be motivated to understand and adopt preventive

measures always.

Also, the people should be made aware of the Þ rst aid measures and adopt early •

health seeking behavior before complications set in.

Information and resource

Patients and care givers may be informed about the

1. Diagnosis

2. Number of cases referred

3. Number of cases expired at health centre



4. Number of cases brought dead

5. The available websites (Annexure XV) and on line resources on snake bites /

scorpion sting are given so that they can learn more about these aspects, if they

like to do.

Community should be informed on the national consensus on the management •

of snake bite / scorpion sting through local media uniformly in their respective

languages, so that they will not be carried away by any other means and different

systems of medicine, etc.,

3.6 What health care provider / professionals should know on snake

bite and scorpion sting?

Once community awareness on Þ rst aid measures and treatment modality of •

snake bite and scorpion sting increases, more number of such cases are likely

to attend the Health Centre / Hospital till the preventive measures are adopted

to reduce the problem.

The time interval between bite / sting and application of scientiÞ c treatment •

modalities should come down

As snake bite and scorpion sting patients are likely to get appropriate treatment •

early in the nearest Health Centre / Hospital, morbidity and mortality are likely

to come down

Health Centre / Hospital may require more materials to handle such cases. So •

the health care provider has to initiate efforts to maintain adequate stock and

replenish their requirements well in advance

If the treatment is initiated for snake bite at Health Centre / Hospital as per •

evidence based (standard treatment guidelines), the total anti snake venom

required per patient will come down and also the referral rate to higher centre

too.

Since the patients are getting treatment at peripheral Health Centre / Hospital, •

the patients may come to the hospital early without wasting time in other

traditional methods

Increased awareness of the welfare measures provided by the State Government •

of Tamil Nadu to the family members of the deceased victim, may result in

bringing the cases who died due to the bite / sting outside hospital for death

certiÞ cate. Under such circumstances the Medical OfÞ cer has to inform the

family members of the deceased victim, to shift the body to a centre where

postmortem could be carried out to ascertain the cause of death if they do not

have postmortem facilities in the respective Health Centre / Hospital.



3.7 Medical pitfalls (“14 Fs”)

Treating doctor should take adequate care to avoid medical pitfalls as these issues are

likely to come up during medical audit. Some of the issues are mentioned here.

F • ailure to provide Þ rst aid measures immediately when the victims of snake

bite / scorpion sting is brought to a health centre / hospital

F • ailure to admit the patient and document the Þ ndings properly

F • ailure to ask and assess the case in detail, and do the needful with the available

measures

F • ailure to monitor the case who are severely envenomed

F • ailure to stablise the airway and vital signs before speciÞ c intervention

F • ailure to treat the patient adequately, because of under-estimation of the

clinical status

F • ailure to observe anticipated complications while under medical care

F • ailure to warn the patient and / or the care givers of the potential complications

that could happen due to the envenomation and / or during treatment

F • ailure to obtain informed consent for interventional procedures

F • ailure to arrange for follow up care

F • ailure to refer to higher centre or to specialist[s] when such services are likely

to beneÞ t the snake bite / scorpion sting victim.

F • ailure to provide adequate records / reports while discharging or demand

F • ailure to initiate treatment with ASV without adequate agents for managing

anaphylaxis or anaphylactoid reaction.

F • ailure to inform the patient / care giver(s) on the persistence of pain / lesion or

paresthesia at the site of bite / sting for days / weeks even after recovery from

the primary illness.

3.8 Medical audit for snake bite and scorpion sting

Medical audit for snake bite and scorpion sting is an attempt to review each case

who was brought alive or dead or died at the health care centre / hospital even after

treatment. In general “audit is a quality improvement process that seeks to improve

patient care and outcome through systematic review of case against explicit criteria

and the implementation of change” [www.nice.org]. The objectives, goals and vision

of medical audit are given below:

Objectives

To determine the probable reasons that might have contributed to death •

To Þ nd out the lapses and failures in the management •



To initiate the root cause analysis (RCA) •

To compare the case fatality on monthly basis at different levels •

Goals

To introduce remedial measures at all levels. •

To counsel and guide the affected victim and their family. •

To create awareness among the community. •

To implement preventive strategies so as to reduce mortality and morbidity. •

Vision

To provide appropriate care and support for snake bite and scorpion sting cases •

at all Health Centre / Hospital at all times.

Principles of audit:

Not to blame each other, but to improve •

Avoid reduplication of cases •

Refrain from false statement / data •

Find out the reasons for lapses / deÞ ciencies •

Provide feed back to members at all levels •

Get suggestions from end users •

Find out ways for improvement and to implement them •

Place the data and resolutions / remedial measures on the web site •

Outcome of audit (“5 Es”):

E • licit the lacunae / limitations / variations at inter-regional and inter institutional

levels

E • numerate the needs for requirements

E • liminate the constraints

E • ducate the providers of health care and beneÞ ciaries

E • ncourage health care providers to perform better



Table No. 26: Levels of analysis

Level Place Reviewer Materials for analysis

I. LocalHealth centre /

Hospital

Chief of the

Health centre /

hospital / unit

Details of snake bite and

scorpion sting treated /died /

brought dead to the respective

health centre / hospital and

health services

II. Health

Unit

OfÞ ce of the

Health Unit of

respective health

districts

Chief of the

health unit

Details collected from all

hospitals [Government /

private], and death due to

snake bite and scorpion sting

collected from Panchayat /

Municipality, etc., and health

services

III. Revenue

district

level

OfÞ ce of the Joint

Director of Health

Services

Joint Director of

Health Services

Details collected from the

health units under them and

death due to snake bite and

scorpion sting collected from

Panchayat / Municipality /

Corporation etc., and as well

as details of welfare measures

provided for such victims

family from the respective

Collectorate.

