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ICMR / NHM Guidelines on Snakebite Management in India

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1. Epidemiological Context

• Indian Cobra (Naja naja) - neurotoxic + cytotoxic
• Common Krait (Bungarus caeruleus) - neurotoxic (presynaptic)
• Russell's Viper (Daboia russelii) - hemotoxic + nephrotoxic
• Saw-scaled Viper (Echis carinatus) - hemotoxic + coagulopathic

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2. Stages of Management

1. First aid at scene
2. Transport to hospital
3. Rapid clinical assessment and resuscitation
4. Investigations / laboratory tests
5. Species diagnosis (clinical or by snake identification)
6. Antivenom (ASV) treatment
7. Observing response to ASV
8. Deciding on further ASV doses
9. Supportive/ancillary treatment
10. Treatment of the bitten part
11. Rehabilitation and follow-up

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3. First Aid - What to DO

• Reassure the victim - death is not imminent, medical care is available
• Control anxiety - anxiety increases heart rate and accelerates venom absorption
• Position: Lay the victim flat, bitten limb below heart level to slow lymphatic spread
• Remove rings, watches, shoes, and tight clothing from the bitten area (to prevent tourniquet effect when swelling develops)
• Immobilize the bitten limb using a splint and light bandage (similar to fracture immobilization)
• Pressure Pad: There is some preliminary evidence for a "pressure pad" at bite site - but this needs further field evaluation in India and is not yet firmly recommended
• Transport immediately to the nearest secondary or tertiary care hospital with antivenom availability
• The victim must not run or drive himself - use vehicle/ambulance (102/108), boat, bicycle, motorbike, or stretcher

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4. First Aid - What NOT to Do

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5. Clinical Assessment on Arrival

Systemic Envenomation Signs

• Ptosis (drooping eyelids) - earliest sign
• Blurred vision, diplopia
• Difficulty swallowing, drooling
• Slurred speech
• Weakness of limbs
• Respiratory paralysis (life-threatening)

• Spontaneous bleeding (gums, sites of venepuncture, haematuria)
• Swelling and bruising
• Blood in urine
• Acute Kidney Injury (Russell's Viper in particular)

• Pain and swelling within minutes
• Blistering, necrosis
• Lymphadenopathy

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6. Investigations

20-Minute Whole Blood Clotting Test (20WBCT) - Key Bedside Test

• Place a few mL of fresh venous blood in a clean, dry glass test tube (NOT plastic)
• Leave undisturbed at ambient temperature for 20 minutes
• Gently tilt the tube - if blood is still liquid (no clot), it is incoagulable - indicates viper envenomation
• Perform every 30 minutes from admission for the first 3 hours, then hourly
• If neurotoxic snake bite is confirmed, repeat at 6 hours

Other Investigations

• CBC, coagulation profile (PT/INR, aPTT), fibrinogen
• Renal function tests (urea, creatinine) - especially Russell's Viper
• Urine examination (for haematuria, haemoglobinuria)
• Arterial blood gas (for respiratory failure in neurotoxic envenomation)
• Note: Arterial puncture is contraindicated in patients with haemostatic abnormalities

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7. Anti-Snake Venom (ASV) - Core Treatment

Indications for ASV

• Signs of systemic envenomation (neurotoxic OR hemotoxic)
• 20WBCT showing incoagulable blood
• Spontaneous bleeding
• Ptosis, respiratory failure, or neurotoxic signs
• Local envenomation with rapidly spreading swelling

ASV Test Dose

• NOT recommended - test doses have not been shown to have predictive value in preventing anaphylaxis or serum sickness
• Adrenaline must always be drawn up and ready (0.5 mg IM in two syringes) before starting ASV

ASV Dosage (Indian Guidelines)

• Each vial = 10 mL of reconstituted polyvalent ASV
• Children receive the same dose as adults (the venom dose does not vary by body weight)
• ASV is given intravenously (IV infusion preferred over IV push)

Repeat Doses of ASV

• After the initial dose, no additional ASV until the next 20WBCT at 6 hours (the liver cannot replace clotting factors in less than 6 hours)
• If 20WBCT still incoagulable at 6 hours: give 5-10 vials (half to full dose)
• Continue 6-hourly until coagulation is restored or species identified as one against which polyvalent ASV is ineffective

• Reassess at 1-2 hours after initial dose
• If symptoms worsened or not improved: give a second dose of 10 vials, then discontinue
• Once patient develops respiratory failure AND has received 20 vials total: discontinue ASV (assume all circulating venom is neutralized) and initiate assisted ventilation
• Exception: King Cobra and Australian elapids may require 50+ vials due to large venom loads

Late Presentations (Patients Arriving Days After Bite)

