SNAKEBITE MANAGEMENT GUIDE FOR

HEALTHCARE PROVIDERS IN MALAYSIA

International Workshop on
Advanced Marine animals & Snake Envenomation Management
(AMSEM)
&
Intermediate Level Workshop on
Snakebite and Envenomation Management
(SEM)

Prepared by Dr Ahmad Khaldun Ismail December 2011. Updated: June 2013 Copyrights UKM 2013
Webpage: http://www.facebook.com/amsemukmmc

Date: ___/___/_____ Time: ______hr Name: ___________________ Age: _____y/o

Reg num: ____________

(Note: All cases should be supervised by a physician or clinical toxinologist who are familiar and experienced
with snakebite and envenomation management in Malaysia)
1. FIRST-AID TREATMENT Avoid any interference with the bite wound (e.g. tourniquet, incisions, sucking,
rubbing, vigorous cleaning, application of herbs/chemicals, massage or electrical shocks).
STEP
ACTION

1
Reassure the victim who may be very anxious. Move away from danger. Reduce physical
movements.
2
Lay patient down in a comfortable position, and immobilize the bitten area/limb with a splint or
sling. Maintain immobilization throughout the patients stay in the ED.
3
Irrigate eyes with copious amount of water if the venom enters the eyes.
4
Remove jewelry and loosen tight-fitting clothing enroute to health centre. Urgent transport.
2. RAPID CLINICAL ASSESSMENT AND RESUSCITATION
STEP
ACTION
1
Manage patient in Priority I or II area with close monitoring of vital signs and cardiac rhythm
2
Primary clinical assessment (ABCDE approach) and resuscitation as indicated
3
Prop up patient to a comfortable position and administer Oxygen to keep sPO2 >95%
4
Obtain two (2) venous access and maintain with Normal Saline solution
5
Immobilize the bitten limb
3. INVESTIGATIONS
20 minute whole-blood clotting test (20WBCT): It is a quick bed-side test (with a questionable sensitivity) for

unidentified bite or when a pit viper bite is suspected.

1
2
Note:

Place 2mls of freshly sampled venous blood in a small, new or heat cleaned, dry, glass vessel.
Leave undisturbed for 20 minutes at ambient temperature, then tip the vessel once.
If initial test was normal (fully clotted) repeat test every 30 minutes for first 3 hours then hourly up to 6hrs
post bite or as necessary. If the blood remain liquid (unclotted), this is suggestive of coagulopathy or
defibrination syndrome secondary to systemic envenomation from a pit viper bite.
Others: Repeat serially. Note: * to include d-dimer and directly measured fibrinogen level.
1
Coagulation profile*
4
Creatine kinase (CPK)
2
Full blood count & picture
5
Urinalysis (myoglobinuria)
3
Renal profile & electrolyte
6
Liver function
4. DETAILED CLINICAL ASSESSMENT
A. History: Obtain precise history of the circumstances of the bite. Useful initial questions:
STEP
QUESTIONS
1
In which part of your body have you been bitten?
2
When were you bitten? What were you doing at that time?
3
Where is the snake or picture of the snake that bit you? Can you describe it? Any eye witness?
4
What did you do after the bite?
5
How are you feeling now? Consider analgesic agent carefully.
B. General examination:
STEP
ACTION (repeat serially)
1
Examine for signs of shock
2
Examine the skin and mucous membranes and in the conjunctivae for evidence of bleeding
3
Thoroughly examine the gingival sulci and the nose for spontaneous systemic bleeding
5
Examine the abdomen for tenderness
6
Examine the Loin (low back) for tenderness
7
Examine for neurological signs

Prepared by Dr Ahmad Khaldun Ismail December 2011. Updated: June 2013 Copyrights UKM 2013
Webpage: http://www.facebook.com/amsemukmmc

