Snakebite Treatment Protocol

8/10/2019 Snakebite Treatment Protocol

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Snakebite Protocol


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Contents

Page

First Aid Treatment Protocol 4Recommended Method Do it R.I.G..T.! 4

Discarded Methods" To#rni$#ets %

Discarded Methods" C#tting and S#ction %

&ashing the &o#nd %

Discarded Methods" 'lectrical and Cr(othera)( *

+e,er Methods Considered Ina))licable to India" PIM *

First Aid Research -

Snakebite Preention and /cc#)ational Adice 0

Snakebite Treatment Protocol 1Patient Arrial 1

Diagnosis Phase" General Princi)les 1

Pain 1

andling To#rni$#ets 23

Diagnosis Phase" Inestigations 23

3 Min#te &hole 5lood Clotting Test 23

Diagnosis Phase" S(m)toms 22

General Signs and S(m)toms o6 7i)erine 'nenomation 22

General Signs and S(m)toms o6 'la)id 'nenomation 2

8ate /nset 'nenoming 2Anti Snake 7enom 2

AS7 Administration Criteria 29

Preention o6 AS7 Reactions : Pro)h(lactic Regimes 24

AS7 Administration Doses 2%

AS7 Test Doses 2*

AS7 Dosage in 7ictims Re$#iring 8i6e Saing S#rger( 2*

Snakebite in Pregnanc( 2*

7ictims &ho Arrie 8ate 2-

AS7 Reactions 2-

+e#roto;ic 'nenomation 20

Recoer( Phase 21Re)eat Doses" Anti aemostatic 21

Rec#rrent 'nenomation 3

Anti aemostatic Ma;im#m AS7 Dosage G#idance 3

Re)eat Doses +e#roto;ic 2

()otension 2

S#rgical Interention 2

Persistent and Seere 5leeding


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Renal Fail#re and AS7 9

'ssential Dr#g and '$#i)ment Pro6ile

6or a Primar( Centre *

Contents

A))endices

Page

A))endi; 2 First Aid Re6erence > Treatment Re6erences 1

A))endi; S#))ort Factors to 'nhance Protocols 9*


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First Aid Treatment Protocol

To enable them to reach the nearest medical facility in the best possible condition.

Much of the first aid currently carried out is ineffective and dangerous (Simpson, 2006).

ndian research has agreed on the follo!ing recommended method having vie!ed andconsidered the available research and concluded that other methods are not appropriate

for the conditions in ndia.

Recommended Method 6or India

The first aid being currently recommended is based around the mnemonic"

?Do it R.I.G..T.@

t consists of the follo!ing"

R. Reass#re the )atient. -3B o6 all snakebites are 6rom non enomo#s s)ecies. /nl( %3B o6 bites b( enomo#s

s)ecies act#all( enenomate the )atient

I Immobilise in the same ,a( as a 6ract#red limb.


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Traditional Methods to 5e Discarded

To#rni$#ets

The use of tight tourni#uets made of rope, belt, string or cloth have been traditionally

used to stop venom flo! into the body follo!ing sna$ebite. 'o!ever, they have thefollo!ing dra!bac$s and problems"

is$ of schemia and loss of the limb (arrell, *+++).

ncreased is$ of &ecrosis !ith %- of the medically significant sna$es of ndia.

(airly, *+2+) (/ugh et al, *+1) (arrell, *++-).

ncreased ris$ of massive neurotoic bloc$ade !hen tourni#uet is released (att,

*+).

is$ of embolism if used in viper bites. /ro3coagulant en4ymes !ill cause clotting

in distal blood. n addition, the effect of the venom in causing vasodilation

presents the danger of massive hypotension !hen the tourni#uet is released.

They do not !or$5 (Tun /e *+1) (hin37hn 8!in *+%). 9enom !as not slo!ed

by the tourni#uet in several eperimental studies, as !ell as in field conditions.

7ften this is because they are tied on the lo!er limb or are incorrectly tied (att,

200:) (;maral, *++) (&ishio$a, 2000).

They give patients a false sense of security, !hich encourages them to delay their

ush, 2000) (>ush, 200%). There has been some evidence that

these devices increase envenomation as they inhibit natural oo4ing of venom from

the !ound (;lberts et al, 200%). n addition, they have been sho!n to increase thelocal effects of necrosis (;lberts et al, 200%).

