Snake bite management India

snake bite management lecture based on snakebite guidelines of India specifically west bengal
2018

1. Snakebite Dr. Chirantan Mandal SenioResident Medicine AIIMS Kalyani based on Snakebite guideline India 2018 9 th October 2021

2. intro life threatening occupational hazard outdoor workers Males bitten >>more>>than females ( more outdoor activity) most snake bite on feet and ankles 97% snakebites are rural (open field latrine/walking barefoot) snakebite peak in summer/ heavy rainfall 70 % of all snakebites are non-venomous 50 % venomousnake bites are dry (no envenomation) Only 7% snakebite deaths reported in India Only 22% attend hospitals. 66% snakebite deaths were due krait bite

3. Epidemiology Snakes found everywhere except artic antartic isolated islands total 250 Snake species in India, out of 250, 60 are venomous . out of 60, 50 are seasnakes (rarely bite) Big 4 species account for 99% of the venomousnakebites 1 ) Spectacle Cobra 2 ) Russell Viper 3 ) Krait and 4 ) sawscaled v iper 75 % of bites in India (not found in WB)

4. Spectacle Cobra Naja naja Saw scaled Viper Echis carinatus Russell’s Viper Daboia russelli Common Krait Bungerus caeruleus Big 4

5. NEUROTOXIC Cobras: Spectacle Cobra ( Naja naja ) Gokhro Monocled Cobra ( Naja kaouthia ) Keute King Cobra ( Ophiophagus hannah ) Sankhachur . Kraits: Common Krait ( Bungarus caeruleus ) Kalachiti , Domnachiti Banded Krait ( Bungarus fasciatus ) Sankhamuti . Black Krait ( Bungarus niger ). Sind Krait ( Bungarus walli ). Coral Snakes ( Calliophis maculiceps (Not found in WB).

6. Spectacled Cobra Naja naja gokhro Monocled Cobra ( Naja kaouthia ) Keute King Cobra ( Ophiophagus hannah ) Sankhachur Krait ( Bungarus caeruleus ) Banded Krait ( Bungarus fasciatus ) Sankhamuti . Black Krait ( Bungarus niger ) Sind Krait ( Bungarus walli ). Coral Snakes ( Calliophis maculiceps

7. HEMOTOXIC Rusell’s Viper ( Daboia russelii) Chandrabora . Saw Scalled Viper ( Echis carinatus ) Pure Haemotoxic (very rare in WB) Humpnose Pit viper ( Hypnale hypnale ): Pure Hemotoxic (Only in Western Ghats; Kerala and TN). Green Pit vipers ( Trimeresurus gramineus ): mild venom, causes local swelling only. (Gechhobora). Mountain Pit Viper ( Ovophis monticola ) found in Darjeeling Hills of WB. ( Gurbe ).

8. Russell's Viper ( Daboia russelii) Chandrabora. Saw Scalled Viper ( Echis carinatus ) Saw Scalled Viper ( Echis carinatus ) Green Pit vipers ( Trimeresurus gramineus (Gechhobora ). Mountain Pit Viper ( Ovophis monticola )

9. NON poisonous Jal dhora gharchiti Bengal monitor lizard

10. Hele laudoga Bethacchra Danras NON poisonous

11. pathophysiology of venomousnakebite 2 venom glands (modified salivaryglands connected to hollow hypodermic fangs) inject venom into softissue , gradually absorbed via lymphatics Fatal dose venom (42mg Russel Viper /15 mg Cobras/ 1mg Krait) 90% wt of venom is biologically active proteins enzymes. Hemotoxic viper venoms containing procoagulant enzymes activate clotting & stimulate fibrin formation in blood. fibrin clot is broken down immediately by plasmin resulting incoagulable blood (consumption coagulopathy) within 30min postsynaptic neurotoxins Krait α - bungarotoxin & cobrotoxin both are (irreversible nicotinic acetylcholine receptor blocker) AKI/ ATN direct nephrotoxicity renal tubules Hemoglobinuria