C. Examination of the bitten area:

STEP
ACTION (repeat serially)
1
The extent of swelling (start proximally). Take pictures. Measure distance from bite marks
2
Palpate lymph nodes draining the limb. Note overlying ecchymosis and lymphangitic lines
3
If significant swelling, intra-compartmental pressure should be measured (consider fasciotomy
only when >40 mmHg)
4
Blood flow, perfusion and patency of arteries and veins assessed. Capillary refill time < 2secs
D. Examination for neurotoxic envenoming:
STEP
ACTION (repeat serially)
1
Ask patient to look down then look up and observe the upper lids retracting fully or lagging
2
Test eye movements for external ophthalmoplegia
3
Check the size and reaction of the pupils to light (fixed dilated in postsynaptic neurotoxicity)
4
Ask the patient to open his/her mouth wide and protrude his/her tongue (trismus)
5
Check other muscles innervated by the cranial nerves (facial muscles, tongue, gag reflex etc).
6
Examine the neck muscle (the neck flexor muscles may be paralyzed, i.e. broken neck sign)
7
Check if patient can swallow or secretions accumulating in the pharynx (early sign of bulbar
paralysis)
8
Ask the patient to take deep breaths in and out (look for Paradoxical respiration)
9
Measure the ventilatory capacity. Use a peak flowmeter/spirometer (FEV1 or FVC)

5. SPECIES IDENTIFICATION (Ref: Image Gallery of Land Snakes of Medical Significance in Malaysia)
If the dead snake has been brought or a picture taken, it may be possible to identify it.
Take pictures of the dead specimen with a measurement reference (e.g. measuring tape):
a. 2 views of the head: top (dorsal) and lateral
b. Coil the specimen for 1 dorsal view and 1 ventral view
Get an experienced physician or clinical toxinologist familiar with snakes species to verify (e.g. via email
or MMS etc.). You may preserve the dead specimen in an airtight container submerged in 10%
Formaldehyde (Formalin) or 70% alcohol.

6. ANTIVENOM
Antivenom is selected ONLY if its stated range of specificity and para-specific neutralization capacity includes the
species known or highly suspected to have been responsible for the bite. Antivenom treatment is recommended
when a patient with proven or suspected snake-bite develops one or more of the following signs:
Envenomation

A. Systemic envenoming
1.
Haemostatic abnormalities: Spontaneous systemic bleeding, coagulopathy (20WBCT or other
laboratory tests) or thrombocytopenia (<100 x 109/l).
2.
Neurotoxic signs: ptosis, external ophthalmoplegia, paralysis etc.
3.
Cardiovascular abnormalities: hypotension, shock, cardiac arrhythmia, progressively abnormal
ECG.
4.
Acute kidney injury (renal failure): oliguria/anuria, rising blood creatinine/urea.
5.
Haemoglobin-/myoglobinuria (dark brown/black urine).
6.
Other evidence of intravascular haemolysis or generalized rhabdomyolysis (muscle aches and
pains, hyperkalaemia, rapidly raising Creatine Kinase/CPK level).
B. Local envenoming (requires other considerations)
1.
Local painful swelling involving more than half of the bitten limb (in the absence of a
tourniquet) within 48 hours of the bite.
2.
Rapid extension of swelling (for example, beyond the wrist or ankle within a few hours of bite
on the hands or feet) or significant swelling after bites on the digits (toes and especially fingers).
3.
Development of enlarged tender lymph nodes draining the bitten limb.

Prepared by Dr Ahmad Khaldun Ismail December 2011. Updated: June 2013 Copyrights UKM 2013
Webpage: http://www.facebook.com/amsemukmmc

7. ANTIVENOM ADMINISTRATION
Choice of antivenom must be selected by a physician or clinical toxinologist who is familiar and experienced with
snakebite management in Malaysia. All antivenom is administered intravenously.
STEP
ACTION

1
The snake species is known (use monovalent/mono-specific antivenom)
2
The snake species is unknown (use Neuro-polyvalent or Hemato-polyvalent antivenom)
3
Adrenaline drawn up in readiness before antivenom is administered (0.5 mg for adults and
0.01mg/kg body weight for children (0.1% solutions, 1 in 1,000 dilution, 1mg/ml).
4
Method 1: Intravenous push injection: Reconstituted freeze-dried antivenom or neat liquid
antivenom is given by slow intravenous injection (not more than 2 ml/minute). This method has
the advantage that the doctor, nurse or dispenser administering the antivenom must remain with
the patient during the time when some early reactions may develop. It is also economical,
saving the use of intravenous fluids, giving sets, cannula etc.
Method 2: Intravenous infusion: Reconstituted freeze-dried or neat liquid antivenom is further
diluted in approximately 5-10 ml of isotonic fluid per kg body weight (i.e. 250-500 ml of
isotonic saline or 5% dextrose in the case of an adult patient) and is infused within a period of
one hour or earlier, starting slow over 10-15 min then increased to a higher rate if no reaction.
5
Closely observe patient during and for at least one hour AFTER completion of intravenous
infusion. Serially chart vitals signs and clinical progression.