&ashing the &o#nd

9ictims and bystanders often !ant to !ash the !ound to remove any venom on the

surface. This should not be done as the action of !ashing increases the flo! of venominto the system by stimulating the lymphatic system (?ray, 200:).


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'lectrical Thera)( and Cr(othera)(

@lectric shoc$ therapy for sna$ebite received a significant amount of press in the *+0As.

The theory behind it stated that applying an electric current to the !ound denatures the

venom (?uderian et al, *+6). Much of the support for this method came from letters touc$nall, *++*) (roegal et al, *+6).

The research sho!ed ho!ever that the venom is not denatured (Bavis et al, *++2). naddition, it has been demonstrated that the electric shoc$ has no beneficial effect (Bart et

al, *++*) ('o!e et al, *+) (ussell, *+1) (ussell, *+1a) (Snyder et al, *+1) ('ardy,

*++2). t has no! been abandoned as a method of first aid.

=ryotherapy involving the application of ice to the bite !as proposed in the *+-0As

(Stan$e *+-*) (?lass, *+*). t !as subse#uently sho!n that this method had no benefit

and merely increased the necrotic effect of the venom.

+e,er Methods Considered Ina))licable in the Indian Conte;t

Press#re Immobilisation Method PIM

/ressure mmobilisation has gained some supporters on television and in the herpetology

literature. Some medical tetboo$s have referred to it. They have not ho!ever, revie!edthe research, nor considered /MAs applicability in the ndian contet5

/M !as developed in ;ustralia in *+1% by Sutherland (Sutherland *+*). 'is

research involved tying mon$eys to !ooden frames and in


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n addition, pressure bandages should not be used !here there is a ris$ of local

necrosis, that is in %- of the medically significant sna$es of ndia (>ush, 200%).

Therefore, ndian rural !or$ers !ould need"

*) To be in possession of crepe bandages and splints.

2) or the victim to immediately drop to the ground !hen bitten.:) To have to be in pairs as the bystander must tie the bandage and

splint, !hile the victim remains immobile.%) To be able to tie the bandage to the correct level of pressure depending

on !hether an upper or lo!er limb !as involved, !hen only *:D

of emergency room doctors could achieve this.-) ;nd not to have to !al$ for more than *0 minutes.

For the aboe reasons Press#re Immobilisation is not recommended 6or #se in

India.

F#rther First Aid ResearchThere has been some initial research that has suggested that a E/ressure /ad or MonashTechni#ueA may have some benefit in the first aid treatment of sna$ebite (;n$er et al,

*+2) (Tun /e et al, *++-) (Tun /e et al, 2000). n this method, a hard pad of rubber or

cloth is applied directly to the !ound in an attempt to reduce venom entering the system.

This method should be sub


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Snakebite Preention > /cc#)ational Risk

The normal perception is that rural agricultural !or$ers are most at ris$ and the bites

occur first thing in the morning and last thing at night. 'o!ever, this is of very little

practical use to rural !or$ers in preventing sna$ebite since it ignores the fact that often

sna$ebites cluster around certain bio3mechanical activities, in certain geographic areas, atcertain times of the day.

?rass3cutting remains a ma


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Snake 5ite Treatment Protocol

Patient Assessment Phase" /n arrial.Beal !ith any life threatening symptoms on presentation. i.e. ;ir!ay, >reathing and=irculation.

f there is evidence of a bite, !here the s$in has been bro$en, give Tetanus Tooid

outine use of anti3biotic is not necessary, although it should be considered if there isevidence of cellulitis or necrosis.

Diagnosis Phase" General Princi)les

here possible identify the sna$e responsible. Sna$e colouration is a very

unreliable means of determining species as is most of the advice given

concerning pupil shape and scalation. 'ave the victim carefully bring thesna$e to hospital if it has been $illed.

All )atients ,ill be ke)t #nder obseration 6or a minim#m o6 4 ho#rs. n some countries bite mar$s have limited use in determining species

(&ishio$a et al, *++-) (&orris, *++-). 'o!ever, in ndia bite mar$s are of no

use in identifying if a species is venomous or not. Many non venomous

species leave


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andling To#rni$#ets=are must be ta$en !hen removing tight tourni#uets tied by the victim. Sudden removal

can lead to a massive surge of venom leading to neurological paralysis, hypotension due

to vasodilation etc.

