What to do if we suspect snake bite

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snakebite first aid management guidelines 2024 WHO

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This clinical photograph illustrates a community-based demonstration of traditional healing practices for snakebite management. The central focus is a person's lower leg and foot, which feature black ink demarcations consisting of geometric outlines and a circular zone, likely indicating surgical or extraction boundaries. Parallel skin incisions are visible within these marked areas. An improvised suction device is depicted, consisting of a 20cc plastic syringe barrel (with the distal end removed) applied directly to the skin, connected via transparent tubing to a second syringe held by a practitioner to create negative pressure. On the ground adjacent to the limb is a large, weathered blade used for making the incisions. The scene highlights traditional first aid interventions, specifically the 'cut and suck' method, which is medically discouraged in modern toxicology due to the risks of secondary infection, tissue damage, and lack of efficacy in removing systemic venom. This image serves as educational material for global health and toxicology to illustrate cultural health practices and the challenges of pre-hospital snakebite care.

This clinical photograph displays a human lower limb resting on a pillow, illustrating complications related to snakebite management. The anatomical focus is the lower leg and foot, which exhibits significant edema (swelling) and skin tension. A small, dark, circular puncture or lesion is visible on the anterior aspect of the lower leg, suggestive of a bite site. The skin shows areas of mottled pigmentation and localized dryness, particularly around the heel and ankle. Adjacent to the limb is a discarded makeshift tourniquet made of yellow plastic rope, which was reportedly used as a tight ligature. This image serves as a clinical example of traditional first aid practices for snakebites, highlighting the physiological changes in the affected limb, such as swelling and potential tissue ischemia, as well as the use of non-medical interventions like mechanical constriction and localized topical applications.

This clinical photograph displays the right foot and ankle of a patient in a medical setting, following a reported snakebite. The foot exhibits moderate diffuse swelling (edema). The skin is coated in a thick, shiny, and viscous amber-colored substance, identified as honey, which was applied as a traditional first-aid remedy prior to hospital arrival. A high specular light reflection is visible across the dorsal and lateral surfaces of the foot due to the topical application. There is a dark, circular lesion or puncture mark on the lateral aspect of the distal lower leg, near the ankle joint, potentially representing the bite site. The ankle is partially covered by a light blue medical cloth. This image illustrates traditional pre-hospital practices and local wound management for snakebite envenomation in a clinical context, highlighting the intersection of traditional medicine and emergency medical care.

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Suspected Snakebite: What to Do

1. Recognize the Situation

Not all snakebites inject venom - up to 25% of pit viper bites and up to 50% of some species' bites are "dry bites" (no envenomation). However, you must treat every suspected snakebite as potentially serious until proven otherwise in a clinical setting.

Signs that envenomation has occurred:

Local: pain, swelling, bruising, blistering, fang marks at the bite site
Systemic: nausea/vomiting, dizziness, blurred vision, difficulty swallowing, drooling, drooping eyelids (ptosis)
Neurological: numbness/tingling, muscle weakness, difficulty breathing
Hematological: bleeding from gums or wounds, dark/bloody urine

2. Immediate First Aid - What TO DO

At the Scene

Stay calm and keep the victim still - Movement accelerates venom absorption. Immobilize the entire patient and especially the bitten limb.
Call emergency services immediately (or arrange fastest transport to a hospital). Do not wait for symptoms to develop.
Immobilize the bitten limb at or below heart level - keep it still and lower than the heart to slow systemic spread.
Remove constrictive items - Remove jewelry (rings, bracelets, watches), tight clothing, and footwear from the affected limb before swelling makes this impossible.
Note the time of the bite - This helps doctors calculate envenomation progression.
Try to safely identify the snake - Do NOT try to catch or handle it. A photograph taken at a safe distance is useful. Remember: even a recently killed snake can still bite reflexively.
Keep the victim warm and positioned comfortably (lying down is ideal).
If venom is sprayed into the eyes (spitting cobras), irrigate immediately with large volumes of water.

In Australia Specifically (Elapid snakes - neurotoxic)

Apply Pressure Immobilization Bandaging (PIB): wrap a broad (15 cm) elastic bandage over the bite site and then from distal to proximal, covering the whole limb - as tight as a sprained ankle bandage. Then immobilize the entire limb with a splint. This is recommended specifically for neurotoxic snakes and should stay on until antivenom is available at hospital.