8. DOSE OF ANTIVENOM
In practice, the choice of an initial dose of antivenom is usually empirical (based on clinical presentation)
or based on manufacturers recommendation. (Appendix 1)
Children are given exactly the same dose of antivenom as adults.

9. OBSERVATION OF THE RESPONSE TO ANTIVENOM

If an adequate dose of appropriate antivenom has been administered, the following responses may be observed:
RESPONSE

A
General: The patient feels better. Nausea, headache and generalized aches and pains may
disappear very quickly. This may be partly attributable to a placebo effect.
B
Spontaneous systemic bleeding (e.g. from the gums): This usually stops within 15-30 minutes.
C
Blood coagulability (as measured by 20WBCT): This is usually restored in 3-9 hours.
D
In shocked patients: Blood pressure may increase within the first 30-60 minutes and
arrhythmias such as sinus bradycardia may resolve.
E
Neurotoxic envenoming of the post-synaptic type (cobra bites) may begin to improve as early as
30 minutes after antivenom, but usually takes several hours. Envenoming with pre-synaptic
toxins (kraits and sea snakes) will not respond in this way.
F
Active haemolysis and rhabdomyolysis may cease within a few hours and the urine returns to its
normal colour.

10. CRITERIA FOR REPEATING THE INITIAL DOSE OF ANTIVENOM

CRITERIA
1.
If the blood remains incoagulable (as measured by 20WBCT) six hours after the initial dose of
antivenom, the same dose should be repeated
2.
In patients who continue to bleed briskly (the dose of antivenom should be repeated within 1-2
hours)
3.
In case of deteriorating neurotoxicity or cardiovascular signs, the initial dose of antivenom
should be repeated after 1-2 hours (full supportive treatment must be considered)

Prepared by Dr Ahmad Khaldun Ismail December 2011. Updated: June 2013 Copyrights UKM 2013
Webpage: http://www.facebook.com/amsemukmmc

11. ANTIVENOM REACTION A proportion of patients, usually more than 10%, develop a reaction early (within
2 hours) or late (five days or more) after antivenom (especially if large repeated doses) is given.
STEP
ACTION

Early anaphylactic and pyrogenic antivenom reaction treatment:

1
Antivenom administration must be temporarily suspended
2
Adrenaline, is given intramuscularly (into upper lateral thigh) in an initial dose of 0.5 mg for
adults and 0.01mg/kg body weight for children (0.1% solution, 1 in 1,000, 1mg/ml).
3
The dose can be repeated every 5-10 minutes or start IV infusion at 1 microgm/kg/min if the
condition deteriorates.
4
Additional treatment: an antihistamine (anti-H1 blocker) chlorpheniramine maleate (adult 10
mg. children 0.2 mg/kg by IV injection over a few minutes should be given.
5
Intravenous hydrocortisone (adult 100 mg, children 2mg/kg body weight). The corticosteroid
can prevent delayed and recurrent anaphylaxis.
6
In pyrogenic reactions the patients must also be cooled physically and with antipyretics (e.g.
paracetamol by oral or suppository)
7
Intravenous fluids given to correct hypovolemia
Treatment of late (serum sickness) reactions:
1
Late reactions may respond to a 5-day course of oral antihistamine.
2
Patients who fail to respond in 24-48 hours should be given a 5-day course of prednisolone:
adults 5 mg six hourly, children 0.7 mg/kg/day in divided doses for 5-7 days.