>efore removal of the tourni#uet, test for the presence of a pulse distal to the

tourni#uet. f the pulse is absent ensure a doctor is present before removal.

>e prepared to handle the complications such as sudden respiratory distress or

hypotension. f the tourni#uet has occluded the distal pulse, then a blood pressurecuff can be applied to reduce the pressure slo!ly.

Diagnosis Phase" Inestigations

3 Min#te &hole 5lood Clotting Test 3&5CT

=onsidered the most reliable test of coagulation and can be carried out at the bedside

!ithout specialist training. t can also be carried out in the most basic settings. t is

significantly superior to the Ecapillary tubeA method of establishing clotting capabilityand is the preferred method of choice in sna$ebite.

; fe! mls of fresh venous blood is placed in a ne!, clean and dry glass vessel and left

at ambient temperature for 20 minutes. The vessel ideally should be a small glass testtube. t is important that the tube is clean, glass and dry as the mechanism under revie!

is the contact clotting mechanism. The use of plastic bottles, tubes or syringes !ill give

false readings and should not be used.

The glass vessel should be left undisturbed for 20 minutes and then gently tilted, notshaken. f the blood is still li#uid then the patient has incoagulable blood. The vesselmust not have been !ashed !ith detergent as this !ill inhibit the contact element of the

clotting mechanism.

The test should be carried out every :0 minutes from admission for three hours and thenhourly after that. f incoagulable blood is discovered, the 6 hourly cycle !ill then be

adopted to test for the re#uirement for repeat doses of ;S9.

7ther Fseful Tests depending on availability 'aemoglobin /=9 /latelet =ount /T ;/TT B/ B3Bimer

/eripheral Smear

Frine Tests for /roteinuria >= 'aemoglobinuria Myoglobinuria

>iochemistry for Serum =reatinine Frea /otassium

7ygen Saturation />/ /ostural >lood /ressure

@=? G3ay =T Fltrasound (The use of G3ay and ultrasound are of

unproven benefit, apart from identification of bleeding in 9iperine bites).


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Diagnosis Phase" S(m)toms

General

There are a great many myths surrounding sna$e symptoms. The table belo! summarises

the evidence based situation. 'aemostatic abnormalities are prima facie evidence of a

9iper bite. =obras and raits do not cause haemostatic disturbances.

Sa! Scaled 9ipers do not cause renal failure !hereas ussells 9iper and 'ump3nosed

/itviper do.

ussells 9iper can also manifest neurotoic symptoms in a !ide area of ndia. This can

sometimes cause confusion and further !or$ is necessary to establish ho! !ide this area

might be. The neurotoic symptoms in ussells 9iper are believed to be pre synaptic orrait li$e in nature. t is for this reason that a doubt is epressed over the response of

both species to &eostigmine (See belo! for use of neostigmine).

Feat#re Cobras Hraits R#ssells

7i)er

Sa,

Scaled

7i)er

#m)

+osed

7i)er

8ocal Pain= Tiss#e Damage 'S +/ 'S 'S 'S

Ptosis= +e#rological Signs 'S 'S 'SE +/ +/

aemostatic abnormalities +/ +/E 'S 'S 'S

Renal Com)lications +/ +/ 'S +/ 'S

Res)onse to +eostigmine 'S +/J +/J +/ +/

Res)onse to AS7 'S 'S 'S 'S +/

General signs and s(m)toms o6 7i)erine enenomation

S!elling and local pain.

Tender enlargement of local lymph nodes as large molecular !eight 9iper venom

molecules enter the system via the lymphatics.

>leeding from the gingival sulci and other orifices.

@pistais.

9omiting (alantri S/ et al. 2006).

;cute abdominal tenderness !hich may suggest gastro3intestinal or retro

peritoneal bleeding.

'ypotension resulting from hypovolaemia or direct vasodilation.

8o! bac$ pain, indicative of a early renal failure or retroperitoneal bleeding,

although this must be carefully investigated as many rural !or$ers involved in

pic$ing activities complain of bac$ pain generally.

The s$in and mucous membranes may sho! evidence of petechiae, purpura

ecchymoses.


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The passing of reddish or dar$3bro!n urine or declining or no urine output.

8ateralising neurological symptoms and asymmetrical pupils may be indicative of

intra3cranial bleeding.

Muscle pain indicating rhabdomyolysis.

