Case Study: Snake Poisoning (Sarpavisha / Sarpa Damsha)

Prepared for BAMS Students - Agadatantra & Forensic Medicine

CASE PRESENTATION

• Pulse: 110/min (tachycardic), BP: 90/60 mmHg (hypotensive), RR: 18/min
• Two fang marks ~1 cm apart on right ankle
• Massive edema, erythema, ecchymosis extending to the knee
• Tender inguinal lymphadenopathy
• Gum bleeding noted
• Consciousness: alert but anxious

STEP 1 - IDENTIFICATION OF THE SNAKE

India's "Big Four" Venomous Snakes

STEP 2 - CLASSIFICATION OF SNAKE VENOM (Modern & Ayurvedic)

Modern Classification

• Causes local tissue destruction, necrosis
• Disrupts coagulation cascade (DIC-like picture)
• Thrombocytopenia, hypofibrinogenemia
• Renal failure (acute tubular necrosis)

• Pre-synaptic toxins (beta-bungarotoxin) - irreversible blockade of ACh release
• Post-synaptic toxins (alpha-neurotoxin) - competitive block of nicotinic receptors
• Ptosis, ophthalmoplegia, descending paralysis, respiratory failure
• Minimal local effects especially with Krait

• Local necrosis, blister formation, ulceration

Ayurvedic Classification (Sarpavisha Chikitsa)

• Vegawise grading: 1st - 7th Vega (stages of envenomation), each progressively worse
• Dosha involvement: Pitta (burning, bleeding) dominant in Mandali (viper), Vata (neurological) in Darvikara
• Time of bite: Bites at dusk, rainy season, or in agricultural settings are considered more severe

STEP 3 - CLINICAL FEATURES (Case Analysis)

Local Effects (present in this case - Russell's Viper)

• Immediate pain and swelling at bite site
• Fang marks with local ecchymosis
• Progressive edema (can spread to entire limb)
• Blister/bullae formation
• Tissue necrosis in severe cases

Systemic Effects - Hemotoxic

• Coagulopathy: Spontaneous bleeding (gums, wound, IV sites), positive 20-minute whole-blood clotting test (20WBCT)
• Thrombocytopenia: platelet count <100,000/μL
• Hypofibrinogenemia: <100 mg/dL
• DIC: Fibrin degradation, prolonged PT/aPTT
• Shock: Hypotension (as seen in this patient)

Systemic Effects - Neurotoxic (not dominant here but important for BAMS exams)

• Ptosis (first sign)
• Diplopia, dysarthria, dysphagia
• Descending paralysis
• Respiratory failure - main cause of death in elapid bites

Stages in Ayurveda (Damshopadravam/Vegawise progression)

• 1st Vega: Local pain, swelling, itching
• 2nd-3rd Vega: Nausea, vomiting, drowsiness
• 4th-5th Vega: Bleeding, hematuria, shock
• 6th-7th Vega: Unconsciousness, organ failure, death

STEP 4 - INVESTIGATIONS (Laboratory Workup)

Bedside Tests

• 20-minute Whole Blood Clotting Test (20WBCT): Place 2 mL fresh venous blood in a clean, dry glass tube; leave undisturbed for 20 minutes. If blood does not clot = coagulopathy = viper envenomation. This is the single most useful bedside test in resource-limited settings.

Laboratory Tests

STEP 5 - FIRST AID (Dos and Don'ts)

DO:

• Reassure and calm the patient (reduce heart rate, slow venom spread)
• Immobilize the bitten limb at or below heart level
• Remove jewelry, tight clothing from the affected limb
• Transport rapidly to nearest health facility with antivenom
• Mark the leading edge of swelling with a pen + time notation
• Establish IV access in an unaffected limb

DO NOT (Avoidable Treatments - Sabiston Textbook):

• ❌ Do NOT incise the wound (was abandoned since 1980 - increases morbidity, negligible venom removal)
• ❌ Do NOT apply ice / tourniquet proximal to bite (concentrates venom, causes necrosis)
• ❌ Do NOT suck out venom orally
• ❌ Do NOT apply electric shock (proven ineffective in animal studies)
• ❌ Do NOT give aspirin or NSAIDs (worsen bleeding)
• ❌ Do NOT try to catch or handle the snake (reflexive bite from "dead" snake still occurs)

STEP 6 - HOSPITAL MANAGEMENT

A. Anti-Snake Venom (ASV) - Cornerstone of Treatment

• Any evidence of systemic envenomation (coagulopathy, neurotoxicity, shock)
• Worsening local envenomation (progressive swelling, ecchymosis)
• Abnormal 20WBCT

• Initial dose: 8-10 vials diluted in 100-200 mL normal saline over 1 hour
• Repeat dose if no improvement in 6 hours or if 20WBCT remains positive