3. What NOT to Do - Dangerous Myths

These actions cause more harm than good and must be avoided:

Action	Why It's Harmful
Cutting or incising the bite	Causes tissue damage, introduces infection, does not remove venom
Sucking out venom	Does not remove significant venom; contaminates wound with oral bacteria
Applying a tourniquet	Causes ischemia, nerve injury, and gangrene within 20 minutes to 2 hours
Applying ice or cold packs	Can worsen tissue damage from cytotoxic venom
Applying electric shock	No evidence of benefit, can cause injury
Drinking alcohol	Vasodilates and accelerates absorption
Traditional remedies / "black stones"	No proven benefit; waste critical time
Letting the victim walk	Increases venom spread

4. Hospital Management

Once at the emergency department, the clinical team will:

Rapid Assessment

Full vital signs, airway/breathing/circulation (ABC) assessment
IV access and blood draws (CBC, coagulation panel, renal/liver function, urinalysis)
Mark the edge of swelling with a pen and measure limb circumference every 30 minutes to track progression

Species Identification + Envenomation Grading

Envenomation is graded mild, moderate, or severe based on local and systemic findings:

Mild: local swelling only, no systemic signs
Moderate: swelling extending beyond bite area, mild systemic signs
Severe: rapidly advancing swelling, coagulopathy, neurotoxicity, hemodynamic instability

Antivenom - The Only Definitive Treatment

Antivenom is the only specific treatment that can prevent or reverse envenomation effects. Per WHO guidelines, it should be given as early as possible.

Key antivenom principles:

Children require the same dose as adults (dose is based on venom load, not body weight)
Must be given in a setting with resuscitation equipment available (epinephrine must be immediately available for anaphylaxis)
If an acute allergic reaction occurs, stop infusion, give antihistamines (H1 + H2 blockers)
Repeat dosing may be required if symptoms progress
Rosen's Emergency Medicine notes: CroFab and Anavip F(ab')2 are the antivenoms of choice for North American pit viper (crotalid) bites

Supportive Care

IV fluids + vasopressors for hypotension/shock
Blood products if active bleeding (after antivenom)
Compartment syndrome management: if compartment pressure >30 mmHg, elevate limb, give mannitol (1-2 g/kg IV), additional antivenom; fasciotomy only as a last resort
Wound care: debridement of necrotic tissue as needed
Tetanus prophylaxis
Dialysis support if acute kidney injury develops (kidneys can fail in viper envenomation)

5. When to Suspect Envenomation vs. Dry Bite

Watch closely for the first 6-12 hours. A bite with:

No pain or swelling beyond the bite site
No systemic symptoms
Normal lab values

...may represent a dry bite. However, observation in hospital is still mandatory for this period, since some elapid neurotoxicity can be delayed.

Summary Pocket Guide

SUSPECT SNAKEBITE?
  ✓ Stay calm, keep victim still
  ✓ Immobilize limb below heart level
  ✓ Remove rings/watches/tight clothing
  ✓ Call ambulance / go to ER IMMEDIATELY
  ✓ Note the time, try to photograph snake safely

  ✗ Do NOT cut/suck wound
  ✗ Do NOT apply tourniquet
  ✗ Do NOT apply ice
  ✗ Do NOT let patient walk
  ✗ Do NOT use traditional remedies

Sources: Tintinalli's Emergency Medicine (Chapter 212), Rosen's Emergency Medicine, WHO Snakebite Treatment Guidelines, First Aid and Pre-Hospital Management - PMC, UN/DHMOSH Snakebite Guidance 2024

Important: This information is for general education. In an actual emergency, call your local emergency number immediately (911 in USA, 102/112 in India, 999 in UK, 000 in Australia, etc.).

In hospital

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In-Hospital Management of Snakebite

Step 1: Rapid Assessment & Stabilization (on arrival)

Primary Survey - ABCs First

Airway: Elapid (cobra/krait/coral snake) bites can cause respiratory paralysis - assess immediately. Intubate early if there is any sign of bulbar weakness, drooling, dysphagia, or worsening respiratory effort.
Breathing: Baseline and serial pulmonary function measurements (inspiratory pressure, vital capacity) in suspected elapid bites - respiratory failure is the main cause of death.
Circulation: Establish IV access (in an unaffected limb), assess for hypotension and tachycardia (signs of hypovolemia from venom-induced plasma/blood extravasation into tissues).

