Chapter 3

Snake bite treatment Protocol

Snake envenomation constitutes a medical hazard in many regions of the world.
Symptoms and signs vary according to the species of snake responsible for the bite and the
amount of venom injected. Sometimes the identity of the biting snake can be confirmed by
examining the dead snake.
It may be strongly suspected from
the patients description or the circumstance of the bite or from the knowledge of the clinical
effects of the venom of that species.
This information will able the doctor to choose appropriate anti venom, anticipate the
likely complications and therefore take appropriate action. If the biting species is unknown,
recognition of the emerging pattern of symptoms, signs and results of laboratory tests (clinical
syndromes), may suggest which species was responsible.

Local symptoms and signs in the bitten part

Fang marks
Local pain
Local bleeding
Bruising
Lymphangitis
Lymph node enlargement
Inflammation (swelling, red, heat)
Blistering
Local infection, abscess formation
Necrosis

Management of snakebite
1. First aid treatment
2. Transport to hospital
3. Rapid clinical assessment and resuscitation
4. Detailed clinical assessment and species diagnosis
5. Investigations / laboratory tests

6. Antivenom treatment
7. Observation of the response to the Antivenom; decision about the need for further dose(s) of
Antivenom
8. Supportive treatment
9. Treatment of the bitten part
10.Rehabilitation
11. Treatment of chronic complications

First aid treatment

First aid treatment is carried out immediately or very soon after bite, before the patient reaches
a hospital or dispensary. It can be performed by the snake bite victim himself/herself or by
anyone else who is present.

Aim of First aid --------> Do it R. I. G. H. T

1) Reassure the victim
Calm the victim down. Un-necessary panic will only raise the pulse rate and blood- pressure
and moves the venom in to the system faster. Make the patient aware that 70% of the snakebites are from non-poisonous species. Of the remaining 30% only half will actually involve
injecting venom.
2) Immobilize the bitten limb without with out compression If the bite is on a hand or arm
place it in a sling bandage or use a piece of cloth to support the arm. In the case of a leg
bite, use a splint to support both legs and bandage them together. Do not tie the bandages
tightly and apply any pressure.

3) Get the patient to Hospital immediately

Get the patient immediately to the hospital with out wasting the valuable time but as
safely and comfortable as possible. Any movement, but especially the movement of the
bitten limb must be reduced to an absolute minimum to avoid increasing the systemic
absorption of venom.

4) Tell the doctor any of the following signs appearing on the way to hospital

Difficulty breathing if the patient stops breathing give artificial respiration. In

cobra and krait bite this will save victims life

Drooping eyelids
Bleeding from gums or any unusual bruising appearing
Increases in swelling
Drowsiness
Difficulty in speaking
Bleeding from the wound that does not seems to stop

Antivenom treatment
Antivenom is the only specific antidote to snake venom. A most important decision
in the management of a snake bite victim is whether or not to give Antivenom. Antivenom
is immunoglobulin purified from the serum or plasma of a horse or a sheep that has been
immunized with the venoms of one or more species of snake. Specific Antivenom implies
that the Antivenom has been raised against the venom the snake that has bitten the
patient and that it can therefore be expected to contain specific antibody that will
neutralize that particular venom.

Monovalent or monospecific antinenom neutralizes the venom of only one species of the
snake. Polyvalent or polyspecific Antivenom neutralizes venoms of several species of
snakes, usually most important species. Polyvalent anti snake venom serum developed in
Serum institute of India is raised in the horses using the venom of the four most important
venomous snakes in India (Indiancobra,Indian krait, Russells viper, and saw-scaled viper).
Antibodies raised against the venom of one species may have cross-neutralizing activity
against other venoms, usually from closely related species. This is known as paraspecific
activity.

Indications for Antivenom treatment

Antivenom treatments carry a risk of severe adverse reactions and in most countries it is
costly and may be in limited supply. It should be therefore be used only in patients in
whom the benefits of Antivenom treatment are considered to exceed the risk. Antivenom
treatment is recommended if and when a patient with proven or suspected snake develops
one or more of the following signs;

Systemic envenoming
Haemostatic abnormalities: spontaneous systemic bleeding, coagulopathy or
thrombocytopenia
Neurotoxic signs: ptosis, external ophthalmoplegia, paralysis etc
Cardiovascular abnormalities: hypotension, shock, cardiac arrhythmia, abnormal ECG
Acute renal failure: oliguria/anuria, raising blood creatinine/urea
Supporting laboratory evidences of systemic envenoming

Local envenoming

Local swelling involving more than half of the bitten limb(in the absence of a

tourniquet) Swelling after bites on the digits(toes and especially fingers)

Rapid extension of swelling (for example beyond the wrist or ankle with in a few

hours of bites on the hands or feet).

Development of an enlarged tender lymph node draining the bitten limb.