/arotid s!elling, con


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identifying the sna$e species, in the absence of the dead sna$e. t !ould be impossible for

the physician to determine !hich type of Monovalent ;S9 to employ in treating the

patient.

;n ndian medical college is currently !or$ing to develop @n4yme 8in$ed mmuno

Sorbent ;ssay testing for sna$e species and level of envenomation, although it !ill ta$emany years before a reliable and effective $it is available to doctors.

There are $no!n species such as the 'ump3nosed pitviper (Hypnale hypnale) !herepolyvalent ;S9 is $no!n to be ineffective. n addition, there are regionally specific

species such as Sochure$As Sa! Scaled 9iper (Echis carinatus sochureki) in a=T or visiblespontaneous systemic bleeding, gums etc.

urther laboratory tests for thrombocytopenia, 'b abnormalities, /=9,peripheral smear etc provide confirmation, but 20>=T is paramount.


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@vidence of neurotoicity" ptosis, eternal ophthalmoplegia, muscle paralysis,

inability to lift the head etc.

The above t!o methods of establishing systemic envenomation are the primary

determinants. They are simple to carry out, involving bedside tests or identification of

visible neurological signs and symptoms. n the ndian contet and in the vast ma


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The dose for children is 0.*30.:mg$g of antihistamine 9 and 2mg$g of

hydrocortisone 9. ;ntihistamine should be used !ith caution in pediatric

patients.

0.2-30.:mg adrenaline *"*000 given subcutaneously.

The conclusion in respect of prophylactic regimens to prevent anaphylactic reactions, is

that there is no evidence from good #uality randomi4ed clinical trials to support their

routine use. f they are used then the decision must rest on other grounds, such as politicalpolicy in the case of ?overnment 'ospitals, !hich may opt for a maimum safety policy,

irrespective of the lac$ of definitive trial evidence.

f the victim has a $no!n sensitivity to ;S9, pre3medication !ith adrenaline,hydrocortisone and anti3histamine may be advisable, in order to prevent severe reactions.

AS7 Administration" Dosage

n the absence of definitive data on the level of envenomation, such as provided by@8S; testing (?reen!ood et al, *+1%) (Thea$ston et al, *+11) ('o et al, *+6),

symptomology is not a useful guide to the level of envenomation. ;ny ;S9 regimenadopted is only a best estimate. hat is important is that a single protocol is established

and adhered to, in order to enable results to be reliably revie!ed.

The recommended dosage level has been based on published research that ussells 9iper

in


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+/ AS7 T'ST D/S' M


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/regnant !omen are treated in eactly the same !ay as other victims. The same dosage

of ;S9 is given.

The victim should be referred to a gynaecologist for assessment of any impact on the

foetus.

7ictims &ho Arrie 8ate; fre#uent problem is victims !ho arrive late after the bite, often after several days,usually !ith acute renal failure. Should the clinician administer ;S9J The $ey

determining factor is, are there any signs of current venom activityJ 9enom can only be

neutralised if it is unattached5 /erform a 20>=T and determine if any coagulopathy ispresent. f coagulopathy is present, administer ;S9. f no coagulopathy is evident treat

any renal failure by reference to a nephrologist and dialysis.

n the case of neurotoic envenoming !here the victim is evidencing symptoms such as

ptosis, respiratory failure etc, it is probably !ise to administer * dose of 3*0 vials of;S9 to ensure that no unbound venom is present. 'o!ever, at this stage it is li$ely that

all the venom is bound and respiratory support or normal recovery !ill be the outcome.

AS7 Reactions;naphylais is life3threatening, but despite the reluctance in giving ;S9 due toreactions (alantri et al, 200-), if the correct protocol is follo!ed, it can be effectively

treated and dealt !ith. ;naphylais can be rapid onset and can deteriorate into a life3

threatening emergency very rapidly. ;drenaline should al!ays be immediatelyavailable.

The patient should be monitored closely (/eshin et al, *++1) and at the first sign of anyof the follo!ing"

Frticaria, itching, fever, sha$ing chills, nausea, vomiting, diarrhoea, abdominal cramps,

tachycardia, hypotension, bronchospasm and angio3oedema

2. AS7 ,ill be discontin#ed

. 3.%mg o6 2"2333 adrenaline ,ill be gien IM

=hildren are given 0.0*mg$g body !eight of adrenaline M.

n addition, to provide longer term protection against anaphylactoid reaction, *00mg ofhydrocortisone and an '* antihistamine, such as /henimarine maleate can be used at

22.-mg 9 or /rometha4ine '=l can be used at 2-mg M, or *0mg chlorphenirmarine

maleate if available, !ill be administered 9.