12. patterns in identifying the types of snake snake identification only by appearance can be misleading not an essential step in snake bite management. Current guidelines do not promote killing of snake Never try to catch dead / alive snake l ̶o̶n̶g̶i̶t̶u̶d̶i̶n̶a̶l̶ ̶r̶o̶w̶s̶ ̶ o̶f ̶ ̶ l̶a̶r̶g̶e ̶,̶ ̶ d̶a̶r̶k ̶-̶ r̶i̶m̶m̶e̶d ̶,̶ ̶ p̶a̶l̶e ̶-̶ c̶e̶n̶t̶e̶r̶e̶d ̶ ̶ s̶p̶o̶t̶s ̶ ̶ a̶r̶e ̶ ̶ i̶n̶d̶i̶c̶a̶t̶i̶v̶e ̶ ̶ o̶f ̶ ̶ t̶h̶e ̶ ̶R̶U̶S̶S̶E̶L̶L̶’̶S̶ ̶V̶I̶P̶E̶R̶S̶̶ ̶H̶A̶E̶M̶O̶T̶O̶X̶I̶C ̶ .̶ ̶ ̶ a̶ l̶t̶e̶r̶n̶a̶t̶i̶n̶g ̶ ̶ b̶l̶a̶c̶k ̶ ̶ & ̶ ̶ y̶e̶l̶l̶o̶w ̶/̶ ̶ w̶h̶i̶t̶e ̶ ̶ c̶i̶r̶c̶u̶m̶f̶e̶r̶e̶n̶t̶i̶a̶l ̶ ̶ b̶a̶n̶d̶s ̶ ̶ K̶R̶A̶I̶T̶S̶-̶N̶E̶U̶R̶O̶T̶O̶X̶I̶C̶ .̶ ̶ ̶ F ̶l̶a̶t ̶ ̶ t̶a̶i̶l̶s ̶ ̶ a̶r̶e ̶ ̶ u̶s̶u̶a̶l̶l̶y ̶ ̶ s̶e̶a ̶ ̶ s̶n̶a̶k̶e̶s ̶

13. Don’ts after snakebite occurs Do NOT waste time in traditional first aid methods Do NOT apply a tourniquet. Do NOT apply pressure cold compresses Do NOT cut into with a knife or razor Do NOT try to suck out the venom by mouth or Do NOT wash the snakebite wound Do NOT attempt to kill or catch the snake

14. Death in untreated snakebites If death within 1 st hr of bite mostly due to like old age cardiac causes takes few hours for untreated neurotoxic elapid (cobra/krait) to succumb several days for a untreated viper traditional healers/transportation problems inadequate artificial ventilation / Late dialysis to treat hypovolemia shock / airway obstruction complicating infections (fasciitis/ extensive cellulitis)

15. First Aid Treatment both tourniquets and Pressure Immobilization Method are discouraged in India since it needs skilled medical or paramedical person to be present at the site of accident PRACTICALY IMPOSSIBLE

16. First AID do it RIGHT REASSURE patient panicked tachycardia spreads venom rapidly. 70% snakebites nonvenomous. 50% of venomousnake bites dry IMMOBILIZE the bitten limb in the same way as a fractured limb. GO HOSPITAL immediately. TELL DOCTOR of any progress/new symptoms such as ptosis that

17. Don’t look for bite marks Bite marks pattern cannot differentiate venomous/nonvenomous . fang marks pattern cannot ascertain the amount of venom injected, severity of systemic poisoning and nature of neurotoxic/hemotoxic bite from venomous snake may show one or more punctures

18. signs / symptoms of Viper (Hemotoxic ) envenomation Progressive swelling & local pain/necrosis/blistering Epistaxis / bleeding from the gum and other orifices. Vomiting + Acute abdominal pain (may GI bleed). Hypotension (due to hypovolaemia / direct vasodilation). early AKI (renal failure) hematuria reduced/ nil urine output. skin petechiae , purpura, and ecchymosis . Lateralising neurological symptoms and asymmetrical pupils (intra-cranial bleeding) conjunctival oedema , sub- conjunctival haemorrhage

19. Signs/symptoms of Neurotoxic envenomation cranialnerves paralysis (ptosis, gaze fatigue, diplopia, ophthalmoplegia ) pharyngeal palsy ( paralysis of jaw ± tongue causing upper airway obstruction aspiration of pooled secretions ( patient’s inability to swallow ) Numbness around lips/mouth, bulbar paralysis, respiratory failure Early morning stomach pain (submucosal hemorrhage) commonest in Krait Krait bite often in early morning, resultant paralysis often mimmics stroke. inadequate ventilation cause cyanosis, alteredsensorium coma. Paradoxical respiration (intercostal muscles becoming paralyzed) Neuroparalytic Cobra bites symptoms typical present within 30 min– 2 hours Krait bite symptom presents within 3 – 24 hours

