Treat the syndrome, not the snake. Classify early as neurotoxic (ptosis, bulbar weakness, respiratory failure) or haemotoxic (incoagulable blood, bleeding, swelling, AKI), apply sensible first aid, avoid harmful traditional measures, and observe every bite for at least 24 h.
At the bedside
Timed steps- 1
First aid: 'Do it R.I.G.H.T.'
Pre-hospitalReassure, Immobilise the limb like a fracture, Get to hospital, Tell the doctor of symptoms. No cutting, suction, tight tourniquet or herbal remedies.
- 2
Triage
0 minABC, IV access in unbitten limb, 20WBCT, bite site and swelling (mark the edge with time), ptosis, single breath count, urine colour.
- 3
Remove carefully
TourniquetRelease slowly only after IV access and ASV ready – sudden release can precipitate collapse from venom bolus.
- 4
Syndrome
ClassifyNeurotoxic: cobra (local swelling/necrosis) or krait (painless night bite on the floor, abdominal pain, little local sign). Haemotoxic: Russell's or saw-scaled viper (swelling, bleeding, incoagulable 20WBCT, AKI in Russell's).
- 5
24 h minimum
ObserveEven with no signs; krait envenoming can be delayed several hours. Repeat 20WBCT and neuro checks.
- 6
Avoid harm
SupportiveParacetamol for pain (no NSAIDs, no IM injections in coagulopathy); tetanus toxoid once coagulopathy corrected; antibiotics only for infected wounds.
India's Big Four: typical syndromes
| Snake | Local signs | Systemic picture | Typical complications |
|---|---|---|---|
| Spectacled cobra (Naja naja) | Painful swelling, blistering, necrosis | Descending paralysis (ptosis, bulbar, respiratory) | Respiratory failure, local necrosis |
| Common krait (Bungarus caeruleus) | Minimal or none | Night-time bite while sleeping; abdominal pain, then paralysis | Prolonged ventilation; poor neostigmine response |
| Russell's viper (Daboia russelii) | Swelling, bleeding from bite | VICC, bleeding, hypotension | AKI, hypopituitarism, capillary leak |
| Saw-scaled viper (Echis carinatus) | Swelling | VICC, bleeding | Bleeding; AKI less common |
Syndromes overlap (e.g. Russell's viper in parts of south India causes neurotoxicity). Polyvalent ASV covers all four.
References
- 1
- 2
Snakebite triage
Step 1 of ~4
ABC, IV access, 20WBCT, neuro and local exam
Based on Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. Educational use; follow local protocol.
Pathophysiology
- Neurotoxins: cobra alpha-neurotoxins are postsynaptic (reversible, neostigmine-responsive); krait beta-bungarotoxins are presynaptic (destroy nerve terminals, slow recovery).
- Viper venoms activate factor X and prothrombin, causing venom-induced consumption coagulopathy (VICC).
Evidence
- Management recommendations are largely consensus-based (MoHFW STG 2016; WHO SEARO 2016).
🇮🇳 India notes
- India accounts for close to half of global snakebite deaths (most rural, monsoon season, farmers).
- NAPSE (2024) aims to halve snakebite deaths by 2030.
References
- 1
- 2
Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.