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H & FW Dept, GoG_Snake Bite Management_Protocol_Guideline 1 | P a g e

Guideline for Snake bite Treatment, First Aid and Prevention

Health & Family Welfare Department

Government of Gujarat


Core – Committee Members:-

1) Dr Asha Shah – HoD Medicine Department, B. J Medical College Ahmedabad

2) Mr. Soham Mukherjee – Herpetologist – Ahmedabad

3) Dr. Samiraben – HoD Emergency Department, B. J Medical College, Ahmedabad

4) Dr. Mira Desai HoD Pharmacology Department, B. J Medical College, Ahmedabad

5) Dr Jayraj Desai, Head Emergency Medicine Learning & Care (Gujarat) 108 GVK

EMRI.

6) Dr. Dinkar Raval – Deputy Director – Epidemic, Commissionerate, Gandhinagar

7) Dr. Dilip Gheewala HoD Medicine Department, GMERS Medical College, Valsad

8) HoD Medicine Department, V.S Hospital – Ahmedabad

9) Dr. R. M Mehta – Deputy Director – Nursing, Commissionerate Gandhinagar.


Index

Sr. No Description Page No 1 Introduction 4 2 Part 1 Treatment 5 3 Clinical Features in patient bitten by common venomous snake 5 4 Primary Health Centre 6

4.1 How to treat - Do’s 6 4.2 Don’ts 6 4.3 When to transfer 6 5 Community Health Centre 7

5.1 How to Treat – Do’s 7 5.2 Don’ts 7 5.3 When to Transfer 7 6 Tertiary Level – How to Treat 8 7 Part II – First Aid Part 9

7.1 Principles of first – aid 9 7.2 Aims of first-aid 9 7.3 Recommended first-aid methods 9 8 Snake-bite initial management & prevention rural communities 11 9 Protocols developed by 108 GVK EMRI

10 Annexure – 1 (Snakebite Cases & ASV usage detail year 2013) detail of Government Institution

16

11 Annexure – 2 (ASV Usage Details from 2008 – March 2014) by 108 GVK EMRI Gujarat.

17

12 References 18


PART - 1

1. Introduction

Early in 2009, snake-bite was finally included in the WHO’s list of neglected tropical diseases

confirming the experience in many parts of South East Asia region that snake-bite is a

common occupational hazard of farmers, plantation workers and others, resulting in tens of

thousands of deaths each year and many cases of chronic physical handicap (WHO, 2007;

Williams, 2010)

India’s first exhaustive study on annual snake-bite deaths, the Million Death Study (April

2011), has revealed the annual death figures to be as high as 46,000 while the total number

of annual snake-bites are estimated to be around 14,00,000. India has long been thought to

have more snake-bites than any other country. The first ever direct estimates were drawn

from a national mortality survey of 11 lakh homes. The estimated total of 46,000 national

snake-bite deaths constitutes about 5% of all injury deaths and nearly 0.5% of all deaths in

India. It is more than 30-fold higher than the number declared from earlier official hospital

returns. The underreporting of snake bite deaths has a number of possible causes, most

importantly, it is well known that many patients are treated and die outside health facilities

especially in rural areas.

As per the study, states with a high-prevalence of snakebite deaths are defined as those

with more than 1 crore people where the annual snakebite death rate exceeds 3 per

1,00,000 population. Gujarat has an annual snake-bite death rate of 3.5 per 1,00,000

population and is one of the 13 states with high prevalence of snake-bite deaths. This means

around 2,100 people die in Gujarat every year from 1,34,400 bites (non-fatal snake-bite to

death ratio is 64:1 as per hospital records during the study); even if the ratio is halved it

comes to 67,200 bites every year.

This publication aims to pass on a digest of available knowledge about all clinical aspects of

snake-bite to medically trained personnel. The guidelines are intended for medical doctors,

nurses, dispensers and community health workers who have the responsibility of treating

victims of snake-bite. They aim to provide sufficient practical information to allow medically

trained personnel to assess and treat patients with snake-bites at different levels of the

health service.


