AN APPROACH TOWARDS AYURVEDIC - MODERN ASPECT ON MANAGEMENT OF SNAKE & THEIR BITES.

1. A Conceptual Study On Snake
Bites(Sarpa Damsa) As Per Ayurvedic
& Modern Aspect
PRESENTED BY –
DR. ANURAG MISHRA
( M.D , B.A.M.S)
ASSISTANT PROFESSOR
DEPT. OF ATVA
KHALSA AYURVEDIC MEDICAL
COLLEGE,MANSA,PUNJAB

2. God of Health = God Dhanvantari

3. SARPA DAMSA – AYURVEDIC ASPECT
 The problem of poisons and their treatment has been coming since prehistoric
times.
 Information pertaining to the poison is available in Vedic literature. The word
AGADA has referred several times in vedas.
 Later AGADATANTRA was developed as one of the eight branches of Ayurveda
that deals with diagnosis and treatment of poisons.
 MRUTYU is categorized into two in classics :
1. KALA Mrityu  Natural 2. AKALA Mrityu  Unnatural
 The second category is also said to be AGANTUJA and may occur because of
 Water - that is infected / polluted / contaminated
 Agni - like fire accidents
 Weapons
 Stree / Visha Kanya - who is contaminated with STDs
 VISHA – POISONING (Dalhana on Sushruta Sutra 34/6)

4.  AMONG ALL THESE FACTORS, VISHA IS AN IMPORTANT
ONE RESPONSIBLE FOR UNNATURAL DEATH.
 VISHA MAY BE ANY SUBSTANCE THAT INTERFERES
NORMAL PHYSIOLOGY RESULTING IN VISHADA
 UNDER DIFFERENT CATEGORIES OF VISHA SARPA VISHA IS
AN IMPORTANT FACTOR THAT CAUSES UNNATURAL DEATH.
 IT HAS BEEN REPORTED THAT, THERE ARE ONLY 52
VENOMOUS SNAKE OUT OF 216 SPECIES IN INDIA.
 YET, EVERY YEAR 50,000 INDIANS, MOSTLY POOR
VILLAGERS, DIE IN 250,000 INCIDENTS OF SNAKEBITES (~20%).
 HIGH INCIDENCES ARE NOTICED IN THE STATES OF TAMIL
NADU, WEST BENGAL, MAHARASHTRA,UTTAR PRADESH,
AND KERALA.

5. 80
Vasuki Etc.
MANDALI
26 22 10 10
SAVISHA
68
NIRVISHA
12

6. SAVISHA SARPA IN AYURVEDA

7. SAVISHA SARPA IN AYURVEDA

8. CLASSIFICATION SARPA ON THE BASIS OF SEX
(LINGA) IN AYURVEDA

10. TYPES OF DARVIKARA SARPA
 तत्र दर्वीकरा- कृ ष्णसर्पो, महाकृ ष्ण, कृ ष्णोदर, स्र्र्वेत्कर्पोतो, महाकर्पोतो, बलाहको,
महासर्पप,र्प शङ्खकर्पोलो, लोहहताक्षो, गर्वेधृकः,र्पपररसर्पपःर्प ,खण्डफ़न,ृ ककृ द्, र्पपद्यो,
महार्पपद्यो, दरपर्पर्प ृष्र्र्पो, दधधमखःृ , र्पपृण्डरीको, भ्रकृ हहमखोृ , र्वर्वपष्ष्कर, र्पपृष्र्र्पाभकप कणो,
धगररसर्पप,र्पहृजसृर्पप,श्र्र्वतोदरोृे , महाभशरा, अलगदर्प, आशीर्वर्वपष इतत !
 स.ृ स.ृ४/३४

11. 10.Gavedhuk
11.Parisarpa
12.Khandfan
13.Kakud
14.Padhya
15.Mahapadya
16.Darbhpushp
17.Dadhimukh
19.Bhrakutimukh
20.Vishkir
21.Pushpabhikirn
22.Girisarpa
23.Rijusarpa
24.Swetodar
25.Mahashira
26.Algard,Ashivish
1. Krishna sarpa
2. Mahakrishn
3. Krishnodar
4. Shwetkapot
5. Mahakapot
6. Balahak
7. Mahasarpa
8. Shankhkapal
9. Lohitaksh 18.Tundrik

12. रथाङ्गलाङ्गलच्छत्रस्वस्स ्ि काङ्क शधाररणः | ज्ञेयादवीकराःसरापः
फणणनःशीघ्रगामिनः||
स. क.४/२२

13. Hooded
Fast-moving
Having marks of wheel
Plough(हल,मण्डल)
Umbrella
Swastika (Auspicious
cross)
Goad (अन्क श)on the
body.