Immediate Actions

Remove any pre-hospital tourniquets or constricting bands only when antivenom is available and IV access is secured - be prepared for rapid systemic envenomation after removal
Immobilize the bitten limb in a neutral position, below heart level
Administer supplemental oxygen
Tetanus prophylaxis - check immunization status and update as needed
Clean and document the wound (distance between fang marks estimates snake size)

Step 2: Investigations / Labs

Order immediately and repeat every 4 hours (or after each antivenom dose):

Test	What to Look For
CBC	Thrombocytopenia (platelet consumption), hemolysis, hemoconcentration
Coagulation screen (PT/INR, aPTT, fibrinogen)	Prolonged times, hypofibrinogenemia - sign of DIC/coagulopathy
Blood group + crossmatch	In case transfusion needed
Renal function (BUN, creatinine, electrolytes)	AKI from viper envenomation, myoglobinuria
LFTs	Hepatotoxicity with some species
Urinalysis	Hemoglobinuria, myoglobinuria (dark urine = poor sign)
CK	Rhabdomyolysis (sea snakes, some kraits, Australian elapids)
Blood glucose	Hypoglycemia possible
ECG	Arrhythmias rare but documented

Serial monitoring: Measure limb circumference at multiple sites and outline the leading edge of edema with a pen every 30 minutes to track progression.

Step 3: Grading Envenomation Severity

Grade	Features
Dry bite	Fang marks only, no swelling, no systemic signs, normal labs after 8-12 hours
Mild	Local swelling and pain confined to bite site, minimal/no systemic signs
Moderate	Swelling progressing beyond bite site, mild systemic signs, mild lab abnormalities
Severe	Rapidly advancing swelling/ecchymosis, significant coagulopathy, systemic effects (hypotension, altered sensorium, respiratory compromise)

Progression = worsening of ANY of three parameters: (1) local injury, (2) systemic effects, or (3) hematologic abnormalities. This is the trigger for antivenom.

Step 4: Antivenom - The Cornerstone of Treatment

Per Tintinalli's Emergency Medicine (Chapter 212): "Antivenom is the mainstay of therapy for venomous snakebites."

Principles

Antivenoms consist of heterologous antibodies (from immunized sheep or horses) that bind and neutralize venom molecules
Children require the same dose as adults - dosing is based on venom load, not body weight
Must be given in a critical care setting (ED or ICU) with resuscitation equipment and epinephrine immediately available
Give IV, never IM

When to Give Antivenom

Give to any patient showing progression of local injury, systemic signs, or worsening labs. Do not wait for severe envenomation - earlier administration means better outcomes.

North American Pit Viper (Crotalid) Antivenoms

Product	Details
CroFab (Crotalidae Polyvalent Immune Fab, Ovine)	Fab fragments from sheep; shorter half-life; first line
Anavip (Crotalidae Immune F(ab')2, Equine)	F(ab')2 fragments; longer half-life; lower incidence of recurrent coagulopathy; caution in horse allergy

Strategy: Administer IV to establish "initial control" = cessation of progression of all three parameters (local, systemic, hematologic). Then reassess and give additional doses as needed if the patient deteriorates.

Elapid Antivenoms (Coral snakes, Cobras, Kraits, Mambas)

Admit all confirmed/suspected elapid bites - neurological effects can be delayed 12+ hours and are not easily reversed
Coral snake (US): 3-5 vials of Anti-venin (M. fulvius) IV; reserve additional doses if symptoms appear; monitor for respiratory failure
Exotic elapids (cobras, kraits, mambas): Contact regional poison control center for specific antivenom location and dosing

Managing Antivenom Reactions

Acute allergic reaction: Stop infusion immediately, give antihistamines (H1 + H2 blockers). Have epinephrine drawn and ready.
Anaphylaxis: Epinephrine immediately
Serum sickness (delayed, 1-3 weeks): Fever, rash, arthralgias - treat with prednisone 1 mg/kg/day PO tapered over 1-2 weeks