IV. State

level

OfÞ ce of Director

of Public Health

and Preventive

Medicine

Director of

Public Health

and Preventive

Medicine

Data from all revenue

districts along with various

Directorates coming under

Health and Family Welfare

Department of Tamil Nadu,

Chennai

Role of reviewer

Adhere to reviewing of achievement of objectives, goals and vision •

Remember principles and outcome of audit •

Review the data with reference to responsibilities of health care providers/ •

professionals

Consider medical / social problems faced with each case •



Identify gains / setbacks in terms of man power • , skills, service, patient

satisfaction, maintenance of records, availability of drugs, drugs status

including expiry date, functional aspects of medical equipments, morbidity

pattern, referral issues and case fatality rate at different levels [for these use

formats given in Annexure IV to VII, XIII and IV].

1) Case fatality rate at different levels: Formula to calculate Case Fatality Rate

(CFR) at different levels is given in Table 27. CFR is mentioned in percentage.

Table No. 27: Formula to calculate case fatality rate at different levels

Case fatality rate for snake bite

/ scorpion sting at local health

centre / hospital for the particular

month =

Total number of death(s) due to snake bite /

scorpion sting for the particular month x 100

-------------------------------------------------------

Total number of cases (alive & dead) of snake

bite / scorpion sting brought to the health

centre / hospital for the particular month

Case fatality rate for snake bite /

scorpion sting at the level of health

unit for the particular month =


scorpion sting for the particular month in that

health unit area x 100

--------------------------------------------------



centres / hospitals of that health unit for the

particular month


scorpion sting at the level of

revenue district for the particular

month =


scorpion sting of that revenue district for the

particular month x 100

--------------------------------------------------



centres / hospitals and those applied for

welfare to the collectorate for the particular

month




scorpion sting at the level of Tamil

Nadu state for the particular

month =


scorpion sting for the particular month in

different revenue districts x 100

--------------------------------------------------

Total number of cases (alive & dead) of

snake bite / scorpion sting brought to the

health centres / hospitals of different revenue

districts and data from collectorates for the

particular month

2) Ratio of time interval for treatment: In Tamil Nadu due to the available health

infrastructure, the maximum time required to reach the nearest health centre is

estimated to be 30 minutes. Hence the ratio of time interval for treatment is the

ratio of actual time taken to reach health centre / hospital to the estimated time

required [i.e., 30 minutes] and calculated as per the formula given in the box below.

The ratio should always be below one and infact it should be as low as possible. If

the ratio is one or more than one, it indicates delay in reaching the health centre /

hospital. Then elicit the probable reasons for each and try to rectify them. This has

to be reviewed at different levels. (details may be collected from Annexure IV)

Ratio of time interval

for treatment =

The time interval between actual time of snake bite /

scorpion sting and the time of arrival for scientiÞ c

treatment in minutes

----------------------------------------------------------------------

Estimated time required to reach the health centre /

hospital (30 minutes)

*Estimated time required to reach the health centre / hospital (30 minutes) is an

arbitrary one and the ratio of time interval for treatment is calculated to understand

the awareness and utilization of health care. However, the ratio should not be used as

a lone factor to assess or predict the clinical aspects, course and outcome, as these are

inß uenced by multiple factors.

3) Referral rate: Once the treatment is started early, it is expected that referral will

come down. This has to be analysed in relation to the reasons for referral (Annexure

XIV) and efforts to be taken to minimize the referral without compromising patient

care service. Moreover, referral rate has to be analysed at all levels like CFR and

measured in percentage.



Referral rate =

Number of snake bite / scorpion sting referred x 100

----------------------------------------------------------------------

Total number of cases (alive & dead) of snake bite /

scorpion sting brought to the health centre / hospital for

the particular month

4) Availability of drugs and devices: Availability of drugs and devices have to be

analysed (Annexure VII) carefully and corrective efforts should be undertaken well

in advance so that non-availability should not be made as a reason for inadequate

treatment / referral.

5) Utilization of anti-snake venom:

Utilization of anti-snake venom has to be monitored in each and every health

centre / hospital which are providing treatment for snake bite victims. The details

given in the following box may be collected from each health centre / hospital of

the respective health and revenue district as well as at medical college hospitals and

discussed in the monthly medical audit meeting. The minutes of such meeting along

with problems encountered, suggestions for improvement, new clinical observations,

changing trends, recommendations and action taken for previous meeting should be

send to their respective directorates, which will then be consolidated at the ofÞ ce of

the Directorate of Public Health for further updating the modalities of treatment and

community participation.

Sl.No Subjects for discussion

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Bite to needle time

Delay in administration of ASV

Reactions to ASV

Reasons for repeated doses of ASV on case by case basis

Non-responders to ASV

Reasons for referral despite giving ASV

Status of availability of ASV

DeÞ ciencies in the utilization of ASV

Root cause analysis for each

Review of action taken on previous meeting

Changing trends and limitation(s)

Any other. specify

3.9 Areas for research on Snake Bite / Scorpion sting

Areas for research on Snake Bite / Scorpion sting that could be undertaken at health care institutions / organizations either alone or in collaboration with



sister specialties / and institutions are provided below. Interdisciplinary research will bring out enormous information and help to improve the existing system. Though titles are provided more on snake bite, similar areas may be considered for scorpion sting also.

I. Arts and humanities

1. Myths related to snake bite.

2. Socio cultural aspects of snakes and snake bite.

3. Bibliometric studies on snakes, snake venom, anti snake venom and snake

bites from India.

