Snake bite management in India

identification of snakes and clinical features of snakebite , envenomation and management of snake bite
national snake bite treatment protocol

1. Management of snake bite Dr. Prasenjit Gogoi MBBS, MEM(SEMI), PGDHHM Attending Consultant, Emergency Dept., Apollo Hospitals Guwahati

2. Introductio n India is estimated to have the highest snakebite mortality in the world. 2.8 million cases of snakebite annually with 46,900 deaths annually in India (WHO) Snake bite is an occupational hazard in an agricultural country like India. Snake bites are more common in rural areas especially during monsoon season.

3. The Big 4 Common spectacled cobra( Naja naja ) Common Krait( Bungarus caeruleus ) Saw-scaled viper( Echis carinatus ) Russel’s viper( Daboia Russelii ) H emotoxic Neurotoxic

4. Composition of snake venom Procoagulant enzymes ( Viperidae ) Haemorrhagins (zinc metalloproteinases ) Cytolytic or necrotic toxins Haemolytic and m yolytic phospholipases A2 Pre-synaptic neurotoxins ( Elapidae and some viperidae ) Post-synaptic neurotoxins ( Elapidae )

5. Clinical features General – fear and anxiety Local envenoming Local pain at bite site Local swelling Tenderness Painful swelling of regional lymph nodes Other signs : fang marks, persistent local bleeding, bruising, lymphangitis , inflammation, blistering, infection, abscess formation, necrosis

6. Signs of local envenomation

7. Clinical features ( cont ) Systemic envenoming : nausea, vomiting, malaise, abdominal pain, weakness, drowsiness, prostration. Cardiovascular ( Viperidae ) Hypotension, syncope, collapse, shock Cardiac arrhythmias Myocardial damage

8. Clinical features ( cont ) 2. Generalized increase in capillary permeability Facial, periorbital , conjunctival edema Pleural and pericardial effusions, pulmonary edema Massive albuminuria Hemoconcentration 3. Bleeding and clotting disorders( Viperidae ) Local bleeding Spontaneous systemic bleeding (gums. epistaxis, hemoptysis, subarachnoid hemorrhage etc )

9. Clinical features ( cont ) 4. Neurological ( Elapidae , Viperidae ) Bilateral ptosis External ophthalmoplegia Descending paralysis progressing to generalized flaccid paralysis 5. Generalised rhabdomyolysis Muscular stiffness, tenderness Painful on passive stretching, trismus Dark brown urine

10. Clinical features ( cont ) 6. Acute kidney injury Low back pain Hematuria, hemoglobinuria , myoglobinuria Oliguria/anuria Uremia 7. Pituitary insufficiency (Russell’s viper) Acute : shock, hypoglycemia Chronic : weakness, loss of sexual characters, loss of libido, amenorrhea, testicular atrophy, hypothyroidism etc

11. First aid (WHO guidelines) “ CARRY NO R.I.G.H.T.”

12. First aid (cont.) CARRY = Do not allow victim to walk. No = Tourniquet, No- electrotherapy, No - cutting, No -pressure immobilization, No -sucking of venom R = Reassure the patient. I = Immobilize the limb. GH = Get to hospital immediately. Traditional remedies - NO PROVEN benefit T = Tell the doctor of any systemic symptoms that manifest on the way to hospital.

13. Pre - hospital management Manage airway/breathing/ circulation Immobilization Identify neurological symptoms Watch for p aradoxical respiration Secure IV line

14. Emergency hospital management Initial management Access ABCDE CPR if needed Tetanus toxoid if skin is breached Antibiotic if cellulitis or local necrosis present Specific treatment after history and physical examination

15. Diagnosing Envenomation Pure clinical skill No diagnostic kit available yet !!

16. Diagnosis phase

17. Investigations Blood investigations Urine examination Biochemistry – S. Creat / Urea/K + /Na + ABG ECG/X-ray/CT/ USG ELISA - to confirm snake species.

18. Treatment phase Pain management – oral paracetamol /tramadol ~ NO APRIRIN/NSAIDS ~ Handling tourniquets Sudden removal -> neurological paralysis and hypotension. Remove after ASV administration + doctor present Test for the presence of a pulse distal to the tourniquet. If no distal pulse , apply blood pressure cuff & reduce the pressure slowly.

19. Anti Snake Venom ASV is Ig (usually the enzyme refined F( ab )2 fragment of IgG ) purified from the serum/plasma of a horse/sheep immunised with the venoms of one or more species of snake. It neutralises the free, unbound venom and to some extent also dissociates bound toxin. WHO has included ASV in the list for Essential Medicines and should be part of any primary healthcare package where snakebites occur.