The dose for children is of /henimarine maleate at 0.-mg$g day 9 or

/rometha4ine '=l can be used at 0.:30.-mg$g M or 0.2mg$g ofchlorphenimarine maleate 9 and 2mg$g of hydrocortisone 9.


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;ntihistamine use in pediatric cases must be deployed !ith caution.

f after *0 to *- minutes the patientKs condition has not improved or is !orsening, a

second dose of 0.- mg of adrenalin *"*000 M is given. This can be repeated for a third

and final occasion but in the vast ma


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The follo!ing measures are useful oblood coagulability is usually restored in 6 hours. /rincipal test is 20>=T

c) /ost synaptic neurotoic envenoming such as the =obra may begin to improve as early

as :0 minutes after antivenom, but can ta$e several hours.d) /resynaptic neurotoic envenoming such as the rait usually ta$es a considerable time

to improve reflecting the need for the body to generate ne! acetylcholine emitters.

e) ;ctive haemolysis and rhabdomyolysis may cease !ithin a fe! hours and the urinereturns to its normal colour.

f) n shoc$ed patients, blood pressure may increase after :0 minutes.

Re)eat Doses" Anti aemostaticn the case of anti haemostatic envenomation, the ;S9 strategy !ill be based around a

si hour time period. hen the initial blood test reveals a coagulation abnormality, the

initial ;S9 amount !ill be given over * hour.

&o additional ;S9 !ill be given until the net =lotting Test is carried out. This is due to

the inability of the liver to replace clotting factors in under 6 hrs.


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;fter 6 hours a further coagulation test should be performed and a further dose should be

administered in the event of continued coagulation disturbance. This dose should also be

given over * hour. =T tests and repeat doses of ;S9 should continue on a 6 hourlypattern until coagulation is restored, unless a species is identified as one against !hich

/olyvalent ;S9 is not effective.

The repeat dose should be -3*0 vials of ;S9 i.e. half to one full dose of the original

amount. The most logical approach is to administer the same dose again, as !as

administered initially. Some ndian doctors ho!ever, argue that since the amount ofunbound venom is declining, due to its continued binding to tissue, and due to the !ish to

conserve scarce supplies of ;S9, there may be a case for administering a smaller second

dose. n the absence of good trial evidence to determine the ob


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ussells 9iper bites are $no!n to cause acute pituitary adrenal insufficiency (Tun /e et

al, *+1) (@apen et al *+16). This condition may contribute to shoc$. ollo!3up chec$son $no!n ussells 9iper victims need to ensure that no long term pituitary se#uelae are

evident.

S#rgical Interentionhilst there is undoubtedly a place for a surgical debridement of necrotic tissue, the use

of fasciotomy is highly #uestionable. The appearance of (Hoseph, 200:)"

/ain on passive stretching

/ain out of proportion

/ulselessness

/allor

/arasthesia

/aralysis

!ith significant s!elling in the limb, can lead to the conclusion that theintracompartmental pressure is above %0 mm of mercury and thus re#uires a fasciotomy.

asciotomy is re#uired if the intracompartmental pressure is sufficiently high to cause

blood vessels to collapse and lead to ischemia. asciotomy does not remove or reduceany envenomation.

There is little ob


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Snakebite Management in Primar(=Comm#nit(=Dis)ensar( ealth

Care Centres

; $ey ob Assessment

/atient should be placed under observation for 2% hours

The sna$e, if brought, should be carefully eamined and compared to the sna$e

identification material./ain management should be considered.

20>=T in clean, ne!, dry, glass test tubes should be carried out every :0 minutes forthe *st: hours and then hourly after that.

;ttention should be paid for any visible neurological symptoms.Severe, current, local s!elling should be identified

f no symptoms develop after 2% hours the patient can be discharged !ith a T.T.

'nenomationK aemoto;ic

f the patient has evidence of haemotoic envenomation, determined by 20>=T, then

3*0 vials of ;S9 are administered over * hour.;drenaline is made ready in t!o syringes of 0.-mg *"*000 for M administration if

symptoms of any adverse reaction appear. f symptoms do appear, ;S9 is temporarily

suspended !hile the reaction is dealt !ith and then recommenced.

