India has the highest number of snake bite mortality cases in the world. This article details on the National Snakebite Management Protocol issued by DGHS and the Health Ministry for treating patients presenting with snake bites.

 

 

 

According to the “National Snakebite Management Protocol” issued by Directorate General of Health Services Ministry of Health and Family Welfare Government of India in 2009 the treatment protocol is defined.

India is estimated to have the highest snakebite mortality in the world. Almost 52 species of snakes found in India are venomous. According to estimates of World Health Organization (WHO), the number of bites is around 83,000 per annum in India with 11,000 deaths.

Research has shown that primary health care doctors do not treat snakebite mainly due to lack of confidence.

At the secondary and tertiary care level, multiple protocols are followed mainly from western textbooks, which are not appropriate for Indian settings. Anti-snake venom (ASV) is administered when it is not required and/or in doses well in excess of the required amount. The “National Snakebite Management Protocol” issued by Directorate General of Health Services Ministry of Health and Family Welfare Government of India in 2009 the treatment protocol attempts to target such issues.

 

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Treatment protocol for snakebite

According to the “National Snakebite Management Protocol” issued by Directorate General of Health Services Ministry of Health and Family Welfare Government of India in 2009 the treatment protocol should comprise of the following:

The initial management of snake bite should include dealing with airway, breathing and treatment of shock. The victim should be given tetanus toxoid if the skin is breached and antibiotics if there is cellulitis or local necrosis. Oral paracetamol or tramadol can be given for pain. But aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) should NOT be administered. Tourniquet, if applied should be removed after confirming the presence of distal pulse. If it is absent, a doctor should be present to handle complications such as sudden respiratory distress or hypotension. Finally, Anti-snake venom (ASV) should be administered as the mainstay of treatment.

Critical care for Vasculotoxic patients

On arrival of a vasculotoxic patient presenting with symptoms like bleeding from multiple orifices with hypotension, reduced urine output, obtunted mentation (drowsy, confused), cold extremities, urgent attention and ICU care is required. Volume replacement, forced alkaline diuresis (FAD), pressor support, dialysis and infusion of blood and blood products should be done.

Critical care for Neuroparalytic patients

On arrival of neuroparalytic patient presenting with symptoms like respiratory paralysis, tachypnoea or bradypnoea or paradoxical respiration (only moving abdomen), obtunded mentation, and peripheral skeletal muscle paralysis need urgent ventilator management with endotracheal intubation, ventilation bag or ventilator assistance should be done and ‘Atropine Neostigmine (AN)’ administered.

Patient assessment: Non critical arrival and Critical patients after stabilization

• History of the bite
• Physical examination of bite site
• Check vitals
• Perform 20 minutes Whole Blood clotting test (20 WBCT) every hour for first 3 hours and every 4 hours for remaining 24 hours.
• Check distal pulses and monitor if there is presence of gross swelling
• Keep check on Compartment Syndrome

ASV reaction

Any new sign or symptom after starting the ASV in drip should be suspected as a reaction to ASV.Early anaphylactic reactions to ASV occurs within 10–180 min of the start of therapy and is characterized by itching, urticaria, dry cough, nausea and vomiting, abdominal colic, diarrhoea, tachycardia, and fever. Pyrogenic reactions usually develop 1–2 h after treatment with symptoms like chills and rigors, fever, and hypotension. –

Late (serum sickness–type) reactions develop 1–12 (mean 7) days after treatment with clinical features like fever, nausea, vomiting, diarrhoea, itching, recurrent urticaria, arthralgia, myalgia, lymphadenopathy, immune complex nephritis and, rarely, encephalopathy. Rarely patients may develop severe life-threatening anaphylaxis characterized by hypotension, bronchospasm, and angioedema.