4. Economical aspects of snake bite and regional variation.

5. Counseling and guidance to snake bite victims and their family.

6. Judicial aspects and activism related to snakes and snake bites in India

7. Snakes and snake bite in literature.

8. Snake and snake bite in cinema.

9. Snakes and snake bite in mythology.

10. Proverbs related to snakes and snake bite.

11. Interpretation of snakes and snake bite when appeared in dreams.

12. Ethical issues in snake bite.

13. Crime issue related to snake, snake venom and snakebite.

14. Snakes, snake venom and snakebite in lay press and other media.

15. Discussion on snakes, snake venom, anti snake venom and snake bite related

issues in Indian Parliament and Assembly in pre and post independent period.

16. Effects of global warming and climate change on the ecosystem of snakes,

behaviour of snakes, constituents of snake venom and snake bite.

17. Snakes in sculptures: what do they convey?

18. Religious aspects related to snakes, snake bite and recovery.

19. Astrological aspects of snakes, snake bite and recovery.

20. Social status and issues related to snake charmers / handlers.

21. Snakes and snake bite issues in philately.

22. Spatiotemporal variation in snakes and snake bites.

23. Demands, production and supply of anti snake venom.

24. Utilisation of anti snake venom in government and private sector.

II. Basic Sciences

1. Preparation of monovalent anti snake venom.

2. Bedside diagnostic kits to assess snake venom levels.

3. Nature and distribution of snakes in different areas in Tamil Nadu and India

a geographical study.

4. Use of snake venom in diagnostic and therapeutic purposes.

5. Heterogenecity of snake venom in relation to species and sub types.



6. Antioxidant status during snake bites.

7. Metabolic changes during envenomation.

8. Cytokine status during envenomation.

9. Biomarkers to assess envenomation, organ involvement and outcome.

10. Lipid proÞ le during and after envenomation.

11. Trace element proÞ le during envenomation and after recovery.

12. Mechanisms of thrombus formation and its consequences during snake

envenomation and management issues.

13. DNA fragmentation during and after envenomation.

14. Oxidative stress during envenomation.

15. Status of Þ brinogen and Þ brinogen degradation products in snake bite and its

applicability.

16. Inß uencing factors for changes in coagualation proÞ le.

17. Anatomical site of bite and human behaviour.

18. Genetic basis for organ involvement in snake bites.

19. Microbial ß ora of snake oral cavity.

20. Microbial study of snake bite wound.

21. Serological studies while under envenomation.

22. Newer methods in the production of antisnake venom.

23. Postmortem studies in snake bite.

24. Histopathological changes in myocardium and other organs in snake bite

victims.

25. Complement proÞ le during and after envenomation.

26. Immuno analytical studies following snake envenomation.

27. Immunisation against snake venom: experimental studies.

28. Kinetic studies on snake venom in clinical situations and experimental status

29. Humoral response following snake bite.

30. Early indicators of renal involvement in snake bite.

31. Preparation of anti snake venom for poisonous snake other than “Big 4”.

32. Isolation, identiÞ cation and application of components of snake venom.

33. Application of nanotechnology in the diagnosis and management of snake bite.

III. Clinical aspects.

1. Epidemiology of snake bites.

2. Clinical aspects, management issues and outcome of sea snake bite.

3. Community survey on snake bites and outcome.

4. Circadian rhythms of snake bites.

5. Long term follow up of snake bite victims.

6. Challenges in the management of snake bite.

7. Clinical course and outcome of venomous and non-venomous snake bite other

than the “Big 4”.



8. Clinical course of ASV in patients with allergic disorder(s).

9. Adverse reactions to ASV.

10. Long term effects of ASV.

11. Newer modalities to treat snake bites.

12. Use of antioxidants in the treatment of snake bite.

13. Blood group pattern and blood / component requirements in the management

of snake bite.

14. Prophylactic schedule before ASV and its relevance.

15. Clinical and laboratory status of snake charmers / handlers.

16. Pattern of renal involvement in snake bites.

17. Cardiac involvement in snake bite.

18. ECG and Echo cardiographic assessment during envenomation.

19. EEG changes in snake bites before and after treatment.

20. Taste and smell in snake bite victims.

21. Neurological manifestations in snake bites.

22. Snake bite and pregnancy.

23. Snake bite in patients with coagulation disorders.

24. Hematological proÞ le in snake bites.

25. Pulmonary manifestations in snake bite.

26. Effects of Inj.ASV in the unborn.

27. Ophthalmological aspects of snake bite.

28. ENT involvement in snake envenomation an analysis.

29. Endocrine complications following snake bite.

30. Involvement of Pancreas during snake bite.

31. Surgical aspects of snake bite.

32. Compartment syndrome in snake bite.

33. Pattern, clinical course and management of ulcers following snake bite.

34. Snake bite as an occupational hazard.

35. Addiction to snake venom: an emerging issue.

36. Clinical course and outcome of snake bite in tertiary care hospital after

implementation of treatment guidelines for snake bite.

37. Medical errors in the management of snake bite victims.

38. Failure of ASV: what, when, why and how?

39. Clinical and therapeutic aspects in patients who had second snake bite.

40. Effectiveness of ‘Pressure pad or Monash Technique’ in snakebite.

41. Role of insulin in preventing multi organ failure.

42. Plasmapheresis in the management of snake bite.

43. Obstetric and Gynecological aspects of snake bite.

IV. Community aspects:

1. Analysis of pre hospital treatment.

2. Case fatality rate in snake bite: Causes and concern.



3. Natural disasters: will those contribute to snakebite.

4. Global warming and behaviour of snakes.

5. Awarenesss programmes for community on snakes, snakebite: an analysis.

6. Comparison of bites and stings with non-communicable diseases.

7. KABP of personal protective measures against snake bite among victims of

snake bite and their family members.

8. Multisectoral approach to snake bite.

V. Managerial issues:

1. Analysis of welfare programmes: awareness and utilisation members of

deceased snake bite victims.

2. Utilization of facilities for snake bites at primary care level: problems and

solution.

