Management of Snake Bite in India
Immediate First Aid at the Scene
Activate emergency medical services immediately and transport the victim to the nearest hospital as rapidly as possible—this is the single most critical intervention that determines survival. 1, 2, 3
Essential Pre-Hospital Actions
Rest and completely immobilize the bitten extremity to minimize lymphatic absorption of venom, as walking or movement increases systemic venom spread by up to 10 minutes of activity 1, 4
Remove all rings, jewelry, watches, and constricting clothing from the affected limb immediately before progressive swelling causes ischemic injury and potential compartment syndrome 1, 2, 4
Minimize all patient exertion and movement during transport—carry the victim rather than allowing them to walk, as physical activity accelerates venom absorption through increased lymphatic flow 1, 5
Keep the victim calm and reassure them to reduce anxiety-related tachycardia that may increase venom circulation 4
Critical Transport Considerations
Any delay in reaching hospital dramatically increases mortality risk (OR 8.88 for unfavorable outcomes with delays) 3
Presenting to hospital within 1.5 hours significantly improves survival (OR 0.23 for unfavorable outcomes) 3
Motorbike transport is superior to other modes when ambulance is unavailable (OR 0.37 for unfavorable outcomes) 3
Do NOT visit traditional healers or faith practitioners first—this is a significant, preventable cause of fatal delays (OR 3.52 for unfavorable outcomes) 3
Harmful Practices That Must Be Completely Avoided
The following interventions are not only ineffective but actively harmful and must never be performed:
NO tourniquets—they worsen local tissue necrosis and do not prevent systemic envenomation 1, 4, 5
NO ice application—causes additional tissue injury and has no benefit for venom neutralization 1, 4, 5
NO suction devices (with or without incision)—removes only 0.04% of venom while causing significant tissue damage 1, 4, 5
NO electric shock therapy—completely ineffective and potentially harmful 1, 4, 5
NO pressure immobilization bandaging for Indian snakes—while the 2015 AHA guidelines suggested this for certain neurotoxic bites (40-70 mm Hg pressure) 1, the 2024 guidelines now classify this as potentially harmful, particularly for the cytotoxic venoms (Russell's viper, saw-scaled viper) that predominate in India 1, 4
Hospital-Based Definitive Management
Antivenom Administration
Anti-snake venom (ASV) is the only definitive treatment and must be administered as soon as clinical evidence of envenomation is present. 2, 6, 7, 8
Dosing Based on Indian Snake Species
Saw-scaled viper (Echis carinatus) and Russell's viper: 20-250 ml ASV required for hematotoxic envenomation 8
Krait and cobra (neurotoxic): 40-320 ml ASV required 8
Dosing should be guided by clinical response and restoration of blood coagulability, not by fixed protocols 6, 8
Essential Supportive Medications
Neostigmine and atropine for neurotoxic envenomation (krait and cobra bites) to reverse paralysis 6, 7
Epinephrine must be immediately available at bedside before ASV administration for potential anaphylactic reactions 2, 5
Hydrocortisone for allergic reactions to ASV 7
Tranexamic acid may be beneficial in severe hematotoxic cases with ongoing bleeding, though this requires further study 9
Critical Monitoring and Laboratory Tests
20-minute whole blood clotting test (WBCT20) is a simple, rapid, reliable bedside test for coagulopathy that should be performed immediately and repeated to assess ASV effectiveness 6, 7
Urea and creatinine levels to monitor for acute kidney injury 7
Viscoelastometry-guided transfusion (if available) for severe coagulopathy with active bleeding 9
Respiratory Support
Early endotracheal intubation and manual ventilation with Ambu bag are crucial for neurotoxic envenomation (krait and cobra), as respiratory paralysis is the primary cause of death 6, 8
Indian-Specific Epidemiology and Clinical Patterns
Common Venomous Species in India
The "Big Four" venomous snakes account for most envenomations:
Saw-scaled viper (Echis carinatus): 64.2% of envenomations in Maharashtra, causes hematotoxicity with rapid progressive local edema and active bleeding 6, 8
Common krait (Bungarus caeruleus): 9.8% of cases, causes neurotoxic paralysis typically with minimal local signs, bites often occur during sleep between midnight and 08:00 6, 7
Indian cobra (Naja naja): 16.6% of cases, causes neurotoxicity with local tissue necrosis 6, 7, 8
Russell's viper (Daboia russelli): 9.4% of cases, causes severe hematotoxicity and potential acute kidney injury 7, 8
High-Risk Populations and Timing
Farmers (36%), students (30%), and housewives (28%) are most commonly affected 8
68.9% of bites occur between May and November during monsoon and post-monsoon agricultural season 8
80% of bites affect lower extremities 7
65% of bites occur in morning hours 7
Mortality and Outcomes
Overall mortality in envenomated patients: 4.7% with appropriate hospital management 8
Children under 15 years have significantly higher risk of unfavorable outcomes (OR 3.79) 3
Upper limb bites carry higher risk than lower limb bites (OR 2.47) 3
Unavailability of antivenom at initial facility dramatically increases mortality (OR 12.2 for unfavorable outcomes if referred due to ASV shortage) 3
Critical Clinical Pitfalls to Avoid
Delaying hospital transport to attempt any field interventions—transport time is the most modifiable mortality risk factor 3
Failing to identify neurotoxic envenomation early—krait bites often present with no local signs, and paralysis develops insidiously; any snakebite occurring during sleep hours (midnight-08:00) should be presumed krait until proven otherwise 6
Inadequate ASV dosing—Indian snakes may require substantially more ASV than North American protocols suggest; dosing should continue until coagulopathy reverses on WBCT20 6, 8
Discharging patients with "dry bites" too early—approximately 50% of snakebites show no initial envenomation, but patients require minimum 24-hour observation as delayed manifestations can occur 6
Not having ventilatory support readily available—respiratory failure from neurotoxic venom is rapidly fatal without immediate manual or mechanical ventilation 6, 8