Re6erral Criteria

7nce the ;S9 is finished and the adverse reaction dealt !ith the patient should be

automatically referred to a higher centre !ith facilities for blood analysis to determineany systemic bleeding or renal impairment.

The 6 hour rule ensures that a si hour !indo! is no! available in !hich to transport thepatient.

'nenomationK +e#roto;ic

f the patient sho!s signs of neurotoic envenomation 3*0 vials are administered over *hour.

;drenaline is made ready in t!o syringes of 0.-mg *"*000 for M administration ifsymptoms of any adverse reaction appear. f symptoms do appear, ;S9 is temporarily

suspended !hile the reaction is dealt !ith and then recommenced.


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; neostigmine test is administered using *.-32.0mg of neostigmine M plus 0.6mg of

atropine 9. ;n ob


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allo!ing the tongue to fall bac$ and bloc$ the air!ay, !ithout triggering the gagging

refle. mprovised &asopharyngeal tubes can be made by cutting do!n si4e -

endotracheal tubes to the re#uired length i.e. from the tragus to the nostril. &/ tubesshould be prepared and $ept !ith the sna$ebite $it in the /'=. This is preferable as the

patient may !ell be unable to perform a nec$ lift but still remain conscious and breathing.

The danger !ill be that respiratory failure !ill occur after the patient has left the /'=and before arriving at the eventual institution. n that case the patient !ill be pre3prepared

for the use of a resuscitation bag by the use of &/ tubes.

n the unconscious patient, a 8aryngeal Mas$ ;ir!ay or preferably a 8aryngeal Tube

;ir!ay should be inserted before referral !hich !ill enable more effective ventilatory

support to be provided !ith a resuscitation bag until the patient reaches an institution

!ith the facility of mechanical ventilation..

5asic Minimal > 'ssential Dr#g and '$#i)ment Pro6ile 6or a Primar(

Centre

n order to be able to effectively respond to sna$ebite, the primary care centre needs adrug and e#uipment profile that supports sna$ebite treatment. 7ften the level of s$ill to

design such a profile is not readily available. ?ood guidelines are therefore re#uired fordoctors and government procurement groups as to ho! to e#uip a primary centre for its

role.

Antienom = Anti Snake 7enom

The type of ;9;S9 used !ill be determined by availability, cost and effectiveness of the

cold chain. 8yophilised ;9;S9, in po!dered form has a shelf life of - years andre#uires merely to be $ept out of direct sunlight. 8i#uid ;9;S9, !hich is easier to

administer, has a shelf life of t!o years and re#uires refrigeration.

n this instance the holding #uantity can be established using the follo!ing e#uation"(d G *.2) t !here"

Onumber of envenomings on average per monthd O the maimum number of vials li$ely to be applied at the /'= to a single patient

t O length of time normally eperienced for replenishment in months.

Suppose !e are dealing !ith a /'= !ith t!o envenomings per month then O2 The

maimum dose re#uired per patient determines a $ey part of usage, so for eample, in

ndia the maimum dose for a patient at a /'= !ould be 2 doses of *0 vials for a

neurotoic patient, so d O 20. *.2 represents the safety factor to ensure greater thanminimal stoc$ is available. The restoc$ing time in months is represented by t. f the

restoc$ing period is 2 months for ;9;S9 to be replaced the e#uation !ould re#uire 2 G

20 G *.2 G 2 O +6 vials !ould be the ;9;S9 base stoc$ amount.


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The F#t#re o6 Snakebite Management in India

t is recognised that this protocol represents the best available information and guidelinesfor dealing !ith sna$ebite in ndia. t !ill be constantly updated to reflect the best

evidence based research that emerges during its use.


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A))endi; 2

Re6erences

First Aid

;lberts M>, Shalit M, 8ogalbo , Suction for venomous sna$ebite" a study of Qmoc$

venom in a human modelQ ;nn @merg Med. 200% ebC%:(2)"**36.

;maral =, =ampolina B, Bias M>, >ueno =M, e4ende &;. Tourni#uetineffectiveness to reduce the severity of envenoming after =rotalus durissus sna$e bite in

>elo 'ori4onte, Minas ?erais, >ra4il. *++ Toicon. MayC:6(-)"0-3.