20. 5D and 2P Neurotoxic envenomation dyspnea, dysphonia, dysarthria, diplopia, dysphagia, ptosis, paralysis Furrowing of forehead ➜ Ptosis ➜ Diplopia ➜ Dysarthria ➜ Dysphonia ➜ d yspnea ➜ dysphagia 3 rd , 4th , 6th and lower cranial nerve paralysis. paralysis of intercostal/ diaphragmatic paralysis in descending manner absent DTR and head lag heralds impending respiratory failure stridor, ataxia may be seen. Bilateral dilated, poorly or a non-reacting pupil is not the only sign in brain death in elapid (neurotoxic) envenoming

21. Late-onset envenoming The patient should be kept under close observation for at least 24 hours Krait and the Hump-nosed pitviper (not present in WB) can take upto 12 hours for symptoms to manifest. Late onset envenoming is a well-documented occurrence.

22. compartmental syndrome ( Russel viper bite) Compartment syndrome is diagnosed with 5P Pain (severe) on passive movement Pallor Paresthesia Pulselessness Paralysis or weakness of compartment muscle.

23. Signs & symptoms of Snake bite

24. Diagnosis and testing Progressive local swelling is the commonest sign of envenomation local swelling, painful tender, persistent bleeding from the bite wound, epistaxis, hematuria, ptosis and other signs of paralysis cannot use Glasgow Coma scale to assess ( if paralyzed by neurotoxic venom) Monitor the patient every 2 hourly. Pulse rate, respiratory rate, BP and In case of viper bites (hemotoxic) signs of coagulopathy do 20WBCT 20minwholebloodclotting (20WBCT) every hr for 1 st 3h / every 4h next24h pain movement, pallor, pulseless limb, hypoesthesia ( compartment syndrome ) p tosis, hoarseness of voice, respiratory failure (in Cobras & Kraits)

25. 20minute Whole Blood Clotting Test (20WBCT) New dry glass testube /vial (not Plastic) (not cleaned with detergent, else wall may not activate factorXI to clot) draw 3ml blood, keep 20min in testube undisturbed room temperature [normal clotting time is 8 min maximum 20min later gently tilt the tube If the blood is still liquid (not clotted) it`s coagulopathy confirms hemotoxic viper bite (coagulopathy not seen in neurotoxic Cobras or Krait) If 1 st 20WBCTest is “clotted” repeat every hour 1 st 3h, thereafter every 6hr In coagulopathy, there may be continuous oozing from bite site/gum. May lead to hemoptysis and hematuria and ultimately AKI. (In Chandrabora bite there would be Ptosis also).

26. Management of Snakebite INITIALS Admit all cases with history of bites (Snake/unknown) for observation for a minimum of 24 hours Secure ABC Airway, Breathing and Circulation. observe for any sign of local or Systemic envenomation. 50% of known venomous snake bite are dry bite no envenomation If no indications for administration of AVS, (don’t give AVS)

27. following local treatments are contraindicated Washing X Antiseptics. X Incision. X Suction. X (DON’T EVEN THINK ABOUT THIS) Electrotherapy or Cryotherapy. X Venom Stone.X

28. Important don’ts Don't kill/catch snake (dangerous) & not essential for management. Don't wash wound may introduce infection, increase absorption of venom Don't inject antisnakevenom (ASV) locally (it’s designed for IV) Don't tie tourniquets increase risk of ischemia/limb gangrene Cutting the biting site. No venom is removed by this.

29. Patient Assessment identifying the snake (not essential) (20WBCT indirectly helps) Ruleout any possible use of traditional medicines Take history of exact time of the bite. indicates progression symptoms Ask what the victim was doing at the time of the bite. grass cutting or feeding stock animals in the evening can be suggestive of snakebite.