14. These snakes are …
More poisonous during day time
...दववकपरास्ि ि रुणा
Darvikara are fatal in young stage of
life.
कोरयन ् ्यननलःजन ्ि ो ः फणणनः सवप
व वव
All hooded (Darvekara) snakes
aggravate Vata.

15. दर्वीकरर्वर्वपषेणत्र्र्वङ्नयननखदशनर्वपदनमत्रृ र्पपृरीषदंशकृष्णत्र्र्वंरौक्ष्यंभशरसोगौरर्वं
सष्धधर्वेदनाककिीर्पपषृठग्रीर्वापदौबल्र्पयं जमृणं र्वेर्पपथृृःस्र्र्वरार्वपसादो
घृघृरर्पकोजडताशष्कोृ द्गारःकासश्र्र्वासौहहक्कार्वापयोरूधपर्वपगमनंशलृ ृोद्र्र्वेषिृन
तषृ णालालास्रार्वपःफे नागमनंस्रोतोऽर्वपरोधस्ताश्चर्वापतर्वेदनारपर्वष्धत;
सृ.क.४/३७
Poisons of Darvikara causes
Blackness in skin Eyes,Nails,Teeth,Face,Urine and place of bite,
roughness, heaviness of head, pain in joints, dullness, dry eructation,
cough, dyspnoea, hiccough, upward movement of Vayu, cramp due to
pain, thirst, salivation, emitting froth, obstruction in channels and
different types of vatika pain.

16. दर्वीकराणांप्रथमेर्वेगे र्वर्वपषंशोणणतंदषृ यतत,तत ृ प्रदषृिृृंकृ
ष्णतामृर्पैतत,तेनकाष्ण्य र्वर्पपर्पीभलकार्पपररसर्पपणभमर्वपचाङ्गे रपर्वतत;द्र्वर्वपतीये
मांसं दषयतत, तेनात्यथ
कृष्णता शोफो ग्रधथयश्चाङ्गे रपर्वष्धत; ततृृीयेमदे ृो दषयतत,
तेनदंशक्लदःृे
भशरोगौरर्वं स्र्र्वदश्चक्षग्रहे णं च; चतृथे
कोष्ठमनृप्रर्वर्वपश्यकफप्रधानाधदोषाधदषृ यतत,
तेन
तधराप्रसकसष्धधर्वर्वपश्लषाृेृे रपर्वष्धत; र्पपञ्चमऽृे स्थीधयनृप्रर्वर्वपशतत
प्राणमषृनं च
दषृयतत,तेन र्पपर्वपर्पपृेदहहक्कादाहश्च रपर्वतत;षष्ठे मज्जानमनृप्रर्वर्वपशततग्रहणी
चात्यथदं षृयतत,तेनगात्राणां गौरर्वपमतीसारोहृत्र्र्पीडा मृचपृार्पच रपर्वतत;सप्तमे
शृक्रमनृप्रर्वर्वपशततचात्यथं कोर्पपयततकफं च सृक्ष्मस्रोतोभ्यःप्रचपयार्वपयतत,तेन
श्लष्मर्वे ततप्रर्पृादरृृार्पर्वपःककिीर्पपषृठङ्पगः सर्वपचर्पृेषिृृार्वर्वपघातो
लालास्र्र्वेदयोरततप्रर्वपर्वृ िृरुर्च्रर्वापसतनरोधश्चरपर्वतत||

