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NATIONAL SNAKEBITE MANAGEMENT PROTOCOL 2008 (INDIA)

Surjit Singh
Department of Internal Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh-160012, India
surjit51@hotmail.com, surjit51200@yahoo.co.in

Background
India is recognised as having the highest snakebite mortality in the world, with WHO estimates
placing the numbers at 50,000 per annum. It is predominantly a problem of rural and peri-urban
areas. Most of the fatalities are due to the victim not reaching the hospital in time and are
preventable. The community is not well informed about the occupational risks and simple
measures that can prevent a bite. It continues to adopt harmful practices such as tourniquets,
cutting & suction, herbal remedies, quackery etc. These are not only ineffective but dangerous.
It is recognised that current medical education is reliant on western textbooks for snakebite
management. The teaching training at all levels addresses the problem in a generic way not
suitable to Indian context. Research has shown that primary health care doctors do not treat
snakebite mainly due to lack of confidence. At the secondary and tertiary care level, multiple
protocols are followed mainly from western textbooks which are not appropriate for Indian
settings. Anti snake venom (ASV) are administered when it is not required and/or in doses well
in excess of the required amount.
In response, Government of India, Health & Family Welfare Department has prepared a
National Snakebite Management Protocol to provide doctors and lay people with the best,
evidence based approach to dealing with snakebite in India. This document is a summary of the
salient features.
First Aid Management
The majority of current first aid methods adopted by victims such as tourniquets, cutting and
suction and herbal remedies are completely ineffective and dangerous. It is now recommended
to adopt what has been called the Do it R.I.G.H.T. approach, stressing the need for
Reassurance, Immobilisation as per a fractured limb, Getting to Hospital without delay and
Telling the doctor of any symptoms that develop. Support Posters have been designed detailing
this method and providing pictures of the major venomous species. It is recommended that
these posters are given the widest possible distribution throughout the State in schools,
community centres, hospitals and other public places.
Treatment Protocol
The current medical education in India is reliant on Western textbooks for snake bite
management. This has led to inapplicable protocols being employed in particular the
inappropriate administration of polyvalent anti snake venom (ASV) when it is not required and/or
in doses well in excess of the required amount. The current protocol has been developed in the
Indian context and with reference to Indian species. Research has shown that PHCs do not
treat snakebite mainly due to confidence issues and the ability of Primary Health Centres to deal
with snakebite should be increased. The earlier an envenomed patient is treated with ASV, the
better the outcome.
Diagnosis
The diagnosis phase stresses:
The primacy of the 20 Minute Whole Blood Clotting Test (20WBCT) in the diagnosis and
management of viperine bite
The correct symptoms associated with each species
Pain management has been outlined
ASV Administration Criteria
The grounds for administering ASV have been rationalised to better suit the Indian context. It
should be administered if there is significant envenomation i.e. incoagulable blood shown by the
20WBCT or significant limb swelling for viperine bite, neurological signs for elapidae bite.
ASV Dosage & Repeat Dosage
The recommended initial dose of ASV is 8-10 vials administered over 1 hour.
Liquid or Lyophilised ASV are equally effective and the choice should be determined by the
robustness of the cold chain. (Predominantly in lyophilized anti venom is available)
Mode of administration is IV only
Repeat doses for haemotoxic species is based on the 6 hour rule
Repeat doses for neurotoxic is based on the 1-2 hour rule.
The maximum recommended dose for haemotoxic bites in 30 vials of ASV
The maximum recommended dose for neurotoxic bites is 20 vials of ASV
ASV Reactions
No ASV Test Doses are to be administered. They are not predictive and carry their own risks
Prophylactic regimens of steroids and antihistamines or adrenaline are optional but have no
statistically valid trial evidence to support them.
At the first sign of an adverse reaction the ASV is halted
Adrenaline is given IM.
Steroids and antihistamines perform a secondary support function to adrenaline.
Neurotoxic Bite Support Measures
Despite the fact that the neostigmine test was actually an Indian discovery, it is still poorly used
in India. The neostigmine test should be carried out in all neurotoxic bites
But should be accompanied by objective measures of improvement. It is an all or nothing test. If
there is no positive response to first dose, the neostigmine should be discontinued.

The Management of Snakebite in Primary and Community Care Hospitals
All PHC/CHCs are capable of managing the initial stages of snakebite if confident and equipped
and with explicit referral criteria. Where the new protocol has been trialled this is becoming more
evident.
A basic drug and equipment profile for the PHC/CHC has been proposed. This includes
methods for calculating the ASV requirement. It should be noted that many States already have
ASV in PHC/CHCs but doctor confidence is preventing usage.
Haemotoxic bites with correct signs of envenomation can be treated with 8-10 vials of ASV,
stabilised if any ASV reaction occurs with adrenaline and then transferred to a higher centre
with the ability to carry out the required blood tests to identify occult bleeding or renal
impairment.
Neurotoxic bites with correct signs of envenomation can be treated with 8-10 vials of ASV,
stabilised if any ASV reaction occurs with adrenaline and administered the neostigmine test. If
there is no evidence of impending respiratory failure, determined by patient ability to perform a
neck lift the patient can be treated locally. If the patient is unable to perform a neck lift then they
will be transferred to a higher centre with mechanical ventilatory capability. Transfer steps
including airway support are specified.
Support Posters have been prepared in support of the Protocol for use at the bedside in
PHC/.CHCs, District Hospitals and Tertiary centres.
Conclusion
The new National Snakebite Protocol has shown very positive results where it has been
implemented:
Increased doctor confidence in managing snakebite. Doctors who have not previously treated
snakebite are now intervening and successfully managing this condition.
A reduction in ASV usage as the criteria for administration is now appropriate to the Indian
setting. In West Bengal this has shown a 50% reduction in ASV usage.
A reduction in mortality. This is due to earlier use of ASV by doctors closer to the locality of the
bite and rational dosage and repeat dosage.
A reduction in patient bedtime. The rational application of ASV and repeat doses has resulted in
patients being discharged earlier, freeing up bed space.
In addition to the written protocol there are a number of support materials to aid doctors treating
snakebite. These include tiered treatment protocols for the bedside. These are available for
Primary, District and Tertiary Hospitals and detail each step in the treatment process in simple
form with photographs, First Aid Posters and pamphlets detailing the Do it R.I.G.H.T.
methodology and photographs of the correct method, snake identification posters and booklets
for doctors and members of the public to aid in venomous snake recognition.