30. Management of Bite Pain severe pain at the bite site. use paracetamol Don’t use NSAIDs (avoid aspirin) cause bleeding in coagulopathy Mild opiates Tramadol can be used orally for relief of severe pain. Never remove tourniquet in ER. test for pulse distal to the tourniquet before removal. If occluded the distal pulse, then a BP cuff can be applied to reduce pressure slowly Sudden removal can lead to a massive surge of venom leading to neurological paralysis, hypotension due to vasodilation, sudden respiratory distress or hypotension. Handling Tourniquets

31. Anti-snake Venom Serum (ASV ) Indian Polyvalent Anti Snake Venom Serum is a unique solution to all big 4 venomous snakebite cases in India. c alled polyvalent, can be used to treat most types of snakebites. s pecies specific Monovalent AVS is not available in India. 4 types of snakes are used to prepare this AVS. These snakes are 1 ) Indian Spectacle Cobra 2) Russell Viper 3) Krait and 4) sawscaledviper . Sub lethal dose of venom of all these four snakes are injected to a horse (to hyper immunize). Antibody (Ig G) develops against these snake venoms in the blood of that horse. This horse blood (plasma) is then purified in the laboratories to prepare Polyvalent AVS. AVS is basically a horse protein, and has every chance to be rejected by our human body, as a foreign protein ..

32. Anti-snake Venom Serum (AVS )

33. Anti-snake Venom Serum (AVS) essential Give 0.25 ML Inj. Adrenaline S/C premedication. No prior AVS skin test required since patient is in danger either way 10vials AVS reconstituted in 100ml of distilled water use 400ml NS given over 1hr adult use 200ml NS given over 30min children to avoid fluid overload Initial 10vial AVS for Adults/children/Pregnant/hemotoxic/neurotoxic must to neutralize venom as snakes inject the same amount regardless AKI patient can use infusion pump full dose ASV undiluted over 30 minutes. intracranial bleeding may require lifesaving surgery. coagulation must be restored to avoid bleeding and can give up to 30 vials ASV

34. Criteria for Administration of AVS Use AVS any evidence of envenomation or progressive swelling . viper coagulopathy detected by 20WBCT or visible spontaneous bite site bleeding Cobra/krait neurotoxicity- ptosis,ophthalmoplegia,paralysis , inability to lift head ASV should be administered over 1hr, not longer ASV must NEVER be given by the IM route (poor bioavailability) NEVER inject the ASV locally at the bitesite

35. Signs of recovery (AVS is working) if adequate dose of AVS has been administered s pontaneous systemic bleed (gum bleeding) usually stops within 15–30min. Blood coagulability is usually restored in 6 hours Post synaptic neurotoxic envenoming (Cobra) may improves early Presynaptic neurotoxic envenoming (Krait) bite usually takes several hours to improve. blood pressure recover in shocked patients

36. Repeat doses of AVS In Viper bites, once initial 10vials of AVS over 1 hour no further AVS is required for next 6 hours don’t hurry wait liver needs 6hours to restore clotting factors. 6hr later if 20WBCT +ve repeat 2 nd dose of 10vials AVS immediately . If no active bleeding, keep repeating 20WBCT test every 6 hours 6hr later if 20WBCT – ve (blood clots) no need to give AVS any further regardless viper/cobra bites maximum 30vials of AVS is needed/given No AVS after 30 vials.

37. Monitoring/ General Workup Monitor Pulse, respiratory rate, blood pressure hourly urea , creatinine , WBC count K+ level Urine output, urine RBCs in viper Monitor Vomiting , diarrhea, abnormal bleeding. Look for Extent of local swelling and necrosis

38. Management of Neurotoxicity post-synaptic neurotoxins ( Cobratoxin / krait α- bungarotoxin) both are   ( irreversible nicotinic acetylcholine receptor blocker) Neostigmine (anticholinesterase) prolongs / increases acetylcholine Atropine reversibly blocks muscarinic acetylcholine receptors reverses respiratory failure and neurotoxic symptoms particularly effective for post-synaptic neurotoxins ( Cobra/krait) not useful against / not needed in Russell Viper P ralidoxime cholinesterase regenerator no role in snakebite

39. atropine/neostigmine in neurotoxic bites 1 st dose AVS ➜ 1st ( Inj.IV Atropine 0.6mg) then ➜ ANtrial Neostigmine trial ( 1.5mg IM) ➜ monitor victim closely for 1 st hr Improvement by atropineostigmine indicates Cobra bite pediatric ( neostig loading dose 0.04mg/kg IM) (atropine is 0.05 mg/kg) after 30min 1 st visible improvement in ptosis if ptosis recovers ≥ 50% within 1 st hour then it’s a +ve response If ANtrial is positive, repeat 5 doses inj.neostigmine 0.5 mg IM every 30min with 0.6mg of atropine IV every 8hr continuous infusion. (pediatric, repeated 5 doses Inj . Neostigmine IM 0.01 mg/kg every 30min)