Treatment of Early ASV reaction

• Stop ASV temporarily.
• Start fresh IV normal saline infusion with a new IV set
• Administer Epinephrine (adrenaline) (1 in 1,000 solution, 0.5 mg (i e 0.5 ml) in adults intramuscular over deltoid or over thigh; In children 0.01 mg/kg body weight) for early anaphylactic and pyrogenic ASV reactions.
• Administer Chlorpheniramine maleate (adult dose 10 mg, in children 0.2 mg/kg) intravenously.
• Once the patient has recovered, re-start ASV slowly for 10-15 minutes keeping the patient under close observation.
• Treatment of Late (serum sickness–type) reactions
• Inj. Chlorpheniramine 2 mg in adults (In children 0.25 mg/kg/day) 6 hourly for 5 days.
• In patients who fail to respond within 24–48 h give a 5-day course of Prednisolone (5 mg 6 hourly in adults and 0.7 mg/kg/day in divided doses in children.
• Desensitization only in case of severe anaphylaxis reaction to ASV
• Pre-medication: Administer Inj. Hydrocortisone 100 mg I.V. and Inj. Adrenaline 0.5 ml subcutaneously/ intramuscularly (+/-Promethazine)

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Management of Shock, myocardial damage

• Correct hypovolaemia with colloid/crystalloids, controlled by observation of the central venous pressure.
• Infusion of isotonic crystalloids or albumin, with boluses of up to 20 ml/kg for crystalloids (or albumin equivalent) over 5 to 10 mins titrated to reversing hypotension, increasing urine output, and attaining normal capillary refill, peripheral pulses and level of consciousness without inducing lung crepitations or hepatomegaly.
• If hepatomegaly or rales develop, initiate inotropic support with dopamine or dobutamine. If a patient doesn’t respond to fluid resuscitation, inotropic support must be given.
• In sepsis, noradrenaline is the inotropic agent of choice. Treat patients with hypotension associated with bradycardia with atropine.
• For coagulopathy – in case of prolonged CT, PT, aPTT administer fresh frozen plasma (FFP) infusion. Low fibrinogen and high FDP will require fibrinogen/FFP supplementation. Bleeding leads to anaemia, PCV of 30% must be maintained, therefore, measure serial PCV every 4 –6 h depending upon bleeding severity of patients. If PCV is lower than 30 needs blood transfusion/PCV transfusion. Avoid intramuscular injections. FFP administration after ASV administration results in more rapid restoration of clotting function in most patients, but no decrease in discharge time. Early FFP administration (<6-8h) post-bite is less likely to be effective. Administer 10-15 ml/kg of FFP within over 30–60 min within 4 hours of ASV administration. Non –response to FFP can occur with use of FFP that has low activity of FV and FVIII, because of either poor storage or premature thawing (> 24 hours) prior to administration.
• Heparin is ineffective against venom-induced thrombosis and may cause bleeding on its own account. It should never be used in cases of snakebite. Antifibrinolytic agents are not effective and should not be used in victims of snakebite.

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Management of severe local envenoming

Local necrosis, intracompartmental syndromes and even thrombosis of major vessels is more likely in patients who cannot be treated with ASV.Surgical intervention may be needed but the risks of surgery in a patient with consumption coagulopathy, thrombocytopenia, and enhanced fibrinolysis must be balanced against the life-threatening complications of local envenoming.

Give prophylactic broad-spectrum antimicrobial treatment for cellulitis after completion of first 10 vials of ASV) as following.

• Inj. Amoxiciilin + clavulanic acid 1.2 g IV thrice daily for first 7 days then switch to oral therapy Tab. Amoxiciilin + clavulanic acid 625 mg three times a day for further 3-7 days; In children, the dose is 100 mg/Kg/day in three divided doses intravenously; for oral therapy, the dose is 50 mg/kg/day in three divided doses.
• Inj. Metronidazole 400 mg IV infusion thrice daily for 7 days; in children-30 mg/kg/day in 3-4 divided doses.
• Alternatively, Inj Ceftriaxone 1 g IV twice daily (in children the dose is 100 mg/kg/day in two divided doses) for 7 days if Amoxicillin + clavulanic acid is not available. Both Amoxiciilin+ clavulanic acid and Ceftriaxone are mainly excreted through Kidney. Therefore, in case of acute kidney injury in Viper bites dose of both these antibiotics should be reduced and adjusted according to renal function.

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Surgical procedures like debridement of necrotic tissue may be required in order to specify the line of demarcation between viable and non-viable tissue. Skin grafting and amputation of a necrotic digit may be required in some cases of snakebite. Fasciotomy may be required in cases with clinical evidence of an intra-compartmental syndrome.

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Discharge and follow up

If no symptoms and signs develop after 24 hours the patient can be discharged. Keep the patient under observation for 48 hours if ASV was infused. A snakebite victim discharged from the hospital should continue to be followed up.