3. Inß uencing factors for utilisation of ASV.

4. Production and utilization of ASV in India.

5. Managerial issues in the treatment of snake bite.

6. Analysis of referral status of snake bite.

7. Outcome of snake bite in ralation to transport modalities adopted.

8. Utilisation and issues related to ambulance services for snake bite victims.

9. Medical audit of snake bite records.

10. Public private partnership in the management of snake bite.

11. Utilisation of NGOs in snake bite management.

12. Welfare policies for snakebite victims and their families in different union

territories / states of India.

13. Inter-regional variations on outcome of snake bite.

14. Designing and developing a software for documentation and analysis.

VI. Indigenous medical system related:

1. Traditional treatment for snake bite: an analysis.

2. KABP of alternative medical practitioners on snakes and snake bite.

3. Snakes and snake bite in complementary and alternative medical system.

4. KABP of Traditional Medical practitioners on snakes, snake venom and snake

bite management.

5. Educational modules and training aspects on snakes and snake bite to

traditional medical practitioners.

VII. Educational aspects:

1. KABP of modern medical practitioners and nurses on snakes and snake bite.

2. Analysis of current medical education and training programme on snakes,

snake venom and snakebite management.



3. Inconsistencies and controversies on the diagnosis and management of snakes,

snake venom and snake bite management in the text books used by medical

and nursing students.

4. Educational and training programmes on snake bite for practitioners of

alternative medicines.

5. Academic audit on teaching and training aspects of snakes, snake venom and

snakebite management.

6. Assessement of skills of trainee students of health sciences on snake bite

management by OSPE and OSCE methods.

7. Assessement of skills on snake bite management among medical practitioners

and nurses.

8. Curriculum on snakes, snake venom and snake bite management in science

education at schools and teacher training programme.

9. Analysis of snakes and snake bite management in Þ rst aid training

programme.

3.10 Key points for snakebite and scorpion sting:

* Clinical

Assess every case thoroughly. •

Treat them conÞ dently and observe vigilantly (at health centre / hospital). •

Detect the status and note down the changes, and act accordingly. •

Anticipate complications and treat them immediately. •

Provide care and support with empathy. •

Create conÞ dence among patients, public and care givers continuously. •

Bring down morbidity and mortality. •

Explain the available welfare measures to the family members of the deceased •

victims clearly.

Arrange for follow up programs regularly. •

* Community Aspects

Conduct health education programme so as to promote immediate seeking of •

health care.

Eliminate the barriers that cause delay in health care seeking. •

* Educational & Research

Organise teaching and training programs for health care workers. •

Undertake research activities in a planned manner. •

* Administrative Issues

Arrange for required amount of drugs and devices in health centres / hospitals •

regularly.

Maintain records and reports safely. •

Monitor the activities at all levels periodically. •



3.11 Conclusions:

The ultimate goal is to provide appropriate Þ rst aid and treatment at the nearest

health centre / hospital at the earliest. Complicated cases have to be referred to higher

centre after Þ rst aid and supportive measures. Community should receive health

education on preventive and curative aspects of snakebite and scorpion sting. Each

health centre / hospital irrespective of the status should maintain a registry for snake

bite / scorpion sting and initiate research activities in a trans-disciplinary manner.

All these joint efforts will bring down the morbidity and mortality. In addition health

care institutions should undertake research activities on various aspects of snake bite /

scorpion sting, and share the knowledge and experience with others in order to advance

further in health care delivery.

Titles Page

I Snake bite cases reported in secondary care hospitals 87

II. Fluid requirement chart for children 88

III. Vital signs reference table for pediatric age group 88

IV. Pre hospital treatment for snake bite and issues related to ASV 91

V. Reporting / referral form for snake bite / scorpion sting 93

VI. Snake bite and scorpion sting monthly reporting format 94

VII. List of drugs and devices 95

VIII. Algorithmic approach to bite / sting 96

IX. Algorithmic approach to snake bite 97

X. Algorithmic approach to scorpion sting 98

XI. Frequently asked questions / self assessment queries 99

XII. Snakebite and scorpion sting in Tamil literature 100

XIII. Form to assess the quality of services 104

XIV. Form to analyse and audit the statistics on snake bite /

scorpion sting 105

XV. Useful Websites 106

SECTION - IV

ANNEXURES



Annexure : I

Table No. 28: Snake bite cases & deaths reported and ASV vials used in

secondary care hospitals in Tamil Nadu (District wise)

Sl.

No.District

April 2005- March 2006 April 2006- March 2007

Cases Deaths

ASV

Vials

Used

Cases Deaths

ASV

Vials

Used

1 Coimbatore 1107 2 12236 1109 0 16195

2 Cuddalore 1380 1 11779 2169 2 6898

3 Dharmapuri 679 1 2261 1076 0 3374

4 Dindigul 807 12 3041 972 13 3741

5 Erode 1277 10 11129 1607 6 7237

6 Kancheepuram 670 0 890 714 5 1598

7 Kanyakumari 3 0 3 11 0 5

8 Karur 228 3 1405 286 2 2242

9 Krishnagiri 432 0 1170 453 6 1271

10 Madurai 982 0 1801 677 0 2861

11 Nagapattinam 445 0 2565 420 0 2229

12 Namakkal 804 1 4565 1147 1 5959

13 Perambalur 576 0 3209 475 1 5746

14 Pudukkottai 683 3 2475 581 2 1865

15 Ramanathapuram 428 4 2377 373 3 2485

16 Salem 1175 5 3180 1331 1 4007

17 Sivagangai 328 2 1739 367 3 2023

18 Thanjavur 325 5 3213 514 5 3275

19 The nilgiris 69 0 31 49 1 0

20 Theni 486 0 2179 553 3 2391

21 Thiruvallur 766 0 1254 604 2 1305

22 Thiruvarur 160 2 866 142 9 715

23 Thoothukudi 351 1 1819 381 2 2056

24 Tirunelveli 671 3 2783 540 3 2814

25 Tiruvannamalai 894 5 3776 808 1 5074



26 Trichy 193 6 837 183 0 714

27 Vellore 1098 9 2650 708 2 2164

28 Villupuram 1109 9 5791 1084 2 2861

29 Virudhunagar 1195 1 3457 1343 0 3695

Total 19321 85 94481 20677 75 96800

ASV vials used in secondary care hospitals (District wise)