17. Vega Dushti Symptoms
Prathama Rakhta
Dwitheeya Mamsa
Infects blood and manifests Paridaha
(Burning sensation),
कृष्णतामृर्पैतत(black discoloration)
कृष्णाता शोफ़ोरपर्वष्धत
Tritheeya Meda
(black discoloration of body parts), Earlier
symptoms & भशरोगौरर्वं
Chathurtha Kostha Pravesha
दंसक्लेदः stiffness of eyes
कफ़प्रधानदोषदषृ यतत
Drowsiness Salivation Looseness of joint

18. Vega Dushti Symptoms
Panchama Bones/asthi Vitiate prana and Agni
Generalized pain, burning sensation, hiccough
Shasta Majja Grahani Dushti (Impairs functions of GIT), Atisara
(Diarrhea),
Hritpida (Cardiac Arrest),
Murcha (Unconscious),
Sapthama Shukra Pain in flanks and lumbar Arrests all
functions Respiratory arrest

19. मधत्राररषिृृोत्कतनर्प तनष्र्र्पीडनचषृ णाषृन र्पपररषेकाः!
अर्वपगाह रक्तमोक्ष्णर्वपमनर्वर्वपरेकोर्पपधानातन!! ह्रृ
दयार्वपरणाञ्जन नस्यधृमलहौृेषधप्रशमनातन !
प्रततसारणं प्रततर्वर्वपषंसंज्ञासंस्थार्पपनं लर्पेृः!!
मतृसञ्जीर्वपनमेर्वप च र्वर्वपशंततरेते चतृभरपर्प धधकाः!
स्यरुर्पपक्रयथये यत्र योज्याः श्रणृृतथा तानृ!!
च.धच. 23/25-27

20. TREATMENT MEASURE PROBABLE COMPARISON
1 Mantram Chanting Mantras
2 Arishta bandhanam Application of Tourniquet
3 Utkartanam Incision over the bite excluding vital points
4 Nishpeedanam Compression
5 Achushanam Sucking through the site
6 Agni Thermal cauterisation
7 Parishekam Sprinkling water
8 Avagaham Water bath
9 Rakta mokshana Blood letting
10 Vamana Emesis
11 Virekam Purgation
12 Upadhanam Medication on incised scalp
13 Hrudayavaranam Protection of heart
14 Anjanam Medicated collyrium

21. TREATMENT MEASURE PROBABLE COMPARISON
15 Nasya Medicated nasal insufflations
16 Dhumam Medicated smoking
17 Leham Medicated linctuses
18 Aushadham Anti-poisonous drugs
19 Pradhamanam Medicated snuffing
20 Pratisaranam Local applications
21 Prativisham Specific antidotes
22 Sajna Samstapanam Resuscitation
23 Lepam Application of Medicated pastes
24 Mruta Sanjeevanam Revivation

22. • Charaka emphasized NOT TO
FOLLOW all these 24
UPAKRAMAS in all cases of
poisonings.
A wise physician has to
examine and decide justifiable
procedures for specific
condition.

23. USEFULNESS OF THESE UPAKRAMAS
 Different Upakramas may be helpful in different ways.
 Are to be applied / used appropriately.
THESE MAY BE HELPFUL .. Example from 24 Upakramas
.. in restricting the entry of the
poison into the systemic
circulation
Arista Bandhana, Utkartana,
Chushana etc
.. to eliminate the poison form
body
Rakta Mokshana, Vamana,
Virechana etc
.. to counteract the poisons
(Anti-dot activity)
Leha, Aushadha, Prativisha etc
.. as supportive / symptomatic
measures
Samjnasthapana, Mrita sanjivana
etc
.. as topical applications Anjana, Pratisarana etc

24. Vega Dushti Chikitsa
Prathama Raka Dushti Raktamokshana by sira vedhana
Dwitiya Mamsa Dushti Madhu, Ghrita and Yavagu Pana
Tritiya Medo Dushti Teekshna Virechana, Yavagu Pana
Chaturtha Kostha Pravesha Vamana, Yavagu Pana
Panchama Asthi pravesha Sheetalopachara, Virechana,
and Yavagu Pana
Shashtha Majja Dushti Sheetalopachara, Virechana,
and Yavagu Pana
Saptama Shukra Dushti Tikshna anjana, nasya, kakpada shaped incision
on the scalp and application of blood mixed
flesh over the incision

25. LEHAN YOGAS
External application of HINGU, MARICHA, VACHA ground in
the juice of KIMSUKA BARK on the bite mark subsides
darvikara visha.
Lepa with tankana and grihadhooma ground in urine.
Lepana with paste of lasuna, maricha, ardraka and pippali
ground in the juice of arkapatra.