Step 5: Managing Specific Complications

Coagulopathy / DIC

Best treated with antivenom (which neutralizes the procoagulant venom enzymes)
Blood component replacement (FFP, platelets, cryoprecipitate) only if active bleeding and AFTER antivenom has been given
Do not transfuse first - venom will continue consuming clotting factors until neutralized

Hypotension / Shock

IV isotonic fluid resuscitation (crotalid venom causes plasma extravasation into tissues)
Vasopressors if fluid-refractory

Compartment Syndrome

Presents as severe, compartment-localized pain resistant to opioid analgesia:

Measure intracompartmental pressure
If pressure >30 mmHg: elevate limb + mannitol 1-2 g/kg IV over 30 min + additional antivenom concurrently
Reassess after 60 minutes
Fasciotomy only as a last resort if pressure remains elevated - antivenom is more effective than fasciotomy for venom-induced compartment syndrome, and fasciotomy may actually worsen local tissue loss

Neurotoxicity (Elapid bites)

Watch for: ptosis, drooling, dysarthria, diplopia, dysphagia, respiratory muscle weakness
Onset can be delayed 12+ hours (some species)
Serial vital capacity and inspiratory pressure measurements
Early intubation and ventilatory support may be required for prolonged periods
For coral snake: cholinergic agonists at first sign of symptoms; calcium infusion may reduce seizure onset

Acute Kidney Injury

IV fluids to maintain urine output
Supportive dialysis if needed (same approach as AKI from any other cause)
Early antivenom administration reduces AKI severity

Rhabdomyolysis

Especially with sea snakes, some kraits, some Australian elapids
Aggressive IV hydration, urine alkalinization, monitor CK

Wound Care

Clean wound, debride necrotic tissue as it demarcates
Prophylactic antibiotics: not routinely recommended - infection after snakebite is surprisingly uncommon and most apparent "infections" (erythema, edema, necrosis) are sterile from venom effects
Treat culture-proven infection with appropriate antibiotics (potential organisms: Pseudomonas, Enterobacteriaceae, Staphylococcus, Clostridia)
Steroids: not effective for envenomation; use only for allergic reactions or serum sickness

Step 6: Disposition

Situation	Disposition
Dry bite (8-12 hrs observation, no signs)	Discharge with return precautions
Mild-moderate, antivenom completed	General ward
Severe, life-threatening, receiving antivenom	ICU
All confirmed elapid bites	Admit (ICU preferred) - delayed neurological effects

Discharge criteria: Swelling beginning to resolve, coagulopathy reversed, patient ambulatory.

At discharge: Arrange outpatient follow-up to monitor for infection and serum sickness. Advise patient to return for bruising, swelling recurrence, or serum sickness symptoms (fever, rash, joint pain, appearing 1-3 weeks post-antivenom). Physical therapy for affected hand/limb once swelling resolves.

Quick Reference: In-Hospital Flowchart

ARRIVAL
  → ABCs (airway priority for elapid bites)
  → IV access (unaffected limb)
  → Remove prehospital tourniquets (with antivenom ready)
  → Labs: CBC, coag, renal, LFTs, UA, CK, type & screen
  → ECG
  → Mark edema border, measure limb circumference
  ↓
GRADE ENVENOMATION
  → Dry bite? → Observe 8-12 hrs → discharge if stable
  → Signs of progression? → ANTIVENOM
  ↓
ANTIVENOM (IV, in ICU/ED, epinephrine drawn)
  → Establish "initial control" (stop progression)
  → Reassess q30 min, repeat labs q4h
  → Re-dose if progression continues
  ↓
MANAGE COMPLICATIONS
  → Coagulopathy → more antivenom → blood products if active bleed
  → Compartment syndrome → mannitol + antivenom → fasciotomy last resort
  → Respiratory failure → intubate early in elapid bites
  → Hypotension → fluids → vasopressors
  → AKI → fluids → dialysis if needed
  ↓
DISPOSITION
  → ICU (severe) / ward (moderate) / discharge (dry bite)

Sources: Tintinalli's Emergency Medicine, Chapter 212 (Snakebite) | Rosen's Emergency Medicine, Chapter 53 | Mulholland & Greenfield's Surgery, Chapter 33 | WHO Snakebite Treatment Guidelines

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