ASV - Anti snake venom (each vial contains 10ml)

Annexure II: Fluid requirement chart for children

Table No. 29: Fluid requirement chart for children

Weight Fluid requirement

Upto 10 kg 4 ml / kg / hour

11 kg to 20 kg 40 ml + 2 ml / kg / hour

21 kg & above 60 ml + 2ml / kg / hour

Example:

8 kg child with snake bite is admitted – add the vials to 2 hours of ß uid.

8 kg requirement = 4 ml / kg / hour

= 4 ml / 8 kg / 2 hour = 64 ml

So mix the vials in 65 ml to 75 ml of IV ß uid and run it for 2 hours as given in the

treatment column.

Annexure: III: Vital signs reference table for paediatric age group

Respiratory rate

Normal spontaneous ventilation is accomplished with minimal work, resulting in

quiet breathing with easy inspiration and passive expiration. The normal respiratory

rate is inversely related to age. It is rapid in the neonate, then decreases in older infants

and children. A respiratory rate consistently greater than 60 breaths per minute in a

child of any age is abnormal and is a “red ß ag”.

Table No. 30: Normal Respiratory Rate by Age

Age Breaths per Minutes

Infants (< 1 year) less than 2months

2months - less than one year

40 to 60

30 - 50

Toddler (1 to 3 years) 24 to 40



Preschooler (4 to 5 years) 22 to 34

School age ( 6 to 12 years) 18 to 30

Adolescent (13 to 18 years) 12 to 16

Heart Rate

Heart rate should be appropriate for the child’s age, level of activity and clinical

condition (Table 2). Note that there is a wide range for normal heart rate and that it

varies in a sleeping and awake child.

Table No. 31: Normal Heart Rate (Per Minute) by Age

Age Awake Rate Sleeping Rate

Neonate 100 to 180 80 to 160

Infant 100 to 160 75 to 160

Toddler 80 to 110 60 to 90

Preschool 70 to 110 60 to 90

School age child 65 to 110 60 to 90

Adolescent 60 to 90 50 to 90

References :

Hazinski.M. Children are different In:Hazinski M, ed. Manual of Pediatric •

Critical care. St.Louis, MO: Mosby year book ; 1999. Chapter 1,5-6.

Allen HD, Driscoll DJ, Shaddy RE, Feltes TF (Edrs). Moss and Adams’ Heart •

Disease in Infants Children and Adolescents Including the Fetus and Young

Adult. Lippin cott, Williams and Wilkins, Baltimore, MD, USA, 2007.

Blood Pressure

Normal blood pressure values for children by age is provided in Table 32. This

table summarizes the range from the 33rd to 67th percentile in the Þ rst year of life and

from the 5th to 95th percentile for systolic and diastolic blood pressure according to age

and gender and assuming the 50th percentile for height for children of one year of age

and older. Like heart rate, there is a wide range of values within the normal range.



Table No. 32: Normal Blood Pressure in Children by Age

AgeSystolic BP (mm Hg) Diastolic BP (mm Hg)

Female Male Female Male

Neonate (1st day) 60 to 74 60 to 74 31 to 45 30 to 44

Neonate (4th day) 67 to 83 68 to 84 37 to 53 35 to 53

Infant (1 month) 73 to 91 74 to 94 36 to 56 37 to 55

Infant (3 months) 78 to 100 81 to 103 44 to 64 45 to 65

Infant (6 months) 82 to 102 87 to 105 46 to 66 48 to 68

Infant (1 year) 68 to 104 67 to 103 22 to 60 20 to 58

Child (2 years) 71 to 105 70 to 106 27 to 65 25 to 63

Child (7 years) 79 to 113 79 to 115 39 to 77 38 to 78

Adolescent

(15 years)93 to 127 95 to 131 47 to 85 45 to 85

Blood Pressure ranges taken from the following source:

“Neonate, Infant (1 to 6 months) 8; Infant (1 year) Child, Adolescent”. •

Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood •

Pressure in Children and Adolescents: NHLBI, USA May 2004

Hypotension

Hypotension is deÞ ned by the following thresholds of systolic blood pressure

Table No. 33: Hypotension by Systolic Blood Pressure and Age

Age Systolic Blood Pressure (mm Hg)

Term Neonates (0 to 28 days) < 60

Infants (1 to 12 months) < 70

Children 1 to 10 years 5th BP percentile < 70 + (age in years x 2)

Children > 10 years < 90



Annexure IV: Pre hospital treatment for Snake bite and issues

related to ASV

(one for each case)

1. Name: S.No: Date:

2. Age:

3. Medical unit: IP NO:

4. Gender: Male / Female:

5. Hospital:

Details about the snakebite:

6. Time of snake bite ________ am / pm

7. Victim walked home - yes / no

8. Shifted home manually - yes / no

9. If yes, state poisonous / non-poisonous

10. Nature of snake specify - Viper (type)...../ Cobra / Krait / Sea snake / others...

11. Nature of snake specify - Viper............./ Cobra / Krait......./ Sea snake group

Pre hospital treatment:

12. Household medicines given to the patient – yes / no

If yes, specify_____________

13. Taken to the traditional healer – yes / no. If yes, specify_____________

14. Taken to the Local Medical Practitioner – yes / no. If yes, Nature of the Þ rst aid

given-

15. Other traditional practices followed:

tourniquet - yes / no

cutting and letting the blood out – yes / no

applying traditional substances externally -yes / no

any other, specify_________________

Anatomical site of the bite:

16. Upper limb / lower limb

17. Right side / left side / bilateral

18. Other areas in the body ........ specify____________

19. Multiple sites ....... specify____________



ASV related:

20. ASV administered – yes / no

21. If yes, Time of starting ASV___________ am / pm

22. Time interval between snakebite to time at which ASV started (21 - 7)......

23. Probable reason for delay in bite to needle time

a. Travel related

b. Beliefs and practices of traditional medicine

c. Failure to recognize symptoms

d. Sub optimal family support systems

e. Financial constraints

f. Any other, specify______________

24. Test dose for ASV given – yes / no

25 If yes, mention the details of reaction(s):...................

26 Mention if any prophylactic medications given - yes / no

27 If yes, mention the details of drugs given ....................

28. Reaction(s) while on ASV – yes / no

If yes, describe the nature of reaction to ASV and details of

management...............

29. Time taken to complete Þ rst dose of ASV...............

30. Time interval between starting and completing Þ rst dose of ASV

(29 - 21)......

31. Form of ASV used - Lyophilized / liquid form

32. Name of the manufacturer of ASV________________ Lot No.__________

Batch No._______________ Date of Expiry_____________

33. Mention if any repeat dose of ASV given -yes / no

If yes, reasons for repeat dose .........................................

34. Total quantity of ASV given (in ml)

35. Any others (specify) …..........

Medical Offi cer Name / Signature / Designation / Seal / Date



Annexure V: Reporting / Referral form for Snake bite / Scorpion sting

(One for referral, second for reporting & third to be retained)

1. O.P NO................................. / I.P.NO..................................

2. Date on which snake bite / scorpion sting case attended:

3. Time at which snake bite / scorpion sting case reported to Health Center:

4. Name of the Patient:

5. Address: Father / Mother / Husband / Wife / Son / Daughter of

Door No: Street/ Lane / Ward:

Village: Nearest Town / Post OfÞ ce:

Pincode: Taluk:

District: Phone/Mobile No:

6. Sex: Male / Female

7. Age:

8. Nature of snake bite / scorpion sting (describe what type of snake / scorpion):

9. Describe the condition of the patient on arrival

Pulse....../min; Respiration......./ min; BP............mm of Mercury

Clinical status of envenomation

10. Describe the nature of Þ rst aid and treatment given:

11. Name and designation of the person who gave Þ rst aid:

12. If referred, to other hospital:

a. Referral time and date

b. Details of the hospital to which referred

c. Staff accompanied - yes / no, if yes details................

d. Status of the patient at the time of referral

e. Others

13. Any other remarks – mention:

14. Follow up action & outcome:




Annexure VI: Snake bite / Scorpion sting monthly reporting format

(age & gender wise)

(Use separate tables for snake bite and scorpion sting would be helpful because we can

get rates for each eg. M/F, deaths, referrals etc...)

Name of the Health Centre ………………

Address: …..........

Sl.

No.Details

Reporting Month..............Year 200...

TotalBelow

5 yrs

6-9

yrs

10-14

yrs

15-24

yrs

25-44

yrs

45-64

yrs

65 and

above

M F M F M F M F M F M F M F

I a. Snake bite

/Scorpion

sting

Total cases

treated

II Out come of

the treatment

1. No.

Recovered

2. No.

referred

3. No.

Expired

at health

centre

III No. of cases

brought dead




Annexure VII: List of drugs and devices to be stocked at

health centre

Name of the Agent / Material Available as Numbers

Tab.Prazosin (plain) 1mg 20

Inj. Antisnake venom (ASV) 10ml/vial 20 vials

Inj. Atropine (0.6mg / amp) 2ml/amp 100 ampoules

Inj. Adrenaline 1ml/amp 15 ampoules

Inj. Chlorpheneramine maleate 2ml/amp 15 ampoules

Inj. Neostigmine 0.5mg/ml 20 ampoules

Inj. Lignocaine without adrenaline 30ml/vial 2 Vials

Inj. Hydrocortisone 100mg 5 ampoules / vials

Inj. Dexamethasone 4mg/ml 5 ampoules / vials

Inj. Ranitidine 50mg/2ml 20 ampoules

Inj. Diazepam 10mg/2ml 10 ampoules

Inj. Dobutamine 10 ml/ampoule 5 ampoules

Intravenous fl uids 35 bottles

a. Normal saline 500ml 15 bottles

b. Dextrose saline 500ml 20 bottles

IV Set 20 sets

Intravenous Cannula (Venfl on)

18 Size – Green 5

20 Size – Pink 5

22 Size – Blue 5

24 Size – Yellow 5

Nasogastric tube (different size) 10 each

Airway (different size) 5 each

Ambu bag (Adult) / (Pediatric) One each

Laryngoscope set (Adult) 1

Endotracheal tube (different size) 5

Glass test tube (5 or 10 ml) 20

Laryngeal Mask Airway

Others if any..............2



Drugs to be indented based on the requirement

Check for the expiry date and change accordingly

Other items that should be available in the emergency tray:

Sterile Glass syringes, Splint (to support the limb / hand), Compression bandage

linen cloth, Laryngeal mask airway, Gloves, Suction Apparatus [Electrically and or

manually operated], Thermometer, Torch Light (2 cells) and other item as per need.

Annexure VIII: Algorithmic approach to bite / sting at primary level

2

prazosin

C



symptoms

R

I

G

T

H

for2

&

f

x

Annexure IX: Algorithmic approach to Snake bite



NGT - Nasogastric Tube; IV - Intravenous; NS – Normal Saline;

RL - Ringer Lactate; NG – Nitroglycerine; SNP - Sodium Nitroprusside

Annexure X: Algorithmic approach to scorpion sting

S

persists

x

Paresthesia



Annexure XI: Frequently asked questions / self assessment queries.