26.  Internal administration of trikatu equal amount of pippali ,
maricha & sringavera with kanji or water nullifies all visha.
 Intake of paste of Ashwagandha with pure water.
 Mixed paste of guduchi and kola(piper cubeba).
 Oral administration of shirisha flower and seed of arka and equal
amount of vyosha is ground in arka kshira.

27.  Saindhava ground in the juice of tambula patra and
dhatura patra is used as nasya in unconscious
poisoned person.
 Nasya with swarasa of tulasi & dronapushpi with
maricha.
 Nasya with hingu maricha & saindhav in human urine or
tulasi swarasa.

28. MAHA ग दा
Trivrt visalya, madhuka, haridra, daruharidra, rakta
manjistha, aragvadha and the group of salts and trikatu-
these should be powdered finely, mixed with honey and
preserved in a horn.
This anti-poisonous formulation destroys poison
used as intake.
This is known as MAHAGADA as it has great power.

29. It is prepared by grinding the fine powder of
vidanga,patha, triphala ajamoda, hingu, tagara,
trikatu,chitraka and pancha lavana with honey
into a fine paste and kept covering with the lid of
same material

30. MODERN ASPECT

31. • As per the estimates of WHO : India
has highest number of deaths due to
snake bites in the world.
• Majority of the deaths are due to
Delay / Lack in treatment, Unable to
reach hospitals in time

32. Snake
Identification

34. Cobra
•“Spectacle” like marking in
Dorsum of the Hood.
•When excited this fold
expands into ahood .

35. Common/IndianKrait
• Oily,shiny,Bluish black appearance
• Paired white bands on the dorsAl
surface

36. SriLankanKrait
• Blackish brown snakewith white bands onthe
body

37. Russell’sViper
• Highly poisonous 40%of deaths is due to this snakein
Sri Lanka
Largest & most widely distributed viper in Sri Lanka.•

38. • “V” shaped white
marking in thehead.
• Has3 rows of black
elliptical markings
running alone the
length.

40. SawScaled Viper
• Sandybrown in
colour
• birds foot mark
over the head
• When disturbed,it
rubs the coils
against eachother
producing ahissing
noise
(characteristic)

42. HumpNosed Viper
• Brown in colour
with dark brown
& blackmarkings.
• Upturned hump.

44. GreenPit Viper
• Bright green in colour withblack markings

45. Cobra & common
krait

46. Russels viper & Saw scaled
Viper

47. Saw-scaled viper ( Echis
carinatus )
Russell’s viper ( Daboia russelii )
Common krait (bungarus
caeruleus)
Indian cobra (Naja naja)
Neurotoxic
20-30%
1 2 43
Majority of bites 70-80%
hemotoxin / vasculotoxic

48. HighlyVenomousSnakes
• Cobra(Naja naja)
• Common krait (Bungarus
caeruleus)
• Sri Lankakrait (Bungarus
ceylonicus)
• Russells'sviper (Daboia russelii)
• Sawscaled viper (Echis carinatus)

49. Moderately VenomousSnakes
• Hump nosed viper (Hypnale hypnale)
• Green pit viper (Trimeresurus
trigonocephalus)

50. COMMON COBRA
King cobra-राज नाग, राज सर्पप /Nagara Havu (Kannada)
Naja bangarus ,Ohiophagus hannah
 The name "cobra" is short for cobra-de-capelo, which is uses
for snake with hood", or "hood-snake"
 Zoological name- Naja naja
 Latin name-naja tripudians
 Common name- नाग(Hindi), Moorkan (Malayalam)
 Family - Elapidae
 Venom- neurotoxic
 Common cobras are usually brown or black in color
 Hood is present. Dorsal aspect of hood may have monocellate
or binocellate mark. Ventral surface of hood have two dark spot

