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 confi dence.
Evidence suggests that doctors are not willing to make use of ASV and other
medications, even when equipped, due to lack of confi 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
Vital signs
• Pulse
• BP
• Respiration
Symptoms and signs
• Bite marks
• Ptosis
• Double vision
• Diffi 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
CLASSIFY
Vital signs (Adult)*
• Pulse rate: 60-100/min
• BP 110 / 70 to 140/95
• Respiratory rate <20/
min
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 fi ndings are there
at the time of assessment
classify as No systemic
envenomation
TREATMENT
Tab.Paracetamol
Inj.Tetanus Toxoid IM
Routine antimicrobials are
not necessary
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 specifi 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
ASSESS
Vital signs
• Pulse
• BP
• Respiration
Symptoms and signs
• Bite marks
• Ptosis
• Double vision
• Diffi culty in
swallowing
• Bleeding sites
• Reduced urine output
• Swelling and local
pain
• Local necrosis
• Descending paralysis
• Unconsciousness
• Lymphadenitis
• Breathing diffi culty
• Any other, note
down
CLASSIFY
Vital signs (Adult)*
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 fi ndings are
there at the time of
examination classify as
Haemotoxic
envenomation
TREATMENT
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 fi ve minutes
interval for fi 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 fl uid requirement chart provided in Annexure II.
[Table No.29]
* Vital signs for children (see age specifi c chart) are provided in Annexure III.
[Table no.30 to 33].
Table No. 14: Neurotoxic envenomation
ASSESS
For local
envenomation
refer to Table
4.
For systemic
envenomation
refer to Tables
12 and 13
CLASSIFY
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, diffi 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
TREATMENT
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 fi ve minutes for
30 minutes for signs of
response