1. Mention the poisonous snakes / scorpions noticed in Tamil Nadu.

2. Mention the predisposing factors for snake bite / scorpion sting.

3. What are the implications of snake bite / scorpion sting?

4. Mention the various clinical symptoms and signs of snake bite / scorpion sting

5. Describe the local effect of snake bite / scorpion sting.

6. Mention the reasons why the presenting features, clinical course, complications

and outcome vary from case to case in snake bite / scorpion sting.

7. What is late onset envenomation in scorpion sting and mention the

mechanisms?

8. Mention the various risks involved in tourniquet.

9. What is pressure pad technique and how is it used for snake bite cases?

10. Criteria for the diagnosis of snake bite / scorpion sting at the bed side.

11. What are the laboratory investigation required for snake bite / scorpion sting?

12. Mention the details of 20WBCT - the procedures, the advantages, the

requirements and the interpretation.

13. What are the additional investigations and care that should be adopted while

treating a case of pregnant women with snake bite / scorpion sting.

14. What are the principles involved in the treatment of snake bite / scorpion

sting?

15. What are the prognostic features for a better outcome in snake bite / scorpion

sting?

16. What are the long term complications of snake bite / scorpion sting?

17. How do you monitor the cases of snake bite / scorpion sting in resource limited

setting?

18. Describe the various complications observed in acute snake bite / scorpion

sting.

19. What are the Þ rst aid methods to be adopted for snake bite / scorpion sting?

20. Describe the methods to take care of the site of bite / sting.

21. Describe the management of snake bite / scorpion sting in special situation.

22. What are the precautions to be adopted while managing a case of snake bite /

scorpion sting in a patient who has one or other co-morbid illness or taking any

other medication?

23. Can a patient on ASV therapy for a poisonous snake bite undergo dental

procedure?

24. What are the prophylactic medications to be used, to avoid reactions to ASV?

25. Why is prazosin tablet preferred for scorpion sting?

26. What are the alternative for Tab.prazosin in scorpion sting?

27. Why should antihistamines not be given while a patient is getting treated for

scorpion sting?

28. Do we have anti snake venom for each and every snake individually?

29. Narrate the pharmacological aspects of ASV.



30. Describe the methods adopted to administer ASV.

31. Is there any concept called prophylactic medication for ASV?

32. What are the immediate reactions that follow after ASV?

33. Mention brieß y the treatment a modalities adopted to tackle reactions to ASV.

34. Describe clearly the guidelines to be adopted while planning to repeat ASV.

35. What are the measures to be adopted to tackle a case of snake bite for which no

anti-venom is available?

36. What will you do if a patient treated for snake bite with ASV comes back with

poisonous snake bite again?

37. What is the role of Heparin / botropase in snake bite?

38. What are the reasons for referring a case of snake bite / scorpion sting to higher

centre / specialist?

39. Discuss the measures you would like to adopt to prevent snake bite / scorpion

sting?

40. What are the components of competency of a health care provider / doctor?

41. What are the quality care indicators used to assess the management of snake

bite / scorpion sting?

42. What facts should patients and care givers know about snake bite / scorpion

sting?

43. What should Health Care Providers (HCP) know about snake bite / scorpion

sting?

44. What are the medical pitfalls associated with snake bite / scorpion sting?

45. How can HCP help the family members of deceased victim?

46. Why should narcotics not be used in scorpion sting?

47. Describe the late serum sickness reaction and treatment of the same.

48. What are the various unusual complications of snake bite / scorpion sting?

49. What are the various surgical issues related to snake bite / scorpion sting?

50. What are the various uses of venom?

Annexure XII: Snake bite and scorpion sting in Tamil Literature.

Tamil language is an ancient language. The poems and proverbs of the Tamil •

language describe the status of living at that time, highlight their knowledge,

express talents, reß ect cultures, bring out tradition and reveal their beliefs and

practices, though the place of origin may not be available clearly. One can

also appreciate the changes that had happened over a period of time through

literature. Based on the circumstantial evidences the time of origin has been

calculated.

Communicating to a group of persons in their own language using the poems, •

proverbs and the procedures adopted in that region, will help to win their



conÞ dence. Thereafter changing them and bringing them into the scientiÞ c

arena is easier. Once a community gets convinced, it is easy to convey health

messages and they get adapted to newer methods which will be of immense use

for their health and welfare.

Good amount of information is available in Tamil Literature and Tamil medicine •

on symptoms, clinical course and outcome of it. Infact the descriptions are

better than what is available today. Their knowledge on types of snakes and

scorpions are simply astonishing. This can be used to educate the community

and make them realize the usefulness of modern medical treatment for better

outcome.

Proverbs irrespective of the language help to explain or convey messages within •

and outside a community. Historically collected proverbs of Tamil literature is

displayed as early as 5 A.D. one each under one poem of “Pathinen keezh

kanakku Nool”. Tamil being an advanced language with high level of grammer,

it has given criteria / guidelines for poems and proverbs and these are made

available in Tholkappiam (poem 177) and Agananooru (poem No.101: 2 – 2

and 66 : 5-6)

Most of the proverbs are thought provoking, contain rich information and are •

unique to the language. Also, these proverbs help to transfer relevant facts with

beauty and brevity between the speaker and the audience or readers. Moreover

poems and proverbs act as a bridge between health care professional and the

patients or the public to convey health messages convincingly, clearly, and

conÞ dentially within few minutes.