Antivenom treatment should be given as soon as it is indicated. It may reverse

systemic envenoming even when this has persisted for several days or, in the case of
haemostatic abnormalities, for two or more weeks. However, when there are signs of local
envenoming without the signs of systemic envenoming, antivenom will be effective only if it
can be given within first few hours after the bite.

Antivenom reactions
Skin and conjunctival hypersensitivity tests may reveal IgE mediated Type 1
hypersensitivity to sheep or horse protein but do not predict large majority of
early(anaphylactic) or late(serum sickness type) Antivenom reactions. Since they may delay
treatment and can in themselves be sensitizing, these test should not be used.
Contraindication of Antivenom
There is no absolute contraindication to Antivenom treatment, but patients who
have reacted to horse (equine) or sheep (ovine) serum in the past (for example after
treatment with equine anti-tetanus serum, equine anti-rabies serum or equine or ovine
antivenom) and those with a strong history of atopic diseases (especially severe asthma)
should be given antivenom only if they have signs of systemic envenoming.

Administration of Antivenom
Epinephrine (adrenaline) should always be drawn up in readiness before Antivenom is
administrated
Antivenom should be given by the intravenous route whenever possible, (lyophilized)
antivenoms are reconstituted, usually with 10 ml of sterile -water for injection per
ampoule. The freeze-dried protein may be difficult to dissolve; Two methods of
administration are recommended:

1) Intravenous push injection: reconstituted freeze-dried antivenom or neat liquid

antivenom is given by slow intravenous injection (not more than 2ml/minute). This method
has the advantage that the doctor/nurse/dispenser giving the antivenom must remain
with the patient during the time when some early reactions may develop. It is also
economical, saving the use of intravenous fluids, giving sets, cannulae etc.

2) Intravenous infusion: reconstituted freeze-dried or neat liquid antivenom is diluted in

an approximately 5-10 ml of isotonic fluid per kg of body weight (ie 250-500 ml of isotonic

saline or 5% dextrose in the case of an adult patient ) and is infused at a constant rate
over a period of about one hour.

Conservative treatment when no antivenom is available

This will be the situation in parts of the region, where the supplies of Antivenom
run out or the bite is known to have been inflicted by a species against whose venom there
is no available specific antivenom. In such cases, following conservative measure are
suggested.

Neurotoxic envenoming with respiratory paralysis: assisted ventilation. This has

proved effective and has been followed by complete recovery, even after being maintained
for periods of more than one month. Manual ventilation (anaesthetic bag) by relays of
doctors, medical students, relatives and nurses has been effective where no mechanical
ventilator was available

Haemoststic abnormalities: strict bed rest to avoid even minor trauma; transfusion
of clotting factors and platelets, ideally fresh frozen plasma and cryoprecipitate with
platelet concentrate or if these are not available, fresh whole blood. Intramuscular
injections must be avoided.

Shock, myocardial damage: hypovolemia should be corrected with

colloid/crystalloids, controlled by observation of the central venous pressure. Patients with
hypotension associated with bradycardia should be treated with atropine.

Severe local envenoming: local necrosis, intracompartmental syndromes and even

thrombosis of major vessels is more likely in patients who cannot be treated with
Antivenom. Surgical intervention may be needed but the risk of surgery in a patient with
consumption coagulopathy, thrombocytopenia, and

enhanced fibrinolysis must be balanced against the lifethreatning complication of the local
envenoming. Prophylactic broad spectrum antimicrobial treatment is justified.

Treatment of the bitten part

The bitten limb, which may be painful and swollen, should be nursed in the most
comfortable position preferably slightly elevated, to encourage the reabsorption of oedema
fluid. Bulle may be large and tense but they should be aspirated only if they seem likely to
rupture. Infection at the time of the bite with the organisms from the snake venom and
buccal cavity is a problem with some species and in such cases a prophylactic course of
pencillin and a single dose of gentamicin or a course of chloramphenicol, together with a
booster dose of tetanus toxoid is recommended.

Rehabilitation
Restoration of normal function in the bitten part after the patient has been
discharged from hospital is not usually supervised. Conventional physiotherapy may well
accelerate this process.In patient with severe local envenoming, the limb should be
maintained in a functional position.

Chapter 4
Sarpa visha Chikitsa
In Agadatantra, the whole poisonous animals are categorized under Jangama
Visha. Charaka acharya distinctly describes the wide range of poisonous animals which
include serpents, insects, rats, spider, scorpions, houselizards, leeches, fishes, frogs,
hornets, dogs, tiger, jackals, hyenas, mangooses and other fanged animals.

Among the Jangamavishas sarpavisha grabs primary attention because of its high
rate of mortality. The fast spreading, quick acting and destructive nature of sarpavisha in
the human body is due to its guna/characteristic properities.