12. MANAGEMENT OF VENOM OPTHALMIA

Topical or intravenous antivenom and topical corticosteroids are not recommended.
STEP
ACTION
1.
Urgent decontamination by copious irrigation of both eyes. Consider Morgan lens irrigation
device.
2.
Analgesia by vasoconstrictors with weak mydriatic activity (e.g. epinephrine) and limited use
of topical administration of local anesthetics (e.g. tetracaine)
3.
Apply topical cycloplegics to prevent posterior synechiae, ciliary spasm and discomfort
4.
Application of prophylactic topical antibiotics if corneal abrasions present
5.
Apply dressing pads to close the eyes and refer for ophthalmologists examination

13. ADMISSION/REFERRAL/DISPOSITION: These should be decided by a physician or clinical toxinologist

who are familiar and experienced with snakebite and envenomation management in Malaysia.

CONTACT
1.
2.
3.
4.
5.

REMOTE ENVENOMATION CONSULTATION SERVICES (RECS)

MOBILE NUMBER
E-MAIL

Dr Ahmad Khaldun Ismail

Dr Anisah Adnan
Dr Azhana Hassan
Dr Zainal Abidin Mohamed Ismail
Dr Razak Daud

+60 13 3276273
+60 16 2336727
+60 12 2384595
+60 19 3525201
+60 19 9876904

khaldun_ismail@yahoo.com
isqanis@yahoo.com
azhana_hassan@yahoo.cm
drzainalemergency@gmail.com
sitisuraiya@yahoo.com.sg

RELAVANT REFERENCES AND RECOMENDATON FOR FURTHER READING

AUTHOR/EDITOR
TITLE
1.
2.

David A Warrell
WHO Expert Committee

3.
4.
5.

Stephen P Mackessy
Jean P Chippaux
Scott A Weinstein et. al.

6.

Indraneil Das

Guidelines for the management of snake-bites in South East Asia. WHO/SEARO. 2010
Guidelines for the Production, Control and Regulation of Snake Antivenom
Immunoglobulins. WHO. 2010
CRC Handbook of Reptile Venoms and Toxins. Taylor and Francis. 2009
Snake Venom and Envenomations. Krieger Publishing. 2006
"Venomous" Bites from Non-Venomous Snakes: A Critical Analysis of Risk and
Management of "Colubrid" Snake Bites. Elsevier. 2011
A Naturalist's Guide to the Snakes of Southeast Asia (Naturalists' Guides). John Beaufoy
Publishing, 2013

Prepared by Dr Ahmad Khaldun Ismail December 2011. Updated: June 2013 Copyrights UKM 2013
Webpage: http://www.facebook.com/amsemukmmc

Appendix 1

Species

GUIDE TO ANTIVENOM APPROPRIATE FOR MALAYSIA

Antivenom manufacturer
First Dose/vial

Monocle cobra, Naja kaouthia

King Cobra, Ophiophagus hannah
Malayan krait, Bungarus candidus
Banded krait, Bungarus fasciatus
Malayan pit viper, Calloselasma Rhodostoma
Green pit viper, Cryptelytrops Albolabris
Malayan pit viper, Calloselasma rhodostoma,
Green pit viper, Cryptelytrops Albolabris, SEA
Russells Viper, Daboia russelli siamensis
Monocled Cobra, Naja kaouthia, King Cobra
Ophiophagus hannah, Banded Krait Bungarus
fasciatus, Malayan Krait, Bungarus candidus.
Sea snakes, Hydrophiidae family.

QSMI Thai Red Cross: Cobra Antivenin to neutralize 0.6

mg/ml of venom
QSMI Thai Red Cross: King Cobra Antivenin to
Neutralize 0.8 mg/ml of venom
QSMI Thai Red Cross: Malayan Krait Antivenin to
Neutralize 0.4 mg/ml of venom
QSMI Thai Red Cross: Banded Krait Antivenin to
Neutralize 0.6 mg/ml of venom
QSMI Thai Red Cross: Malayan Pit Viper Antivenin to
Neutralize 1.6 mg/ml of venom
QSMI Thai Red Cross: Green Pit Viper Antivenin to
Neutralize 0.7 mg/ml of venom
QSMI Thai Red Cross: Hemato Polyvalent Snake
Antivenom

