What is the clinical management and treatment of snake bites in India?

Clinical Management and Treatment of Snake Bites in India

The mainstay of treatment for venomous snakebites in India is prompt administration of antivenom in a hospital setting with appropriate monitoring for adverse reactions. 1

Epidemiology and Clinical Profile in India

• Snake bites in India show distinct patterns:
  • Annual incidence of approximately 36 per 100,000 population 2
  • Higher prevalence in males (52-69%) 2, 3
  • Most common in 18-45 age group (66%) 2
  • Seasonal variation with highest incidence during monsoon (58%) 2
  • Lower extremities are the most common bite site (63%) 2
  • Venomous bites account for approximately 76% of cases 2

Initial Assessment and Management

First Aid and Transport

• Call emergency services immediately 1
• Rest and immobilize the bitten extremity to reduce venom spread 1
• Remove rings and other constricting jewelry from the affected limb 1
• Apply a pressure immobilization bandage (40-70 mmHg for upper extremity, 55-70 mmHg for lower extremity) 1
• Transport to the nearest healthcare facility as quickly as possible 4

DO NOT:

• Apply ice
• Use suction devices
• Apply electric shock
• Apply tourniquets
• Delay transport to hospital 1

Hospital Management

Immediate Assessment

• Identify the snake if possible (brought by victim) 5
• Assess for signs of envenomation:
  • Neurotoxic (krait and cobra): Paralysis, respiratory distress 5
  • Vasculotoxic (Russell's viper and Echis carinatus): Local edema, bleeding 5
• Perform 20-minute whole blood clotting test (WBCT) - simple, rapid, and reliable test for coagulopathy 5

Laboratory Investigations

• Complete blood count
• Coagulation studies
• Renal function tests
• Electrolytes
• Cardiac monitoring 1

Treatment Protocol

Antivenom Administration

• Antivenom is the definitive treatment for venomous snakebites 1
• Average dose in Indian settings: 7.5±0.63 vials (range 2-40) 2
• Monitor closely for adverse reactions during administration 1
• Skin testing has poor predictive value for identifying allergic reactions 1
• Continue antivenom until clinical improvement or restoration of blood coagulability 5

Supportive Care

• Respiratory support:
  • Monitor oxygen saturation
  • Provide supplemental oxygen if hypoxic
  • Early endotracheal intubation and manual ventilation for neurotoxic envenomation 1, 5
• Anticholinesterase treatment for Elapidae (krait and cobra) envenomation 5
• Pain management
• Tetanus prophylaxis
• Prophylactic antibiotics if indicated for wound infection 1

Special Considerations

Complications to Monitor

• Acute kidney injury (particularly with Russell's viper bites) 3
• Coagulopathy and bleeding complications (including rare presentations like subarachnoid hemorrhage) 6
• Neutrophilic leukocytosis and deranged liver enzymes (associated with poor prognosis) 3
• Delayed reactions to antivenom (serum sickness) 1

Regional Challenges in India

• Limited availability of treatment facilities near bite locations 4
• Many primary healthcare centers lack confidence in treating snakebites 4
• Patients often referred to distant hospitals without antivenom cover during transport 4
• Lack of uniform protocol adherence to National Snakebite Management Protocol 2

Outcome Predictors

• Early presentation to healthcare facility 3
• Timely administration of antivenom 5, 3
• Early respiratory support for neurotoxic envenomation 5
• Normal Glasgow Coma Scale at presentation associated with better outcomes 3

With proper and timely management, mortality rates can be significantly reduced, with some centers reporting mortality as low as 0.7% 3.