When a speaker uses an apt poem or proverb or both to convey a message to •

the community, their understanding is greater, ability to accept is better and

the capacity to transfer the message in real life is superior. Keeping all these

in mind efforts are made to bring / provide Tamil proverbs and certain aspects

of Tamil medical practices in relation to snake bite and scorpion sting is given

below.

The health care professions involved in patient care and community education •

programme are informed to make use of the information provided. When the

professionals use the literary phrases / poems available in their own language,

community acceptance the greater. Hence changes will occur which can be

measured quantitatively. Health care providers can make use of the proverbs

and collect more proverbs and poems related to snakebite and scorpion sting,

and forward to us which will be of great use to subsequent editions.



Tamil proverbs related to Snake bite and Scorpion sting

ešthœÎ fšéæš fyªJiuahl gh«ò k‰W« njŸ r«gªj¥g£l

gHbkhêfŸ

1. mut¤ij f©lhš Ñç éLkh? (mšyJ) muit¡f©lhš Ñç éLkh?

2. Ïo nf£l ehf« nghy

3. Ïiu Â‹w gh«ò nghy

4. fUlid¡ f©l gh«ò nghy

5. fiwah‹ ò‰W gh«ò¡F cjÎ»wJ

6. fiwah‹ ò‰bwL¡f¡ fUehf« FoòFªjJ nghy

7. fiwah‹ ò‰¿š mut« Fobfh©lJ nghy

8. vè ÏU¡»w Ïl¤Âš gh«ò ÏU¡F«

9. gl« vL¤jhš jh‹ gh«ò

10. gukÁt‹ fG¤ÂèU¡F« gh«ò nghy

11. fhiy R‰¿a gh«ò fo¡fhkš élhJ

12. gh«Ã‹ fhš gh«g¿Í«

13. gh«ÃY«, gh«ò F£o¡F éõK«, ÅçaK« mÂf«

14. gh«Ã‰F gšèš k£L« jh‹ éõ« Mdhš ghéfS¡F clš KGtJ« éõ«

15. gh«Ã‹ F£o gh«ò, mj‹ F£o e£Lth¡fèah?

16. gh«ò v‹whš gilÍ« eL§F«

17. gh«ò Mæu«, gid Mæu«, gh«Ã‹ fhš Mæu«

18. gh«ò¡F gif fUl‹

19. gh«ò¡F _¥ò Ïšiy

20. gh«ò j‹ gÁia ãid¡F«, njiunah j‹ éÂia ãid¡F«

21. gh«ò Â§»w CU¡F nghdhš eL¡f©l« ek¡F

22. gh«ò ò‰Wf©L, m§F »zW bt£L

23. gh«ò gif, njhš cwth?



24. ghé¡F gh«ò f©

25. ghé¡F gh«ò bré

26. éÂ Koªjtid éça‹ fo¡F«

27. éça‹ fo¤jhš éÂ KoÍ«

28. Ñç¡F« gh«ò¡F« Ôuh¥gif

29. ÑçÍ« gh«ò« nghy

30. Ú®¥gh«ò fo¤jhY« Ïurg£o MF«

31. bg£o gh«ghf ml§»dh‹

32. njS¡F kâa« bfhL¤jhš, rhk¤J¡F (bghGJ éoÍ« k£L« ãäl¤J¡F ãäl«)

bfh£L«

33. njS¡F éõ« bfhL¡»ny, gh«ò¡F éõ« gšèny

34. bfh£odhš njŸ, bfh£lhé£lhš ÃŸisó¢Áah?

35. njiu Â‹w gh«ò fo¤jhš Ïw¥ò ã¢ra«.

gh£L

f©lJ gh«ò

fo¤jJ fU¡F

Â‹wJ kUªJ

bfh‹wJ kU¤Jt‹



Annexure XIII: Form to assess the quality of services rendered to snake bite /

scorpion sting for the month of ……….200…/ for the quarter ending March /

June / September / December200........

Name of the Health Centre / Hospital …………………………Code No……….

Sl.

NoQuality of services

Observations /

Problems /

Complaints

Remarks

1. Clinical matters

Admission •

Assessment & Administration of •

appropriate drugs

Observation on adverse reactions to •

ASV and / other drugs

Lapses in clinical care •

Referral of cases •

Morbidity status for the reporting •

month

Mortality •

Sharing of experiences with others •

Guiding on welfare programme •

Others –specify •

2. Preventive aspects

Organising awareness programmes •

Reduction in the time interval •

between bite / sting to

hospitalisation

Immobilisation of the victim •

Avoidance of traditional practices •

Any other – specify •

3. Administrative issues

Availability of medications •

Submission of report to higher •

authorities

Monitoring and review of •

a. Patient care

b. Preventive aspects

Any other – specify •

Name, Designation, Signature, Date and Offi ce seal of Medical Offi cer



Annexure XIV: Form to analyse and audit the statistics on snake bite /scorpion sting for the month of ……….200…../ for the quarter ending March / June / September / December 200…Name of the Health Centre / Hospital ………………….....Code No……

Name, Designation, Signature, Date and Offi ce seal of Medical Offi cer

b

1.

2.

3.

4.

5.

6.

7.

8.

9.

.



Annexure XV: Useful Websites:

http:// • www.globalcrisis.info/poisonandvenomemergency.html

http:// • www.whosea.org/bct/snake/5htm

http:// • www.whosea.org/bct/snake/2introB.htm

http://www • .whosea.org/bct/snake/5f.html

http://www.fda.gov/Fdac/features/995_snakes.htm • l

http://www.emedicine.com/MED/topic2143.ht • m

http://www.emedicinehealth.com/snakebite/article_em.htm •

http://www.lfsru.org/Þ rstaid.ht • m

http://www.healthcentral.com/ency/408/000031.htm • l

http://www.umm.edu/non_trauma/snake.htm •

handbook on treatment guidelines for snake bite and scorpion sting 2008 - tnhsp publication

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