;n$er 8, Staffon ?, 8oiselle BS, ;n$er M, etarding the upta$e of moc$ venom in

humans. =omparison of three first aid treatments Medical Hournal of ;ustralia *+2.

2*232*%

>uc$nall &, @lectrical Treatment of venomous bites and stings" a mini revie!. Toicon

*++*C 2+" :+13%00

>ush S/, Sna$ebite suction devices donAt remove venom" They ush S/, ?reen SM, 8aac$ T;, 'ayes , =ard!ell MB, Tanen B;, /ressuremmobilisation delays mortality and increases intracompartmental pressure after artificial

intramuscular rattlesna$e envenomation in a porcine model ;nnals of @mergency

Medicine 200%C %%(6)"-++360%

=urrie >. /ressure3immobili4ation first aid for sna$ebite 3 fact and fancy. *++: G

nternational =ongress for Tropical Medicine and Malaria. Homtien, /attaya, Thailand 2+

&ov3% Bec. Toxicon *++2C :* ()"+:*3+:2.(abstract).

Bavidson TM, Sam splint for !rap and immobilisation of sna$ebite. Hournal ofilderness Medicine 200*C (*2)" 2063201

Bavis B, >ranch , @gen &>, ussell @, ?errish , ;uerbach /S, The effect of an

electrical current on sna$e venom toicity. Hournal of ilderness Medicine *++2C (:)" %3-:
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ussell @ ;nother arning about @lectroshoc$ for Sna$ebite /ostgrad Med *+1a C2 "

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;ugC1*(2)"2:%3.

Simpson B Sna$ebite" ecent ;dvances 2006 in Medicine Fpdate 2006 @d Sahay >

The ;ssociation of /hysicians of ndia 6:+36%:

Snyder ==, Murdoc$ T, hile ?8, uitu H @lectric Shoc$ Treatment for Sna$ebite

8ancet *++C *"*022

Sutherland, =oulter ;, 'arris B, ationalisation of first aid methods for elapid

sna$ebite 8ancet *+1+C i "*:3*6

Sutherland S, 'arris B, =oulter ;, 8overing @, irst aid for =obra (&aur$e =.

;cute and chronic pituitary failure resembling SheehanKs syndrome follo!ing bites by

ussellKs viper in >urma. 8ancet*+1C(-62)"16:31.

Tun /e, ;ye ;ye Myint, hin @i 'an et al, 8ocal =ompression pads as a first aid measure

for victims of bites by ussells 9iper (Baboia russelii siamensis) in Myanmar. Transoyal Society of Trop Medicine *++-C +"2+:32+-

Tun /e, Sann Mya, ;ye ;ye Myint, &u &u ;ung, hin ;ye yu, Tin 7o, ield Trials of@fficacy of 8ocal =ompression mmobilisation irst ;id Techni#ue in ussells 9iper

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Sri 8an$an =obra (&a


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en an ', Marcopito 8, =ardoso H8=, ranca 7S, Mala#ue =MS, errari ;,

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A))endi;

S#))ort Factors to 'nhance Snakebite Protocols

Snakes o6 Medical Signi6icance

ndian venomous sna$es of medical significance have usually been regarded as only four

species" ussells 9iper, Sa! Scaled 9iper, =obra and rait. These species !ere believed

to be causing all fatalities in ndia. 'o!ever this concept has led to some seriousproblems"

*. ;S9 Manufacturers only produce antivenom against these species2. The assumption that only EThe E>ig %A can cause serious symptoms and death has

led to mis3identification of species.

:. 7ther deadly sna$es may be going un3noticed and causing death and disability5The recent discovery of the 'ump3nosed /itviper as a species capable of causing

life threatening symptoms has demonstrated this.

n order to determine the actual list of medically significant species in ndia, the old

concept of EThe >ig ourA is to be abandoned for a ne!er more fleible model that

enables better classification of species. The .'.7. Model, produced in *+*, has been

adopted as the ndian preferred method for categorising sna$es of medical importance.The model is sho!n belo!"

Sna$es of Medical Significance based on (.'.7. *+*)

Class I"Commonl( ca#se death or serio#s disabilit(

FSS@88S 9/@=7>;S; S=;8@B 9/@

Class II"

Snakebite Treatment Protocol

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