What is the treatment for a Russell viper snake bite?

Russell Viper Snake Bite Treatment

Immediate Management

Activate emergency services immediately and transport the victim to a medical facility as quickly as possible, as antivenom is the cornerstone of treatment and is only available in healthcare settings 1, 2.

Critical First Aid Measures

• Rest and immobilize the bitten extremity to reduce systemic venom absorption through the lymphatic system 1
• Remove all rings, watches, and constricting objects from the affected limb immediately to prevent ischemic injury as progressive swelling develops 1, 2
• Minimize victim exertion during transport to slow venom dissemination 1

Harmful Practices That Must Be Avoided

• Do NOT apply suction devices (with or without incision) as they are ineffective and may cause tissue injury 3, 1
• Do NOT apply ice to the bite wound as it has no proven benefit and may worsen tissue damage 1
• Do NOT use tourniquets as they worsen local tissue injury 1
• Do NOT apply pressure immobilization bandaging for Russell viper bites, as this technique is contraindicated for cytotoxic venoms and may worsen tissue injury 1
• Do NOT use electric shock as it is ineffective and potentially harmful 1

Hospital-Based Definitive Treatment

Antivenom Administration

The recommended initial dose is 10 vials of polyvalent anti-snake venom administered intravenously after hypersensitivity testing 2. This single-dose approach does not increase adverse reaction risk compared to lower doses 2.

• Early antivenom administration (within 3-6 hours) is critical to prevent severe complications, particularly acute renal failure 4
• Studies show that antivenom given within 5 hours can prevent renal failure entirely, while delayed administration results in significantly worse renal outcomes 5, 4
• Have 12 vials available at the facility, though 10 vials is typically sufficient for initial treatment 2
• Keep epinephrine readily available (0.3-0.5 mg IM in adults, 0.01 mg/kg up to 0.3 mg in children) for potential anaphylactic reactions 2

Clinical Monitoring for Russell Viper-Specific Complications

Russell viper envenomation presents with a distinct clinical profile requiring vigilant monitoring:

Coagulopathy (most common systemic effect):

• Incoagulable blood occurs in approximately 59% of cases 6
• Monitor for depletion of fibrinogen, factors V and X, with grossly elevated fibrin degradation products 6
• Blood coagulability typically restores 1-25 hours (mean 8.8 hours) after antivenom in survivors 6

Neurotoxicity (highly prevalent with Russell viper):

• External ophthalmoplegia occurs in 82% and ptosis in 77% of cases 6
• Unlike coral snakes, Russell viper causes neurotoxicity alongside significant local tissue injury 6
• Ensure airway management and ventilatory support readiness for neurotoxic manifestations 2

Rhabdomyolysis and myoglobinuria:

• Generalized muscle tenderness occurs in 32% of patients 6
• Myoglobin is detectable in plasma of virtually all patients (100-8000+ ng/ml) and urine in most cases 6
• Black urine from myoglobinuria occurs in 27% 6

Acute renal failure:

• Occurs early and is one of the two most important clinical features 4
• Persistent oliguria develops in approximately 9% of cases 5
• Conservative management succeeds in some cases, but peritoneal dialysis may be needed 5

Rare but documented complications:

• Pulmonary thromboembolism: Monitor for elevated heart rate, breathlessness, and reduced oxygen saturation 7
• Use ECG (sinus tachycardia), CT, and echocardiogram for diagnosis 7
• Low-molecular-weight heparin provides clinical benefit when pulmonary embolism is confirmed 7
• Pulmonary edema can develop and may be fatal 5
• Intravascular hemolysis unrelated to G6PD deficiency 6
• Rectus sheath hematoma presenting as acute abdominal pain 8

Supportive Care

• Administer packed red blood cells, fresh frozen plasma, and platelets as needed for severe coagulopathy and bleeding 8
• Anticoagulant therapy with low-molecular-weight heparin if pulmonary thromboembolism develops 7
• Peritoneal dialysis for acute renal failure unresponsive to conservative management 5

Critical Pitfalls to Avoid

• Delaying transport to attempt ineffective first aid measures in the field 1
• Failing to administer antivenom within the first 3-6 hours, which dramatically increases risk of irreversible renal failure 5, 4
• Underestimating the need for prolonged monitoring as complications like pulmonary embolism can develop days after the bite 7
• Missing neurotoxic signs because of focus on local tissue injury—Russell viper causes both 6