2. Snake bite Medical Management Protocols at Primary,

Secondary and Tertiary Levels

Introduction:

There are more than 250 species of snakes in India, 52 of which are venomous (Poisonous).

There are 4 Families of Venomous snakes:

- Elapidae - Kraits, cobras (neurotoxic)

- Viperidae - Russell’s viper, saw-scaled viper, other vipers (Hemotoxic)

- Hydrophiodae - Sea snakes (neurotoxic; extremely rare bites reported)

- Colabridae – Rear-fanged snakes (mostly harmless due to low toxicity)

Of these, there are only 4 medically important species in Gujarat namely;

1. Spectacled cobra (Naja naja)

2. Common krait (Bungarus caeruleus)

3. Russell’s viper (Daboia russellii)

4. Saw-scaled viper (Echis carinatus)

These four species are referred to as the Big Four snakes of India as they are

collectively responsible for most snake-bite deaths in India. The estimated total of

46,000 national annual snake-bite deaths constitutes about 5% of all injury deaths

and nearly 0.5% of all deaths in India.

Snake-bite preventive strategies by rural communities and effective post bite clinical

management are key mitigation measures.

3. Clinical Features in patient bitten by common venomous

snake:

Species Clinical Features

Viperidae (all) Local Swelling plus bleeding tendencies

Russell’s viper Ptosis, Opthlmoplegia, facial paralysis with dark coloured urine

Cobra Local swelling with Paralysis

Krait Paralysis without local swelling bitten while sleeping on ground


4. Primary Health centre:

How to treat:

Do’s:

1. Reassure the Patient that all the snakes are not venomous and even if venomous,

treatment is available.

2. Immobilize the affected part with splint or bandage.

3. Make the victim lie flat with affected limb below heart level.

4. Remove shoes, tight clothes, rings, jewellery or watches.

5. Be prepared for cardiorespiratory resuscitation. (CPR)

6. Maintain airway, breathing and circulation. (ABC)

7. Administer Inj. Tetanus toxoid IM

8. Give Antibiotics if skin is breached or localized necrosis.

9. Try to identify the snake if available or ask the relatives who have seen that.

10. Monitor the patient for 24 hours for late symptoms.

Don’ts:

1. Do not apply tourniquet.

2. Do not wash the site with soap or water to remove poison.

3. Do not make cuts or incision on or near the bitten area.

4. Do not give electrical shock or apply extreme cold to the bitten area.

5. Do not suck out the venom with mouth.

6. Do not apply any herbal or folk remedies to the bitten area.

7. Do not give any drinks or alcohol to the patient.

When to transfer:

1. If the snake is identified as venomous, do not wait for symptoms to develop.

Immediately transfer to higher level.

2. If during observation following symptoms develop, transfer the patient to CHC

- Bleeding from any site

- Decrease urine output

- Localized excessive swelling or cellulitis

- Respiratory distress

- Chest pain with tightness

- Paralysis

- Any other Deteriorating condition.


5. Community Health Centre:

How to treat:

Do’s:

1. Do not suddenly remove tourniquet which can cause sudden flushing of venom in

circulation.

2. Watch for symptoms whether hemotoxic or neurotoxic.

3. Run Hb, total count, platelets, PT/aPTT, Urine R/M, Urea, Creatinine, Sodium,

Potassium, ECG and Chest X-ray, ABGA.

4. Run 20 minute whole blood clotting test to detect coagulopathy.

5. Administer Anti snake venom.

DOSE:-

8 to 10 vials of ASV is given over 1 hour as it removes most of the unbound toxin.

No next dose to be given till the next Clotting test done after 6 hours.

If WBCT still > 20 minutes repeat dose of 5-10 vials given.

If 20 vials given then no further ASV should be given assuming that all the unbound

toxin has been removed.

Be ready for any anaphylactic reaction.

Inj. Adrenaline + Hydrocortisone (100 mg) + Antihistaminic (Phenylephrine) should

be available before administering ASV.