40. methods to assess response of AN trial Single breath count Length of time upward gaze can be maintained Stop Atropine neostigmine ( ANtrial ) dosage schedule if: Patient has completely recovers from neuroparalysis. side effects fasciculation / bradycardia (signs of neostigmine overdose) ( ℞ 0.3 mg atropine IV stat). If there is no improvement after 3 doses

41. atropineostigmine caveats no improvement in 1 st hr / worsen then give 2 nd/ final dose atropineostigmine If neurodeficit persist/ no improvement dspite 2 nd dose atropineostigmine shift patient to mechanical ventilation. Repeat 2 nd dose of 10 vials AVS this also indicates Krait bite Calcium Gluconate in Krait bites Krait affects pre-synaptic fibers ( Ca +2 acts as neurotransmitter. Give Inj. Calcium gluconate 10ml IV (pediatric 1-2 ml/kg) slowly over 5-10 min every 6hr for next 24hr. (krait neuroparalysis recovers within 5-7 days)

42. Broken neck sign

43. Renal failure = AcuteKidneyInjury = AKI in hemotoxic viper bite abnormal 20WBCT (not clotted ) in viper bites indicates coagulopathy, give 1 st dose of 10 vials AVS ➜ confirm hematuria/abnormal creatinine ➜ refer/send patient to dialysis facility Can give undiluted ASV full dose infusion pump over 30min in AKI AKI mainly due to intravascular haemolysis , DIC, direct nephrotoxicity, hypotension rhabdomyolysis. Very early AKI in Russell viper bite (within 1hr post bite) Suspect AKI if falling/nil urine output creatinine > 5 / Urea > 200 / K + > 5.6 / metabolic acidosis on ABG

44. Referral criteria for Neurotoxic envenomation AVS alone cannot save life of a patient with bulbar and respiratory paralysis. Death may result from aspiration, airway obstruction or respiratory failure If neuroparalysis progresses in a Neurotoxic Envenomation transfer patient by ambulance with life support (Battery operated Transport Ventilator run by qualified staff ) to tertiary center for mechanical ventilation resuscitation bag in ambulance (only as last resort) ‘lift neck’ to elicit broken neck sign (heralds respiratory failure, needs ventilator) immediately refer the patient declining single breath count, pooling of saliva indicate descending paralysis SpO2 <90% patient needs ventilator

45. REFERRAL CRITERIA for hemotoxic envenomation If no ASV available , transfer to a hospital ( where it’s available) If 20 WBCT ( not clotted) despite 1 st loading dose of 10vials ASV & patient continues to bleed ➜ transfer to a tertiary care medical college confirm hematuria/AKI ➜ refer/send patient to dialysis facility Compartment syndrome Progressive septicemia

46. Forced Alkaline Diuresis trial to prevent AKI/ATN trial of forced alkaline diuresis within 1 st 24hr of bite to avoid pigment nephropathy (acute tubular necrosis) Sequence of FAD each 2 1 / 2 hr cycle 1 st Furosemide40mg IV ➜ ( 500ml NS with 20ml NaHCO 3 /20min) ➜ (RL500 ml RL with 20ml NaHCO 3 /20min) ➜ (500ml 5%D with 10ml KCL/90min) ➜ Mannitol150 ml IV/20min 3ml/min urine output is expected, i n response to 1 st cycle continue for 3 cycles FAD converts olig to polyuria (prevent ATN/AKI avoid dialysis >75%) Delayed FAD has no role If unresponsive to Furosemide40mgIV ➜ discontinue FAD and refer to dialysis centre

47. Indications for dialysis are urea >130 BUN > 100 Creatinine > 4 mg K+ >7 daily rise urea>30 /BUN>15 / Creat >1/ K+ >1 daily HCO 3 fall >2 pulmonary oedema Uremic encephalopathy , pericarditis

