What are the guidelines for managing a snake bite in India?

Snake Bite Management in India

For snake bites in India, immediately activate emergency transport to a hospital facility capable of administering antivenom, rest and immobilize the bitten extremity, remove all constricting jewelry, and avoid all traditional harmful interventions including tourniquets, ice, suction, incision, or pressure bandaging. 1, 2

Immediate First Aid at the Scene

Critical Actions to Take

• Activate emergency services immediately and transport to the nearest hospital with antivenom capability—this is the single most important intervention 1, 3
• Rest and completely immobilize the bitten extremity to minimize venom absorption through the lymphatic system, as walking and movement increase systemic venom spread 1, 2, 3
• Remove all rings, jewelry, watches, and constricting objects from the affected limb before swelling develops to prevent compartment syndrome and ischemic injury 1, 2, 3
• Keep the victim calm and minimize all exertion—even 10 minutes of walking significantly increases venom absorption 1, 2

Absolutely Contraindicated Interventions

• Do NOT apply tourniquets—they are ineffective and worsen local tissue necrosis 1, 2, 3
• Do NOT apply ice or immerse in cold water—this causes additional tissue damage without benefit 1, 2, 3
• Do NOT use suction devices (with or without incision)—they remove only 0.04% of venom while increasing tissue injury 1, 2, 3
• Do NOT apply electric shock therapy—completely ineffective and potentially harmful 1, 2, 3
• Do NOT use pressure immobilization bandaging for Indian snake bites—while the 2015 American Heart Association guidelines suggested this technique (40-70 mm Hg) might be reasonable for certain neurotoxic bites 1, the 2024 guidelines now classify it as potentially harmful, particularly for the cytotoxic venoms predominant in India (Russell's viper, saw-scaled viper) 1, 2

Hospital-Based Definitive Management

Antivenom Administration

• Antivenom (Anti-Snake Venom/ASV) is the only definitive treatment and must be administered in a medical facility as soon as possible 2, 3, 4
• India is one of the world's leading producers of snake venom antiserum, making availability less of an issue than timely access to facilities 5
• Establish intravenous access before antivenom administration and have epinephrine readily available for potential anaphylactic reactions 2, 6

Clinical Assessment and Monitoring

• The 20-minute whole blood clotting test is a simple, rapid, and reliable bedside test for coagulopathy that is crucial for assessing effectiveness of ASV and guiding additional doses 4
• Clinical confirmation of envenomation should be based on identification of the dead snake (if brought by victim) and clinical signs: paralysis (krait and cobra), rapid progressive local edema with active bleeding (Russell's viper and saw-scaled viper) 4
• Monitor for neurotoxic effects (paralysis within minutes to hours) with krait and cobra bites, which may require endotracheal intubation and manual ventilation 6, 4
• Monitor for hematotoxic effects (coagulopathy, bleeding, local tissue necrosis) with viper bites 4, 7, 8

India-Specific Considerations

Common Venomous Snakes in India

• Kraits (neurotoxic): Cause paralysis with minimal local signs, especially bites occurring between midnight and 08:00 4
• Cobras (neurotoxic): Cause paralysis with local edema and blebs 4
• Russell's viper and Saw-scaled viper (Echis carinatus) (hematotoxic): Cause rapid progressive local edema, coagulopathy, and active bleeding 4, 7

Primary Healthcare Center Management

• Primary care physicians should not hesitate to initiate treatment even with basic equipment—the majority of Indian medical facilities are primary healthcare centers, and referral without ASV cover significantly increases mortality 5
• Early administration of ASV, endotracheal intubation when needed, and timely anticholinesterase treatment for krait/cobra envenoming are crucial for saving lives at the primary care level 4
• Referral criteria: Transfer to tertiary care only after initial stabilization and ASV administration when advanced interventions (mechanical ventilation, blood products, surgical management) are required 5, 4

Critical Pitfalls to Avoid

• Delaying hospital transport to attempt ineffective first aid measures—this is the most common cause of preventable mortality 2, 5
• Referring patients to distant hospitals without administering ASV first—patients should receive initial ASV at primary care centers before transfer 5
• Failing to remove constricting items before swelling progresses, leading to compartment syndrome 2, 3
• Allowing excessive patient movement during transport, which increases venom absorption through lymphatic flow 2, 3
• Underestimating krait bites that occur at night with minimal local signs—these can rapidly progress to fatal paralysis without early ASV 4