100mls/10 vials
Subsequent dose 1-2 hr
100mls/10 vials
Subsequent dose 1-2 hr
50mls/5 vials
Subsequent dose 1-2 hr
50mls/5 vials
Subsequent dose 1-2 hr
40mls/4 vials
Subsequent dose 6 hr
100mls/10 vials
Subsequent dose 6 hr
30mls/3 vials
Subsequent dose 6 hr

QSMI Thai Red Cross: Neuro Polyvalent Snake

Antivenom

50-100mls/ 5-10 vials

Subsequent dose 1-2 hr

CSL, Australia: Polyvalent Sea snake Antivenom

10-30mls/1-3 vials
Subsequent dose 1-2 hr
Note: Subsequent doses are according to the clinical symptoms. Monocle cobra, Naja kaouthia antivenom has good cross neutralization with the
Equatorial spitting cobra, Naja sumatrana venom. Malayan pit viper, Calloselasma rhodostoma, SEA Russells Viper, Daboia russelli siamensis
and Monocle cobra, Naja kaouthia are not indigenous to Borneo. The ViNS Indian Polyvalent antivenom is not appropriate for treating pit viper
envenomations in Malaysia. It may have limited neutralizing capacity against the venoms of Equatorial spitting cobra, Naja sumatrana, Monocle
cobra, Naja kaouthia, King Cobra, Ophiophagus Hannah and Malayan Krait, Bungarus candidus. However its use is not recommended in
Malaysia or SEA region.

Holding Sufficient Amount of Appropriate Antivenom:

A formula can be used to estimate the total number of particular antivenom (ASV) for a healthcare facility at any
one time:
Holding quantities of ASV = A x D x S x T
A =

D =
S =
T =

Average estimates of snakebite requiring antivenom from a particular species per year. A
retrospective/prospective survey snakebites per year, treated in a particular hospital is required. The
information to note are the incidence, the snake species (identified or unidentified), the signs and
symptoms of envenoming, the antivenom administered and the outcome.
Recommended dose of antivenom for treating an envenomed patient (2 x first dose).
Safety factor to ensure greater than minimal stock is available. The recomended safety factor (S) is 1.2.
The time interval (in months) that is normally required to replace/replenish the used antivenoms.

Suppose we are dealing with a basic facility with two envenomings per month then A=2: the maximum dose
required per patient determines a key part of usage, so for example, if the recommended first dose for a patient at a
basic facility is 10 vials for a patient, D = 20. 1.2 represents the safety factor. If the replenishing period, T = 2
months, the recommended holding quantities would be 2 X 20 X 1.2 X 2 = 96 vials. This would be the base stock
amount for a particular antivenom for that healthcare facility.
Note:The type of appropriate ASV used will be determined by availability, cost and effectiveness of the cold chain.
Lyophilised ASV, in powdered form has a shelf life of 5 years and requires merely to be kept out of direct sunlight.

Prepared by Dr Ahmad Khaldun Ismail December 2011. Updated: June 2013 Copyrights UKM 2013
Webpage: http://www.facebook.com/amsemukmmc

Appendix 2

Snakebite Management Flow

Prepared by Dr Ahmad Khaldun Ismail December 2011. Updated: June 2013 Copyrights UKM 2013
Webpage: http://www.facebook.com/amsemukmmc

ACKNOWLEDGEMENTS
AMSEM Faculty Members
1.

