What is the management approach for a Russell's viper bite?

Russell's Viper Bite Management

Administer polyvalent or monospecific Russell's viper antivenom immediately upon diagnosis, with an initial dose of 60 mL intravenously, repeated every 6 hours until blood coagulability is restored. 1

Immediate First Aid and Emergency Response

• Activate emergency medical services immediately for transport to a hospital capable of providing antivenom and supportive care 2
• Rest and immobilize the bitten extremity to minimize systemic venom absorption 2
• Remove rings, watches, and any constricting objects from the affected limb before swelling develops 2
• Do NOT apply ice, tourniquets, suction devices, electric shock, or pressure immobilization bandaging - these interventions are potentially harmful and ineffective 2

Hospital-Based Definitive Management

Antivenom Therapy (The Cornerstone of Treatment)

• Start monospecific Russell's viper antivenom at 60 mL intravenously every 6 hours until blood coagulability normalizes 1
• The mean total dose required to correct coagulopathy is approximately 165 mL (±59.3 mL) 1
• Early antivenom administration (within 5 hours of bite) may prevent acute renal failure, which is a major cause of morbidity 3
• Monitor clot quality test and evidence of systemic bleeding to guide antivenom dosing 4
• Polyvalent antivenom is an acceptable alternative when monospecific antivenom is unavailable 5

Critical Monitoring and Supportive Care

Coagulation Status:

• Perform serial clot quality tests to assess coagulopathy correction 4
• Russell's viper venom causes disseminated intravascular coagulation (DIC) with defibrination 6
• Continue antivenom until coagulation parameters normalize 1

Renal Function:

• Monitor for acute renal failure, which occurs frequently in Russell's viper envenomation 3, 6
• Initiate conservative management for early renal dysfunction 3
• Prepare for peritoneal dialysis if conservative measures fail - approximately 63% of patients with renal failure require dialysis 3

Bleeding Complications:

• Watch for both local bleeding at the bite site and systemic bleeding (hematemesis, bleeding gums, hematuria) 6
• Patients with higher venom antigenemia levels are at greater risk for clinical bleeding 1
• Monitor for life-threatening cerebral hemorrhage, which can be fatal 6

Respiratory Status:

• Monitor closely for pulmonary edema, which is a common cause of death in severe envenomation 3
• Neurological manifestations occur in approximately 86% of cases 3

Adrenal Function:

• Consider bilateral adrenal hemorrhage in patients with hemodynamic instability despite adequate resuscitation 5
• Administer corticosteroid therapy if Addisonian crisis is suspected 5

Common Pitfalls to Avoid

• Delaying antivenom administration - early treatment (within 5 hours) is associated with prevention of renal failure 3
• Underestimating the total antivenom dose needed - be prepared to administer multiple doses until coagulopathy resolves 1
• Failing to monitor for pulmonary edema, which can develop rapidly and cause death 3
• Missing digital gangrene in finger or toe bites, which occurs more frequently than bites to other sites 6
• Not recognizing that local swelling may be less pronounced with Russell's viper compared to other vipers, despite severe systemic toxicity 6

Adjunctive Measures

• Elevate the affected extremity to reduce swelling 2
• Ensure tetanus prophylaxis is current (0.5 mL tetanus toxoid intramuscularly if status unknown or outdated) 2
• Irrigate the wound with sterile normal saline 2
• Manage generalized myalgia (present in 73% of cases) with appropriate analgesia 3
• Monitor for and treat seizures if they occur (approximately 18% of severe cases) 3