48. coagulopathy specific management prolonged CT, PT, aPTT administer fresh frozen plasma (FFP) infusion FFP administration after 1 st ASV rapidly restores clotting function in most FFP 10-15 ml/kg over 60min given within 4hr of 1 st ASV target INR < 2.0, at 6hr after 1 st FFP low platelets indicates consumption coagulopathy and DIC Low fibrinogen/high FDP will require fibrinogen/FFP infusion PCV > 30 % must be maintained. measure serial PCV every 6hr packed cell PRBC transfusion If anemia PCV < 30 Avoid intramuscular injections in hemotoxic bites

49. Celullitis / swelling specific management Routine antibiotic not necessary, consider only if cellulitis or necrosis. cellulitis give amoxiclav /metronidazole/ceftriaxone after completion 1 st 10 vials ASV swelling of the limb after bite can be successfully managed by repeated MgSO 4 + glycerin compresses (thrice dailyx 7 days)

50. ASV adverse drug reaction ( adr ) Before starting AVS always Premedicate 0.25ml Adrenaline S/C most AVS reactions are prevented monitor patient closely for many anaphylactoid reactions like urticaria , itching, fever, vomiting, diarrhea, cramps, tachycardia, hypotension, bronchospasm angioedema At any sign 1 st stop AVS drip temporarily Give 0.5 ml (1:1000) Adrenaline IM (pediatric 0.01 mg/kg) repeat 2 nd dose If no improvement/worsening within 15min use oxygen/ fresh IV set/500ml NS + 100mg hydrocortisone Promethazine Post recovery 1 st restart ASV 15min slowly then resume normal drip rate

51. DISCHARGE Nonvenomous bite with zero symptoms/signs discharge after 24hr if ASV was infused discharge after 48hr snakebitten victim discharged from hospital must follow up. serum sickness (fever, joint pain/swelling) upto 5-10 days after AVS Patient must return if bleeding , worsening of pain, swelling, difficulty in breathing, altered sensorium, reduced urine output

52. Tourniquet trivia 1 st blood drawn from the patient should be typed and cross-matched, as the effects of both venom and ASV can interfere with later cross-matching. before removal of the tourniquet, find for pulse distal to tourniquet . In confirmed venomous bite, remove tourniquet only after starting of 1 st loading dose of ASV and keep Atropine Neostigmine injection ready.

53. Thank you

54. . Suspect Haemotoxic envenomation If there is definite history of viper bites or signs of abnormal bleeding or 20WBCT test comes ‘not clotted’ indicating coagulopathy, refer the case to a Hospital having facility of kidney function test/ dialysis. 2. Repeat another 10 vials of AVS in fluid in jet if active bleeding persists (this should be done before referral). Suspect Neurotoxic envenomation 1.A Neostigmine test (AN trial) is administered using Atropine and Neostigmine as per dosage described earlier. 2. Observe the patient closely for 1 hour to determine if the neostigmine is effective. a. If the response (AN trial) is positive, repeat dose of neostigmine 0.5 mg IM every 30 minutes for 5 doses with 0.6 mg of atropine IV over an 8 hour period by continuous infusion. b. If after 1 hour the victim has not improved or has worsened then a second and final dose (of Both Atropine and Neostigmine should be given. 3 . If no improvement even after 2nd 4. Repeat 2nd dose of Atropine and Neostigmine, the patient will require mechanical ventilation. 4.Repeat 2 nd dose of 10 vials of AVS & Refer to higher center having Ventilator facility

55. REFERRAL CRITERIA: Suspect Haemotoxic envenomation Once AVS is finished and adverse reaction if any is dealt with Active bleeding persist The 6 hour rule ensures that a six hour windowis now available in which to transport the patient. If haematuria present or kidney function test result is abnormal- may be transfer for dialysis . Suspect Neurotoxic envenomation Progressive neuroparalysis - transfer with life support in ambulance for mechanical ventilation The key criteria to determine whether respiratory failure, requiring mechanical ventilation is likely, is the ‘neck lift’ to elicit broken neck sign. Other tests which indicate descending paralysis are declining single breath count, pooling of saliva . The primary consideration is to be equipped toprovide respiration support to the victim Transfer the patient with a face mask, resuscitation bag and a person, other than the driver of the vehicle, who is trained of how to use these devices. If respiration fails then the victim must be given artificial respiration until arrival at the institute

56. Instructions while referring Give prior intimation to the receiving center using available communication facilities.  Transport in an ambulance equipped with transport ventilator. If ventilator is not available, tight-fitting face mask connected to an anaesthetic ( Ambu ) bag should be available. However, do not waste time to get an ideal ambulance. If ASV is not available at First contact center transfer to the nearest health facility where ASV is available (confirmed by telephone). Transfer to a higher health facility (Secondary Care Hospital or Tertiary Care Hospital) where mechanical ventilator and dialysis facilities are available for ventilation and dialysis, if required after completion of ASV infusion only. During transfer, continue life-supporting measures, insert nasogastric tube and provide airway support with the help of an accompanying staff, if required.