DR. AHMAD KHALDUN ISMAIL, MBBCh, BAO, BMedSci, MEmMed., Senior Medical Lecturer & Emergency Physician,
Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob
Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia.
2. PROFESSOR DR. P GOPALAKRISHNAKONE, MBBS, PhD, FAMS, DSc., Professor of Anatomy and Chairman of the Venom
and Toxin Research Programme, Department of Anatomy & Venom and Toxin, Yong Loo Lin School of Medicine, National
University of Singapore.
3. PROFESSOR DR. TAN NGET HONG, BSc, PhD, Professor, Department of Molecular Medicine, University of Malaya, Kuala
Lumpur, Malaysia.
4. PROFESSOR DR. SUMANA KHOMVILAI. B.Sc. (Hons.) Pharm, MBA, Deputy Director/Technical Director, Queen Saovabha
Memorial Institute, Thai Red Cross Society, Bangkok, Thailand.
5. PROFESSOR DR. INDRANEIL DAS, DPhil, Professor, Institute of Biodiversity and Environmental Conservation, UNIMAS,
Kota Samarahan, Sarawak, Malaysia
6. ASSIST. PROF. DR. SUCHAI SUTEPARUK, MD, MSc, Head of Division of Toxicology, Department of Medicine,
Chulalongkorn University School of Medicine Bangkok, Thailand & QSMI, Thai Red Cross society, Bangkok, Thailand.
7. DR. SCOTT A. WEINSTEIN, BA, MSc, PhD, MBBS, MD, Dip, ABFM, Clinical Toxinologist, Department of Toxinology,
Womens & Childrens Hospital, North Adelaide, South Australia, Australia
8. DR. ANISAH ADNAN MBBS, MMed, Consultant Emergency Physician, Trauma & Emergency Department, Melaka General
Hospital, Melaka, Malaysia.
9. DR. TAN CHOO HOCK, MBBS, PhD, Medical Lecturer, Department of Pharmacology, Faculty of Medicine, University of
Malaya, Kuala Lumpur.
10. Dr. Taksa Vasaruchapong DVM, Veterinarian, Snake Farm, Queen Saovabha Memorial Institute, Thai Red Cross Society,
Bangkok, Thailand.

AMSEM International Advisory Members:

1.
2.
3.
4.
5.
6.
7.
8.

PROFESSOR DR. JULIAN WHITE, MBBS, MD, FACTM, Unit Head and Clinical Toxinologist, Toxinology Department,
Women's and Children's Hospital, 72 King William Road, North Adelaide, SA, 5006, Australia
PROFESSOR DR. VISITH SITPRIJA, MD, Director and Professor of Medicine, Queen Saovabha Memorial Institute &
Division of Nephrology, Department of Medicine, Chulalongkorn University School of Medicine, Bangkok 10330, Thailand.
ASSOC. PROF. DR. PETER J FENNER, MD, DRCOG, FACTM, FRCGP, Marine Sting Expert, School of Public Health, Tropical
Medicine and Rehabilitation Sciences, James Cook University, 1 James Cook Dr, Douglas QLD 4811, Australia.
DR. MARK AULIYA, PhD, Herpetologist and Taxonomist, Dept of Conservation Biology, Helmholtz Centre for
Environmental Research GmbH-UFZ, Permoserstrae 15104318, Leipzig, Germany.
DR. JEFFREY FUNG HIN TAT, MBChB, MRCP(UK), FRCSEd, FHKCEM, FHKAM(EMed), Consultant Emergency Physician &
Head of Toxicology Team, Tun Muen Hospital, Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong.
DR. KENNETH D WINKEL, MBBS, BMedSci, PhD, FACTM, Director, Australian Venom Research Unit, Department of
Pharmacology, University of Melbourne, VIC 3010 Australia.
DR. LISA-ANN GERSHWIN, BSci, PhD, Director, Australian Marine Stinger Advisory Services, 3/127 George Street,
Launceston, Tasmania 7250 Australia.
DR TRI MAHARANI, MSci, SpEM, Emergency Physician, Department of Emergency Medicine, Faculty of Medicine,
University of Brawijaya, Saiful Anwar general Hospital, Jl. Jaksa Agung Suprapto 2, Malang, Indonesia 65111.

Remote Envenomation Consultation Services (RECS):

1.
2.
3.

Dr Azhana Hassan, Emergency Physician, Emergency & Trauma Department, Tuanku Jaafar Hospital, Seremban, Negeri
Sembilan, Malaysia.
Dr Zainal Abidin Mohamed Ismail, Head & Emergency Physician, Emergency &Trauma Department, Tengku Ampuan
Afzan Hospital, Jalan Tanah Putih, 25100 Kuantan, Pahang, Malaysia .
Dr Razak Daud, Head & Emergency Physician, Emergency &Trauma Department, Hospital Raja Perempuan Zainab II Kota
Bharu, Kelantan, Kota Bharu, Kelantan.

Prepared by Dr Ahmad Khaldun Ismail December 2011. Updated: June 2013 Copyrights UKM 2013
Webpage: http://www.facebook.com/amsemukmmc