Administer Inj. Neostigmine 0.5-2 mg i.v if there are neurological symptoms and

repeat every half hourly for next 8 hours if improvement occurs.

When to transfer:

1. Snake identified to belong to dangerous species.

2. Rapid early extension of local swelling from site of bite.

3. Early Tender enlargement of local lymphnodes, indicating spread of venom in the

lymphatic system.

4. Early systemic symptoms: collapse (hypotension, shock), nausea, vomiting.

5. Diarrhoea, severe headache, “Heaviness” of the eyelids, worsening drowsiness or

early ptosis/ opthlmoplegia.

6. Early spontaneous systemic bleeding.

7. Passage of dark brown/ black urine.

8. If ASV not available or patient not recovered with usual dose of ASV.


6. Tertiary Level:-

How to treat:

1) Administer ASV if not given previously as per the recommended guidelines.

2) Give FFP (Fresh frozen Plasma) if there is coagulopathy.

3) Intubate and provide ventilator support to the patient with severe respiratory

distress.

4) Start prednisolone or other immunosuppressant’s to the patient having serum

sickness.

5) Start higher antibiotics according to culture and sensitivity reports.

6) Nephrology opinion and Haemodialysis for the patient having acute renal failure.

7) Surgical opinion and removal of local part if necessary in a patient having

gangrene.

8) Perform D-dimer, FDP, Coagulation studies, cultures and sensitivity.

9) Rehabilitation and disability limitation.


PART - 2 7. Snake-bite first Aid Clinicians

Principles of first-aid

First-aid treatment is carried out immediately or very soon after the bite, before the

patient reaches a dispensary or hospital. It can be performed by the snake-bite victim

himself/herself or by anyone else who is present and able.

Unfortunately, most of the traditional, popular, available and affordable first-aid

methods have proved to be useless or even dangerous. These methods include: making

local incisions or pricks/punctures at the site of the bite or in the bitten limb, attempts

to suck the venom out of the wound, use of (black) snake stones, tying tight bands

(tourniquets) around the limb, electric shock, topical instillation or application of

chemicals, herbs or ice packs. Local people may have great confidence in traditional

(herbal) treatments, but they must not be allowed to delay medical treatment or to do

harm.

Aims of first-aid

Attempt to delay systemic absorption of venom. Preserve life and prevent complications before the patient can receive medical

care Control distressing or dangerous early symptoms of envenoming. Arrange the transport of the patient to a place where they can receive medical

care. ABOVE ALL, AIM TO DO NO HARM!

Recommended first-aid methods

Reassure the victim who may be very anxious Immobilize the whole of the patient’s body by laying him/her down in a

comfortable and safe position and, especially, immobilize the bitten limb with a splint or sling. Any movement or muscular contraction increases absorption of venom into the bloodstream and lymphatic’s.

If the necessary equipment and skills are available, consider pressure-immobilization (see figure below) or pressure pad only if the snake species is identified as cobra or krait.

Avoid any interference with the bite wound (incisions, rubbing, vigorous cleaning, and massage, application of herbs or chemicals) as this may introduce infection, increase absorption of the venom and increase local bleeding.

Release of tight bands, bandages and ligatures: Ideally, these should not be released

until the patient is under medical care in hospital, resuscitation facilities are available

and ASVS treatment has been started.


Tight (arterial) tourniquets are not recommended!

Traditional tight (arterial) tourniquets are not recommended. To be effective, these had

to be applied around the upper part of the limb so tightly that the peripheral pulse gets

occluded. This method can be extremely painful and very dangerous if the tourniquet

was left on for too long (more than about 40 minutes), as the limb might be damaged by

ischemia. Tourniquets have caused many gangrenous limbs.

Snake-bite first aid: pressure immobilization method

Figure 1: Pressure immobilization (Sutherland method)


Spectacled cobra Common krait

Russell’s viper Saw-scaled viper

The above 4 species account for most snake-bite deaths in India.