• Key principle: ASV can only neutralize unbound/circulating venom
• Perform 20WBCT - if coagulopathy is still present, give ASV
• For neurotoxic envenomation with ongoing ptosis/respiratory failure: give 1 dose of 8-10 vials (to clear any residual unbound venom), then provide respiratory support

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8. ASV Reactions and Their Management

Early Reactions (Anaphylaxis/Anaphylactoid)

• Temporarily suspend ASV infusion
• Give Adrenaline 0.25-0.3 mg subcutaneously (IM preferred)
• Once reaction controlled, recommence ASV at a slower rate
• Pre-treatment with subcutaneous adrenaline 0.25 mg may reduce risk in high-risk patients

Pyrogenic (Febrile) Reactions

Late Serum Sickness

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9. Specific Antidotes and Adjunct Treatments

Neostigmine (for Cobra bites - postsynaptic neurotoxins)

• Neostigmine Test: Administer 0.5-2 mg IV neostigmine
• If neurological improvement occurs (ptosis improves, muscle strength returns), continue neostigmine every 30 minutes over the next 8 hours along with atropine
• Effective only against postsynaptic neurotoxins (Cobra)
• NOT effective against presynaptic neurotoxins (Common Krait, Russell's Viper)

Pain Management

• Paracetamol (acetaminophen): Adults 500 mg to 1 g orally; Children 10-15 mg/kg/dose (max 100 mg/kg/day)
• Do NOT give Aspirin or NSAIDs - risk of bleeding and renal dysfunction

Tetanus Prophylaxis

• Administer tetanus toxoid if the skin is breached

Medications NOT to Use

• Heparin: Ineffective against venom-induced thrombin consumption; may worsen bleeding - never use
• Botropase (haemocoagulase): Not recommended
• Antifibrinolytics (tranexamic acid): Not effective in VICC (venom-induced consumption coagulopathy)
• Steroids: Not routinely recommended
• Antihistamines as prophylaxis for ASV reactions: Evidence is weak

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10. Tourniquet Management

• Do NOT suddenly remove a tight tourniquet - sudden removal can cause a massive surge of venom into systemic circulation
• Loosen tourniquet gradually while monitoring the patient closely
• Ensure IV access and resuscitation equipment is ready before loosening

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11. Management at Different Levels of Healthcare

Primary Health Centre (PHC)

• First aid, supportive care
• 20WBCT
• If ASV available and staff trained: administer first dose of ASV
• If not: stabilize and transfer immediately
• Oxygen, IV fluids for shock
• If respiratory paralysis: oxygen by mask/LMA, Ambu bag, arrange urgent transfer with Medical Officer escort

Community / Dispensary Level

• Basic first aid
• Identify need for transfer
• Do NOT attempt ASV if skills/equipment not available

Secondary and Tertiary Care

• Full management including ICU care, dialysis (for Russell's Viper-induced AKI), mechanical ventilation, surgical wound management

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12. Special Situations

Pregnancy

• ASV is not contraindicated in pregnancy
• Benefit of treating envenomation outweighs risk
• Monitor fetal well-being

Venom-Induced Consumption Coagulopathy (VICC)

• Caused by procoagulant toxins (mainly Russell's Viper, Saw-scaled Viper) consuming clotting factors
• Response to ASV may require multiple 6-hourly doses
• Fresh Frozen Plasma (FFP) or blood products may be needed for life-threatening bleeding, but only after adequate ASV

Acute Kidney Injury (Russell's Viper)

• Most common complication of Russell's Viper bite in India
• Monitor urine output, creatinine
• Early dialysis if required
• ASV should still be given if coagulopathy is present

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13. Follow-Up and Rehabilitation

• Patients should be followed up for late serum sickness (5-10 days post-ASV)
• Monitor renal function in Russell's Viper bites for weeks to months
• Wound care and physiotherapy for local necrosis/tissue loss
• Psychological support for patients who develop PTSD

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14. Prevention (Community Level)

• Wear boots and protective clothing in fields
• Use torches at night
• Sleep off the ground (kraits are nocturnal ground-level predators)
• Clear undergrowth and debris around homes
• Community health education through media, role-play, FM radio, mobile messaging
• Display snakebite protocol posters in hospital waiting areas
• Avoid handling or trying to catch/kill snakes

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Key Summary Table

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Note: These guidelines are reviewed every 3 years or whenever there is a major therapeutic breakthrough. Always check the latest NHM/ICMR portal for the most current version.

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ASV Administration and Adrenaline Dosing - ICMR / NHM Guidelines

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PART 1: How to Constitute and Give ASV

Types of ASV Available in India

Lyophilised ASV is preferred for remote/rural areas where power supply is unreliable.