57. Points to be mentioned in Referral Note Suspect Haemotoxic envenomation Site & time of bite Initial symptoms - 20 WBCT result – initial & subsequent - Total AVS dose administered with time of each dose Suspect Neurotoxic envenomation Atropine & Neostigmine – doses & time, if given - Supportive treatment given including blood - Condition at the time of referral and reason of referral

58. Basic Minimal & Essential Drugs/ Equipment profile for primary care Drug: AV/ ASV (in domestic fridge if liquid)  Adrenaline v Neostigmine  Atropine v Hydrocortisone  Antihistaminics ( injectables )  Analgesics o Paracetamol o Tramadol (both oral & injectable) NS bottles  Antibiotics o Inj Amoxicillin+ clavulanic acid o Inj Metronidazole o Inj Ceftriaxone Equipment o Syringes o IV set o Clean new Glass Test tubes o Blood pressure monitor o AMBU Bag with mask Other desirables o Oxygen o Laryngeal tube with laryngeal mask airway (LMA) o Nasopharyngeal Airways (these can be improvised using size 5 Endotracheal tubes cut to the required length)

59. Anti-snake Venom Serum (ASV) Hump nose pit vipers are quite exceptional in India. Their venom is not responsive to common AVS. As these snakes are limited to a small geographic area (Western Ghat hill areas), few laboratories prepare specific Polyvalent AVS including Pit viper snake venom along with other four snakes as mentioned earlier. Indian Polyvalent AVS is available in 10 ML vials; both in liquid and lyophilized form. Liquid ones have to be kept in the domestic refrigerators (2-8 o 25 o C ). No AVS can be freezed . Lyophilized AVS is to be dissolved into 10 ml of water for injection just before mixing in the IV fluid for infusion. Usually Lyophilized AVS lasts for 5 yrs and liquid ones last for 2 – 3 yrs. Both must be discarded if any precipitate is noted before mixing in the IV fluid. 31 C); Lyophilized AVS can be stored in room temperature ( belowOne vial of 10ml AVS is meant for neutralizing 6 mg of Russell’s Viper venom, 6mg of Cobra venom, 4.5 mg of Common Krait venom and 4.5mg of Saw scaled viper venom. Indian polyvalent AVS has some cross sensitivity to other species of snakes also; Spectacle cobra venom AVS has good neutralizing effect on Monocled cobra and King cobra venom. Common Krait venom AVS can neutralize Banded Krait venom also. AVS for sea snake venom is not available in India. Some authorities recommend high dose of Indian polyvalent AVS for sea snake bite cases in India. Many Indian laboratories prepare AVS for commercial use; all of them have to be standardized from the Central Research Laboratory of Govt. of India, situated at Kasauli , Himachal Pradesh. Is SKIN Test before administering AVS recommended ? — NO AVS test doses have been abandoned. They have no predictive value in anaphylactoid or late serum reactions and may pre-sensitize the patient to the protein. This test is mostly false negative

60. Do’s after snakebite occurs Call ambulance and transfer patient to a medical health facility. Arrange transport of the patient to medical care as quickly, safely and passively as possible by vehicle ambulance, boat, bicycle, motorbike, stretcher etc. – Keep the person calm. Reassure them that bites can be effectively treated in an emergency room. Restrict movement. – Remove any rings or constricting items, because the affected area may swell. – Create a loose splint (it should be capable of inserting one finger beneath) to help restrict movement of the area. – Ideally the patient should lie in the recovery position (prone, on the left side) with his/her airway protected to minimize the risk of aspiration of vomitus. – If the area of the bite begins to swell and change colour , the snake was probably venomous. – Monitor the person’s vital signs — temperature, pulse, rate of breathing, and blood pressure — if possible. If there are signs of shock (such as paleness), lay the person flat, raise the feet about a foot, and cover the person with a blanket