8. Snake-bite initial management & prevention rural communities

Snake-bite is one of the more serious health issues, especially in India where deaths

due to snake-bites are estimated well over 46,000 every year. Even though actual

envenomation takes place less often, it is best to stay prepared for an emergency.

Firstly, Things NOT to Do:

Do not suck out venom

Do not make incision to bleed out venom

Do not go to traditional healers or anything similar

Do not try out home remedies

Do not apply tourniquets

Do not apply ice

Do not clean out the bitten part

Do not try to catch/kill the snake

All of the above activities either do not work or are extremely dangerous to perform.


In fact, they will do more harm than good.

Following is what you should do:

Make sure the victim and others are at a safe distance away from the snake; do

not attempt to capture the snake, get the victim and others away from the snake

Try to memorize the snake’s appearance (from a safe distance!)

Remove watches / rings / other jewellery from the bitten part

Keep the victim calm and reassured, do not panic, as trivial as it may sound, it

makes everything from the victim's ability to deal with the situation to your

ability to make decisions better

Try to immobilize the bitten limb; do not make the victim run and avoid making

him/her walk if possible

Do not waste any time and arrange for a quick transport to the nearest hospital

treating snake-bite cases, as safely and comfortably as possible

If possible, note the time of bite and progression of symptoms

Describe the snake and the whole incident to the attending doctor

*Anti Snake Venom Serum is the only cure*

If your neighbourhood has a high density of snakes, it is advisable to prepare a snake-


bite protocol (plan of action in case of an emergency) best suited to you. This can simply

be important contact people and numbers who should be informed first, name / address

of nearest hospital treating snake-bites, best mode of transport and related details,

name / contact no. of doctor, etc. Make sure all family members and friends understand

their role in an emergency.

Spectacled cobra Common krait

Russell’s viper Saw-scaled viper

The above 4 species account for most snake-bite deaths in India. Please be extra careful if

you are around these.

In case of a snake-bite, call 108 from your phone. The emergency response service will

immediately dispatch an ambulance with trained paramedics.

Prevention is always better than cure:


Education: Know your local snakes, know the sort of places where they like to live and hide, at what times of year, at what times of day/night or in what kinds of weather they are most likely to be active.

Be especially vigilant about snake bites after rains, during flooding, at harvest time and at night.

Try to wear proper shoes or boots and long trousers, especially when walking in the dark or in undergrowth. Always check footwear before wearing them!

Use torch / lamp when walking at night. Avoid snakes as far as possible, including snakes performing for snake charmers.

Never handle, threaten or attack a snake and never intentionally trap or corner a snake in an enclosed space.

In the house:

Do not keep livestock, especially chickens, in the house, as snakes may come to hunt them. Store food in rat-proof containers. Regularly check houses for snakes and, if possible, avoid those types of house construction that will provide snakes with hiding.

If at all possible, try to avoid sleeping on the ground. If you have to sleep on the ground use mosquito net that is well tucked in under the mattress or sleeping mat.

In the yard:

Try not to provide hiding places for snakes. Clear termite mounds, heaps of rubbish, building materials etc. from near the house.

Do not have tree branches touching the house. Keep grass short or clear the ground around your house and clear low bushes in the vicinity so that snakes cannot hide close to the house.

Keep your granary away from the house, it may attract rodents that snakes will hunt.

Take great care when clearing vegetation, raking dry leaves in outdoors. Use a light (torch or lamp) when you walk outside the house or visit the latrine at

night.

In the rural areas:

Firewood collection at night is a real danger. Avoid doing.


Watch where you walk especially when walking in the dark or in undergrowth. Do not go barefoot.

Step on to rocks or logs rather than straight over them – snakes may be sunning themselves on the sides.

Avoid handling dead snakes, or snakes that appear to be dead. They can still inject venom!

Keep young children away from areas known to be snake-infested. Many snake-bites occur during ploughing, planting and harvesting and in the

rainy season.

If you see a snake, do nothing; let it go. Do not try to pick it up or kill it. Snakes

prefer not to confront large animals such as humans so give them the chance to

slither away.