Visha Guna
The action of visha completely depends upon its characteristic gunas and it is of ten
in number. Susrutha observed ten gunas such as Ruksha, Ushna, Teekshna, Sukshma,
Aasukari, Vyavayi, Vikasi, Visada, Laghu and Apaki2. Charaka mentioned Anirdesya rasa3
instead of Apaki where as Vagbhada accept Avyakta rasa and Apaki. In this context
Sarngadharacharya explains only eight guna such
as Vyavayi, Vikasi, Sukshmam, Chedi, Madavaham, Agneyam, Jeevithaharam and
Yogavahi.
Table 1 Visha gunas an overview

Visha guna
Ruksha
Ushna
Teekshna
Sukshma
Aasukari
Vyavayi
Vikasi
Visada
Laghu
Apaki
Avyakta rasa
Anirdesya rasa

Charaka

Susruta

Vagbhata

+
+

+
+

+
+

+
+

+
+

+
+

+
+

+
+

+
+

+
+

+
+

+
+

+
X

+
+

+
+

X
+

X
X

+
X

Sarngdhara
Chedi
Agneyam
Madavaham
+
Jeevithaharam
+
+
Yogavahi
X

Action of Visha in the body with respect to its gunas6

1. Ruksha (dryness/roughness): Aggregate Vata in the body
2. Ushna (hotness): Ushna guna vitiates Pitta and Raktha
3. Teekshna (sharpness): Affect the functions of brain and damages the marmas

X
X
X

4. Sukshma (minuteness): Enable visha to penetrate deeper in to the organs and cause
derangement of its functions.
5. Aasukari (quickness): Accelerate the fatal condition.
6. Vyavayi (easily spreading): Enable easily spreading of poison, affect prakruthi
7. Vikashi (expansiveness): This expansive nature of visha loosens body alignment and
debilities the functions of dosha, dathu and mala.
8. Visada (non-viscid/clear): Due to visada guna visha does no adhere any part of the body
and enables easily spreading
9. Laghu (lightness): Will make visha inaccessible and difficult to treat.
10. Apaki (indigestible): As it is indigestible, it remains in the body for a long time causing
troubles for a long time.
11. Avyaktha rasa (un differentiated taste): Only described in Astangasamgraha and
hridya, which probably vitiates Kapha and promote the spread of visha through anna rasa.
12. Anirdesya rasa (un detectable taste): It combines with all kind of anna rasa as it is
undetectable and thus aids the spread of poison.

Immediate consequences of poisoning

Immediately after the entry of visha in the body, it primarily affects raktha dathu, vitiating
kapha, pitha and vatha dosha along with their ashayas and finally reaches hridaya which
in turn make the situation fatal. The outspread of visha from its point of entry to hridaya
through different dathus as well as doshas will take place with in a short span of time due
to its vyavai and aasukari gunas.
Divya and Bhauma Sarpa

Basically snakes are classified in to two types 1. Divya (divine) Sarpa 2. Bhauma (terrestial)
Sarpa8. Divya sarpas are divine or mythical in nature and are supposed to have extranatural powers, glow like fire, they lightens, support and sustain the world and they are
capable of destroying the whole world by their sight and breath.

The only thing we have to do for divya Sarpa visha is to accept it, as there is no
treatement and is absolutely fatal. Bhauma Sarpa (terrestrial snakes) are eighty in
numbers and they are classified in to five groups. This classification is based on their
morphology and characteristic features of poisons. Such a classification is indented to help
the people to identify the snake and give right treatment.

Table 2 Classification of Bhauma sarpa9

1 Darvikara 26
2 Mandali 22
3 Rajimanta 10
4 Nirvisha 12
5 Vaikaranja 10

The five groups of bhauma sarpa includes Darvikara, the hooded snake which is of 26
types, Mandali, the hoodless veritey with circular patches or rings of varied colours on
their skin which is of 22 types, Rajimantha the hoodless variety with stripes on the body of
10 typea, Nirvisha the non-poisonous snakes of 12 types and Vaikaranja, the hybrid
species of 10 types.

Sarpa Damsa Karanam (cause of snake bite) 10

Sarpa damsa will happen when snake mistake part of body as food, when
frightened, being touched by feet, accumulation of more poison in their venom apparatus,
when get angered, as a revenge and when incited by gods, sages or by yama the god of
death. The effect of poison is more prominent in each succeeding one.

Sarpa damsa bhedam (types of bite) 11

Five types of bite are described in Astanga hridaya with respect to the severity of bite.
1. Thundahata: presence of saliva of snake but no marks of teeth
2. Vyalidha: presence of one or two fang marks with out bleeding
3. Vyaalupta: presence of one or two fang marks with out bleeding
4. Dashtaka: presence of three fang marks with bleeding along with thetearing of muscles.
5. Dashtanipeedita: presence of four fang marks, muscle penetrated, puncture of blood
vessels.
Among the five types, first two are poisonous and last three are venomous.
Susrutha names the bite as (1) Sarpita the highly poisonous, (2) Radita reticulate and
(3) Nirvisha non poisonous.

Damstra The fangs

Sarpavisha comes under the category of damstra visha. Charaka gives a detailed description on the position, colour and quantity of venom present in each damstra.