What is the recommended treatment for a patient in India with a snakebite, considering Indian guidelines and potential complications such as renal failure or respiratory distress?

Snakebite Management in India: Evidence-Based Treatment Protocol

Immediate First Aid and Transport

For snakebite victims in India, immediately activate emergency medical services, remove all constricting objects from the bitten limb before swelling develops, immobilize the extremity at or below heart level, minimize all physical exertion during transport, and do NOT apply pressure immobilization bandaging for Indian viper bites (Russell's viper, Saw-scaled viper) as this worsens cytotoxic tissue damage. 1, 2, 3

Critical First Actions

• Remove rings, watches, and jewelry from the affected limb immediately to prevent ischemic injury as progressive edema develops 1, 3
• Immobilize the bitten extremity with a splint and keep it at or below heart level to minimize lymphatic venom absorption 1, 3
• Minimize walking and all physical activity by the victim, as exertion accelerates systemic venom distribution 1, 3
• Irrigate the wound with copious amounts of water or saline for cleaning, though this does not remove venom 4, 2

Venom-Specific Pressure Immobilization Decision

• For Indian cobra and Common krait bites (neurotoxic): Apply pressure immobilization at 40-70 mm Hg (upper extremity) or 55-70 mm Hg (lower extremity) with simultaneous splinting, as these neurotoxic venoms cause minimal local injury but life-threatening paralysis 1, 2
• For Russell's viper and Saw-scaled viper bites (hemotoxic/cytotoxic): Do NOT use pressure immobilization, as trapping cytotoxic venom at the bite site worsens local tissue necrosis 1, 2, 3
• The bandage should be snug enough that only one finger can slip underneath, applied around the entire length of the bitten limb 1

Absolutely Contraindicated Interventions

• Do NOT apply ice or cold therapy—this causes additional tissue injury 1, 3
• Do NOT use suction devices—they remove negligible venom (only 0.04%) and may aggravate injury 4, 1, 3
• Do NOT apply tourniquets—they worsen local tissue injury without preventing systemic envenomation 1, 3
• Do NOT use electric shock therapy—it is completely ineffective and potentially harmful 1, 3

Hospital Management and Antivenom Administration

Indian polyvalent antivenom (PAV) is the cornerstone of treatment and must be administered as early as possible, ideally within 2 hours of the bite, as delayed administration beyond 2 hours independently predicts acute renal failure (OR 2.10) and poor outcomes. 5, 6

Antivenom Protocol

• Indian polyvalent antivenom neutralizes venom from the "Big Four" snakes: Indian cobra (Naja naja), Common krait (Bungarus caeruleus), Russell's viper (Daboia russelli), and Saw-scaled viper (Echis carinatus) 7
• Administer antivenom based on clinical evidence of envenomation, not merely the presence of fang marks 5
• The 20-minute whole blood clotting test (WBCT20) is a simple, rapid, and reliable bedside test for coagulopathy that guides antivenom dosing and assesses treatment effectiveness 5
• Routinely monitor urea and creatinine levels to detect acute renal failure early 8

Clinical Recognition of Envenomation Type

• Neurotoxic envenomation (cobra, krait): Minimal to no local signs at bite site, progressive paralysis developing within minutes to hours (potentially delayed up to 13 hours), ptosis, respiratory failure 1, 2, 5
• Hemotoxic/cytotoxic envenomation (vipers): Rapid progressive local edema, active bleeding, coagulopathy, thrombocytopenia, local tissue necrosis 1, 5, 6
• Krait bites typically occur between midnight and 08:00 hours with no local signs but rapid paralysis 5

Supportive Medications and Monitoring

• Neostigmine and atropine for anticholinesterase treatment in elapid (krait and cobra) envenomation 8, 5
• Adrenaline, hydrocortisone for anaphylaxis management 8
• Amoxicillin for infection prophylaxis 8
• Early endotracheal intubation and manual ventilation with Ambu bag for respiratory paralysis 5
• Viscoelastometry-guided transfusion (cryoprecipitate) and tranexamic acid for severe coagulopathy in hematotoxic bites 9

Complications and Risk Factors

Acute Renal Failure Prevention and Management

• Acute renal failure develops in 13.5% of poisonous snakebite victims in India, with 22.6% mortality among ARF patients 6
• Independent risk factors for ARF: Cellulitis (OR 9.20), regional lymphadenopathy (OR 22.0), intravascular hemolysis (OR 3.70), bite-to-needle time >2 hours (OR 2.10) 6
• Independent predictors of mortality: Bite-to-needle time >2 hours (OR 2.10), intravascular hemolysis (OR 13.0), hypotension (OR 22.2), bleeding manifestations (OR 7.91) 6
• 45.3% of ARF patients require dialysis 6

Hospitalization Duration

• For neurotoxic envenomation: Hospitalize for minimum 48 hours with continuous monitoring, as neurotoxicity onset can be delayed up to 13 hours despite minimal initial findings 1, 2
• For hemotoxic envenomation: Monitor for progressive local tissue injury, coagulopathy, and renal function deterioration 5, 6

Critical Clinical Pitfalls to Avoid

• Never assume no envenomation based on absence of immediate pain or swelling—neurotoxic bites (especially krait) cause life-threatening systemic toxicity despite minimal local findings 1, 2, 5
• Do not delay transport to attempt ineffective field interventions—time to antivenom is the single most important prognostic factor 1, 6
• Do not apply pressure immobilization techniques to viper bites—this worsens cytotoxic tissue damage and is only appropriate for neurotoxic snakes 1, 2, 3
• Failing to remove constricting items leads to ischemic injury as swelling progresses rapidly in viper bites 1, 3
• Do not rely solely on snake identification—treat based on clinical syndrome (neurotoxic vs. hemotoxic) as only 31.9% of victims bring the snake to hospital 5