Annexure - 1

Snakebite Cases & ASV Usage detail Year 2013

Snakebite Cases & ASV Usage Detail Year 2013

Sr No Zone Snake Bite Patients No ASV Usage

1 Surat 2742 7580

2 Vadodara 1175 2382

3 Bhavnagar 375 1346

4 Ahmedabad 341 1139

5 Rajkot 682 3437

6 Gandhinagar 1114 5184

Total 6429 21068

Snakebite Cases & ASV Usage Detail Year 2012 to May 2014

Sr No Zone Snake Bite Patients No ASV Usage

1 2012 3175 20961

2 2013 4503 25482

3 Upto May 2014 1353 8112

Total 9031 54555

Year →

Ahmedabad 16 5 8 3 6 3 71 22 75 26 87 27 5 2 268 88

Amreli 17 5 10 4 6 3 78 26 85 29 76 24 8 3 280 94

Anand 20 6 12 4 5 2 114 37 92 28 137 43 2 1 382 121

Banas Kantha 19 6 19 6 3 1 124 42 156 47 156 49 12 5 489 156

Bharuch 10 3 12 5 5 2 120 36 126 40 122 45 20 9 415 140

Bhavnagar 10 3 11 5 0 0 52 16 70 21 80 25 5 2 228 72

Dahod 6 2 8 3 2 1 98 29 105 35 128 45 10 3 357 118

Gandhinagar 5 2 7 3 1 1 57 17 46 14 55 17 6 2 177 56

Jamnagar 12 4 11 4 0 0 177 53 135 41 126 39 11 4 472 145

Junagadh 33 12 36 14 2 1 225 68 193 58 182 57 15 8 686 218

Kheda 20 6 16 8 5 2 82 25 105 32 84 26 3 1 315 100

Kutch 4 1 2 1 5 3 115 35 127 38 152 47 14 5 419 130

Mahesana 7 2 2 1 1 1 50 15 74 22 65 21 1 1 200 63

Narmada 8 2 4 2 0 0 187 58 191 57 203 72 21 11 614 202

Navsari 16 5 10 3 2 1 214 72 213 74 229 81 26 12 710 248

Panch Mahals 32 11 21 10 4 2 180 58 300 92 311 105 19 12 867 290

Patan 6 2 7 2 2 1 31 9 30 9 29 9 0 0 105 32

Porbandar 16 5 4 2 1 1 103 31 120 36 70 22 10 3 324 100

Rajkot 27 8 19 9 1 1 103 31 81 24 112 35 8 3 351 111

Sabarkantha 33 11 17 8 9 4 125 38 169 51 190 59 15 5 558 176

Surat 14 4 19 7 3 1 254 78 296 89 325 111 43 23 954 313

Surendranagar 5 2 7 3 1 1 30 9 31 9 37 12 3 1 114 37

Tapi 19 6 22 11 4 2 247 74 276 83 356 111 32 18 956 305

The Dangs 4 1 4 1 2 1 265 84 257 77 259 85 31 15 822 264

Vadodara 35 12 36 14 19 9 270 90 306 92 309 100 26 13 1001 330

Valsad 19 6 18 6 0 0 281 95 371 112 482 165 51 22 1222 406

Grand Total 413 132 342 139 89 44 3653 1148 4030 1236 4362 1432 397 184 13286 4315

ASV

Usage

2014

CasesASV

Usage

2012

CasesASV

Usage

2013

CasesASV

Usage

GVK EMRI Gujarat- District & Year Wise Snake Bite Cases and Inj. ASV Usage Details from September 2008 to March 2014

2011

CasesASV

Usage

Grand Total

Cases ASV UsageDistrict ↓

2009

Cases ASV Usage

2010

CasesASV

Usage

2008

Cases


Reference:-

1) Harrison’s Textbook of internal medicine, 18th edition

2) API textbook of medicine, 10th edition

3) National snake bite management guideline

4) WHO SEARO snake bite management guidelines for Asian countries

5) Post Graduate Medicine, Volume 28, Feb 2014

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