51. Snake Bite
• Toxic Snakes
• 1) Neuro Toxic – Nag ( Cobra) & Manyar
(common Krait)
• 2) Haemotoxic or Vasculotoxic – Ghonas (
Russels viper ) & Furse ( Saw scaled
Viper)

52. 2 types of Snake Poison
• 3 stages can be seen in Paralytic Type
• Stage 1 – Ptosis
• Stage 2 – Difficulty in Swallowing
• Stage 3 – Difficulty in Respiration ,
Paralysis

53. 2 types of Snake Poison
• Haemolytic Type
• Local swelling around the bite appears
quickly
• Blood collected in bulb does not clot

55. Venom apparatus of snakes
consists of venomous glands (analogue of the
parotid glands) that produce and store the
venom, venom canals that connect the glands to
the fangs, and the palatine muscles that squeeze
the glands and inject the venom. The fangs are
specialized hollow teeth, located interiorly in
the maxilla

56. Components of snake
venoum
1. Blood coagulants:
prothrombin-like substances
such as thrombin or
and anticoagulants, and
agglutinins, which affect the coagulation and the status
of red blood cells.
2. Cytolysins, proteolysins, and antibactericidin:
which affect blood components as well as the
endothelium of the vessels. Antibactericidin contributes
to suppuration paralyzing the phagocytic activity of the
white blood cells.

57. 3. Neurotoxins A and B: which affect the
nervous system, particularly the
cardiorespiratory higher centers and the
central nervous system. Neurotoxin B also
affects the myoneural junction.

58. 4.Cholinesterase and anticholinesterase: both
of which affect the myoneural junction.
5.Cardiotoxin: which stimulates the heart,
causing dysrhythmias.
6.Hyaluronidase: which facilitates the tissue
spread of the venom.
The proportions and intermixing of the above
components vary from species to species.

59. Difference of Poisonous
& Non Poisonous
5
9
Sr,No Poisonous Non Poisonous
1 Head Scales – Small Head Scales – Large
2 Body scales -- Large Body scales – small or moderate
3 Tail - Compressed Not so
4 Nocturnal Not so
5 Bite mark – 2 Fang marks No fang marks

60. Poisonous Snakes –Special
Anatomical featurs
• 1) All poisonous snakes have broad
ventral plates on the belly that extend right
across.
• 2) All poisonous snakes have 2 fangs,
which really are 2 prominent teeth besides
many other small teeth.

61. Poisonous & Non Poisonous
– Head Scales

62. Poisonous & Non Poisonous
- BodyScales

63. After bite of Snake
• 1) A patient bitten by a poisonous snake
will always complain of pain over the bitten
area.
• 2) Two fang marks are always seen. The
shape of an inverted U (∩).

64. After bite of Snake
• 3) Bite by poisonous snake should not be
considered as serious poisoning every
time, because the poison glands of the
snake at the time of the bite might have
been empty.
• Also even a thin layer of clothing usually
gives great protection.
• 4) Many times fright and panic leadsto
fainting.

65. Watch Symptoms
1) Elapids Neurotoxic – Cobra or Krait
• Local – Mild Burning ,Triple Response i.e
redness, swelling,inflammation
• Systemic – Vomiting, Giddiness, Ptosis
,Difficulty in speaking & swalowing, Staggering
gait ,Difficult respiration, Difficulty in motor
Activities like hand & leg movements, spreading
paralysis ( ascending from lower limbs),
convulsions ,death may results within minutes or
several hours due to respiratory failure

66. Watch Symptoms
• 2) From Russell’s & saw scaled Vipers -
Haemotoxic Symptoms – Local symptoms are
more severe like Intense
pain,swelling,Cellulitis,Ozzing of bloody serum &
formation of blisters & necrosis
• Systemic – Vomiting, Unconsciousness,
Intravascular haemolysis, Epistaxsis,
Haematuria, Haemetemesis, Bleeding under
skin like Petechiae, Bleeding from orifices
,Hypotension.Death result from cardiovascular
shock or renal failure