20. Anti Snake Venom In India, polyvalent ASV, effective against all the four common species; Russell’s viper, common cobra, common Krait and saw-scaled viper is available. ASV is produced both in liquid and lyophilized forms. Liquid ASV requires a reliable cold chain and has 2-year shelf life. Lyophilized ASV, in powder form, has 5-year shelf life and requires only to be kept cool.

21. Each ml of ASVS neutralizes 0.60 mg of Indian Cobra venom 0.45 mg of Common Krait venom 0.60 mg of Russel’s Viper venom 0.45 mg of Saw-scaled Viper venom

22. Prophylaxis of ASV reactions hydrocortisone (100 mg) + antihistamine or 0.25 –0.3 mg adrenaline subcutaneously In asthmatics inhaled adrenergic beta2 agonist may prevent bronchospasm Test dose of ASV is not recommended .

23. National S nakebite T reatment P rotocol For neurotoxicity: 10 vials stat as infusion over 30 mins followed by 2 nd dose of 10 vials after 1 hour (if no improvement within 1 st hour) For hemotoxicity : Low dose infusion therapy – 10 vials for russels viper o r 6 vials for saw scaled viper as stat infusion over 30 mins followed by 2 vials every 6 hours as infusion in 100 ml ns till clotting time normalizes or 3 days whichever is earlier High dose intermittent bolus therapy – 10 vials of asv over 30 mins as infusion followed by 6 vials 6 hourly as bolus therapy till clotting time normalizes or local swelling subsides

24. For saving surgery - high initial dose of ASV is justified (up to 25 vials) Local administration of ASV – not recommended . Criteria for repetition of ASV Persistence/recurrence of blood incoagulopathy after 6 hours or bleeding after 1-2 hours Deteriorating neurotoxic or cardiovascular signs after 1 hour

25. Victims presenting late Often after several days -> acute renal failure. Perform a 20WBCT. Positive -> ASV. Negative -> ARF -> dialysis. Neurotoxic envenoming – 10 vials of ASV + respiratory support.

26. ASV reactions Early anaphylactic reactions – within minutes to 180 miutes . Pyrogenic reactions – within 1-2 hours after treatment. Late reactions (serum sickness type) – within 1-12 days (mean 7) after treatment.

27. Treatment of early ASV reaction Discontinue ASV Epinephrine: 0.5 mg for adults & 0.01 mg/kg for children IM (1:1000) Antihistamine + Corticosteroids * ASV can be restarted slowly after 10 to 15 minutes under observation

28. Role of neostigmine in neurotoxic envenomation Anticholinesterase – prolongs life of acetylcholine. Reverses respiratory failure and neurotoxic symptoms. Effective against postsynaptic neurotoxins - cobra

29. Neostigmine test Step 1 : Administer atropine 0.6 mg IV Step 2 : Administer neostigmine 1.5 to 2 mg IM Step 3 : Observe for 1 hour for effectiveness Responding Not responding 0.5 mg IM ½ hourly + 0.6 mg atropine IV for 5 doses and then 2-12 hourly according to recovery. Stop neostigmine

30. Additional supportive care Respiratory failure : Mechanical ventilation. Significant bleeding : FFP or cryoprecipitate. Shock : I notropic support. Renal failure : Hemodialysis. Compartment syndrome: F asciotomy . Wound necrosis: S urgical debridement.

31. Special situations Same dosage of ASV

32. Follow up Essential D ischarged within 24 hours -> return if any worsening of symptoms Serum S ickness

33. Snakebite prevention Use a torch. A void sleeping on the ground Use mosquito net. Away - animal feed and rubbish from your house .

34. References Jesudasan JE, Abhilash KP. Venomous snakebites: Management and anti-snake venom. Curr Med Issues 2019;17:66- 8 Himmatrao Saluba Bawaskar , Pramodini Himmatrao Bawaskar . Snake bite: prevention and management in rural Indian settings. The Lancet Glocal Health, Vol.7, Issue9, sept2019; Page e1178 Mohan G, Singh A, Singh T. Guidelines for the Management of Snakebites. Curr Trends Diagn Treat 2018;2(2):102-108. Guidelines for the management of snakebite, 2 nd edition; South east asia WHO publication 2016. https:// www.who.int /docs/default-source/ searo / india /health-topic- pdf / who-guidance-on-management-of-snakebites.pdf?sfvrsn =5528d0cf_2 Shibendu Ghosh , Prabuddha Mukhopadhyay , Tanmoy Chatterjee : Management of Snake Bite in India. https:// www.japi.org /r2a48494/management-of-snake-bite-in-india#.YPbjVzpSUO8.link Surjit Singh, Gagandip Singh. Snake Bite: Indian Guidelines and Protocol. Available at  http://www.apiindia.org/medicine_update_2013/chap94. pdf 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 . 2008;1(2):97-105. doi:10.4103/0974-2700.43190

35. Thank You ..!!