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Step-by-Step Constitution of ASV

Lyophilised (Powder) ASV

1. Add sterile water for injection (distilled water) into the vial per manufacturer instructions
2. Gently swirl (do NOT shake) until powder is fully dissolved
3. Reconstitution takes 30-60 minutes - plan ahead
4. Once reconstituted, treat like liquid ASV

Dilution for Infusion

• Dissolve 10 vials of ASV in 100 mL of distilled water first
• Then add this to 400 mL of Normal Saline (0.9% NaCl) = total 500 mL
• In children: Dilute in 5-10 mL/kg body weight of Normal Saline; reduce the volume in the running bottle to 200 mL maximum to avoid fluid overload

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Route of Administration

• IV route ONLY - ASV must never be given IM or SC (except the small prophylactic adrenaline dose described below)
• The physician must be at the bedside during the initial period of infusion to intervene immediately at the first sign of reaction

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Infusion Rate

• Start slowly
• Observe the patient every 5 minutes for the first 30 minutes, then every 15 minutes for the next 2 hours
• Increase the infusion rate gradually in the absence of a reaction
• Target: full starting dose administered over approximately 1 hour
• At the earliest sign of any adverse reaction - suspend immediately

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ASV Dose

Adults

Children

Children receive the EXACT SAME dose as adults. This is because snakes inject the same amount of venom regardless of the victim's body weight. Do NOT reduce the dose.

Pregnancy

• Same dose as adults, no reduction. Refer to gynecologist for fetal monitoring.

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Repeat Doses

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ASV Test Dose

• NOT recommended - test doses do NOT predict anaphylaxis and are not given per Indian guidelines

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PART 2: Prophylactic Adrenaline BEFORE Starting ASV

• Known hypertensive patients
• BP >140/90 mmHg on arrival
• Suspected or known underlying cardiovascular disease

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PART 3: Treatment of EARLY ASV Reaction (Anaphylaxis / Anaphylactoid)

When Does It Happen?

• Within 30-60 minutes of starting ASV
• Signs: urticaria (even a single patch), itching, restlessness, vomiting, hot/cold feeling, sudden dry cough, abdominal pain, dyspnoea, fall in BP, facial swelling, angioedema, tongue protrusion

Step-by-Step Management

Why IM over SC? - IM gives faster peak adrenaline levels (8 minutes to peak vs longer for SC). The deltoid (or vastus lateralis in children) is the recommended injection site. Speed is critical - the faster adrenaline is given, the sooner ASV can be restarted.

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PART 4: Treatment of ANAPHYLACTIC SHOCK

Adrenaline Dose in Shock

The Bhutan National Guideline (adopted from WHO/India protocol) provides a specific infusion chart: See annexure for adrenaline infusion dosing by weight.

Full Resuscitation in Shock

1. Large-bore IV access, rapid IV fluid bolus (Normal Saline 20 mL/kg over 20 min in children; 500-1000 mL in adults)
2. Lay flat, elevate legs
3. Adrenaline IM (first line) or IV infusion (if refractory)
4. Oxygen / airway management
5. Call for ICU/anaesthesia support for intubation if airway is compromised

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PART 5: High-Risk Patients - Special Protocol Before ASV

• Give ASV only if systemic envenomation is confirmed (not for dry bites)
• Pre-medicate with:
  • Inj. Hydrocortisone 200 mg IV AND
  • Inj. Chlorpheniramine maleate 22.75 mg IV

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PART 6: Desensitization (Only for Severe Refractory Anaphylaxis)

• Pre-medicate: Hydrocortisone 100 mg IV + Adrenaline 0.5 mL SC/IM (± Promethazine)
• Change the batch of ASV if available

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PART 7: Late Serum Sickness (5-12 days after ASV)

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Quick Reference Cheat Sheet

ASV INFUSION
- Dilute: 10 vials in 100 mL DW → add to 400 mL NS = 500 mL total
- Children: 5-10 mL/kg NS, max 200 mL in bottle
- Rate: Slowly over ~1 hour, physician at bedside
- Dose: SAME for adults and children (8-10 vials mild; 8 vials severe)

PROPHYLACTIC ADRENALINE (before ASV)
- Adult: 0.25 mg SC of 1:1000
- Child: 0.005 mg/kg SC of 1:1000
- SKIP if: hypertensive, BP >140/90, CVD

ANAPHYLAXIS TREATMENT (adrenaline)
- Adult: 0.5 mg IM (0.5 mL of 1:1000) - deltoid/thigh
- Child: 0.01 mg/kg IM - outer thigh
- Repeat every 5 min if needed
- Refractory shock: IV adrenaline infusion 0.1-1 mcg/kg/min

CHLORPHENIRAMINE (with adrenaline)
- Adult: 10 mg IV
- Child: 0.2 mg/kg IV

RESTART ASV after reaction settled: slowly for 10-15 min, then normal rate