B. Supportive Treatment

• IV fluids (NS/RL) for shock/hypotension - aggressive fluid resuscitation
• Fresh Frozen Plasma (FFP) or cryoprecipitate for coagulopathy/DIC
• Blood transfusion if severe anemia/hemorrhage
• Dialysis for acute kidney injury (AKI)
• Tetanus prophylaxis
• Antibiotics if wound infection signs present
• Do NOT give steroids routinely (not effective for envenomation; reserve for allergic reaction to ASV or serum sickness)

C. Serum Sickness (Delayed Reaction to ASV)

• Occurs 7-21 days after ASV
• Features: fever, urticarial rash, arthralgias, lymphadenopathy
• Treatment: Prednisone 1 mg/kg/day orally, taper over 1-2 weeks. - Tintinalli's Emergency Medicine

STEP 7 - AYURVEDIC PERSPECTIVE (Sarpavisha Chikitsa) - IMPORTANT FOR BAMS

Classical References

• Charaka Samhita (Chikitsa Sthana, Ch. 23): Sarpa damsha chikitsa
• Ashtanga Hridayam (Uttara Sthana, Ch. 35-37): Detailed visha chikitsa
• Sushruta Samhita (Kalpasthana): Agadatantra - the science of toxicology

Chatushpada (Four Pillars of Treatment) in Agadatantra

1. Aushadha (Medicine/Antidote)
2. Vaidya (Skilled physician)
3. Parichara (Nursing care)
4. Rogi (Cooperative patient)

Caturvimshati Vishachikitsa Upakrama (24 Measures)

1. Mantrana (counseling/reassurance)
2. Nishpeedana (expression/squeezing venom)
3. Chushana (suction - classical; NOT recommended in modern practice)
4. Agnikarma (cauterization at bite site)
5. Parisheka (irrigation with medicated decoctions)
6. Lepana (local application of paste - e.g., Shirisha, Haridra)
7. Vamana (therapeutic emesis - to expel venom)
8. Virechana (purgation)
9. Nasya (nasal administration of medicines)
10. Anjana (eye application)

Key Ayurvedic Medicines for Sarpavisha

Important Principle for BAMS Practitioners

Integrative management - timely ASV + supportive modern care for the acute phase + Ayurvedic wound care and rasayana for chronic post-envenomation complications - offers optimal outcomes.

STEP 8 - DIFFERENTIAL DIAGNOSIS OF "SNAKE BITE"

• Many apparent snakebites are "dry bites" (no venom injected - ~20-30% of bites by venomous snakes)
• "Dry bite" signs: pain and two fang marks, but NO progressive swelling, NO systemic signs, normal 20WBCT at 20 minutes
• Non-poisonous snake bite: Multiple small teeth marks in a row (no fang marks), no systemic effects
• Fear response mimics: tachycardia, nausea - can be confused with early envenomation

STEP 9 - PROGNOSIS AND DISPOSITION

• Dry bites: Observe for 6-8 hours; discharge if no progression
• Mild-moderate envenomation: General ward, repeat 20WBCT every 6 hours
• Severe envenomation (this case): ICU admission
• Discharge criteria: Swelling resolving, coagulopathy reversed, patient ambulatory
• Mortality with timely ASV: <1% (estimated <0.1% in well-equipped facilities) - Fitzpatrick's Dermatology

STEP 10 - EXAM QUICK RECAP (BAMS Agadatantra)

REFERENCES

• Tintinalli's Emergency Medicine: A Comprehensive Study Guide - Chapters 212-213 (Snake Envenomation)
• Sabiston Textbook of Surgery - Chapter 44 (Bites and Stings)
• Fitzpatrick's Dermatology - Chapter 182 (Snakebites)
• Goldman-Cecil Medicine - Viperidae/Elapidae envenomation
• Ayurvedic management of post-snakebite ulcers (J Ayurveda Integr Med, 2025 - PMC12547734)
• Charaka Samhita, Chikitsa Sthana Ch. 23; Ashtanga Hridayam, Uttara Sthana Ch. 35-37

Snake Poisoning - Brief Case Study (BAMS)

Case

Classification of Venom

Key Bedside Test

First Aid (Dos & Don'ts)

Treatment

1. ASV (Anti-Snake Venom) - 8-10 vials IV, polyvalent - cornerstone of treatment
2. IV fluids for shock
3. FFP/blood for coagulopathy
4. Dialysis if AKI
5. Tetanus prophylaxis
6. No steroids routinely (only for serum sickness)

Ayurvedic Approach (Agadatantra)

• Best plant: Shirisha (Albizia lebbeck)
• Key medicines: Sarpavishantaka Vati, Gandhaka Rasayana, Mahamanjishtadi Kashaya
• Treatments: Lepana, Parisheka, Vamana, Nasya
• Role today: Adjunct for chronic post-bite wound healing; ASV remains primary for acute phase

Exam Points

• First sign of neurotoxicity = Ptosis
• Most deaths in India = Russell's Viper
• Most neurotoxic = Common Krait
• Serum sickness (7-21 days post-ASV) = treat with Prednisone
• Dry bite (no venom) = ~25% of venomous snakebites