67. Bite Marks Bleedingfrom the
Site
Necrosis
Blistering

68. GumBleeding
Subconjunctival Haemorrhage

69. Neurological
• Drowsiness
• Paraesthesiae
• abnormalities of taste andsmell
• “heavy” eyelids
• ptosis
• external ophthalmoplegia
• paralysis of facialmuscles
• difficulty in swallowing
• respiratory and generalised flaccidparalysis

70. Symptoms of Snake Bite

71. Snake Bite

72. Signs of Poisoning
• 2 puncture marks ,3/4th to 1 cm apart can
be of Poisonous snake bite

73. When person can die ?
• 1) After bite of Elapidae –20 min to 6 hrs
• 2) After bite of Viperine – 2 to 4 days

74. When Hospital Admission is
must in Snake Bite ?
• Patients who start bleeding extensively or
• Develop blackish red urine or
• Extensive paralysis

75. Snake Bite Management

76. Management of ASnakeBite

79. FirstAids

80. Treatment of the bittenpart
• Thebitten limb is nursed in themost
• comfortable position, slightlyelevated
• Bullae aspirated only if likely torupture

82. Transport to hospital
• Quickly, but safely andComfortably
• Minimal Movements avoid systemicabsorption

83. Dos
•Reassure.
•Removeall rings, Bracelets
from bitten parts of the
body.
•Washthe bitten area with soap
and water.
•Keepthe stricken limb below
the heart.
•Immobilize the bitten limb with
splint or slings.
•Get medical help asquick as
possible.

84. Do
Nots
•Don’t panic
•Don’t make any cut, scratchor
incision
•Don’t suckat thewound
•Don’t apply ice packsto the
bitten area.
•Don’t usetight bandsor
tourniquet.
•Don’t drink alcohol, takeherbal
medicine orAspirin.

85. In the ETU
• RapidClinicalAssessment& Resuscitation.
(ABC)
• Bite site was cleaned with soapandwater.
• IV canulae was inserted.
• Blood was taken for 20WBCT
(20 minute whole blood clottingtest)
• O.Paracetamol 500mg
• IV Ranitidine 25mg
• Patient was sent to theward.

86. Detailed Clinical
Assessment
History
• 3 Preliminary Qs
– In which part of thebody?
– How long ago?
– Brought the snake?Candescribe it?

87. If the snakeisidentified asnonvenomous, patient canbe
dischargedafter abooster dose of Tetanustoxoid.

88. Snake Bite Management
• 1) Snake bites should be treated as
wounds. Antibiotics is given for secondary
infection and Inj. Tetanus toxoid.
• 2) If the patient is completely alright 6-8
hours after the bite, he is usually out of
danger.

89. Snake Bite Management
• To Slow the absorption and spread of the
poison:
• 1) Patient is prevented from walking. Bitten limb
is immobilized, preferably in a splint.
• 2) Strip of cloth or handkerchief or a rubber
tourniquet should applied a few cms. above the
bitten area. Be released every 15 minutes for a
period of one minute.
• 3) Tourniquet should not be too tight .It is just to
occlude venous & lymphatic return

90. Snake Bite Management
• 4) Ice should be applied to and around the bitten
area.
• 5) Immobilize the part .Because movements can
cause more absorption of poison

91. Snake Bite Management
• When there are No signs of Poison –
• Tab Diazepam – 1 tab stat as a
Tranquilizer
• Tab Paracetamol – As Analgesic

92. Snake Bite Management
Haemolytic Type –
• Inj Decadron 2 cc IV stat
• Inj Avil 1 amp IV stat
• Inj ASV 2 to 6 vials IV slowly ( Old
Thought -- AST)
• Repeat Inj ASV ,if local swelling continues
to increase
• Repeat CT ,every 4 to 6 hours

93. Snake Bite Management
Haemolytic Type
• Inj ASV 1 vial ,if Local swelling continues to
increase
• Locally -- around the site-
• Inj ASC -1 to 2 ml
• Elevation of Leg
• Application of Thrombophob ointment
• Megasulph compresses

94. Snake Bite Management
Haemolytic Type
• Local –
• If Oedema is very less then,
• Apply -- Elastrocrepe bandage
• After 6 hours ,remove the bandage + watch Skin
• If necessary -- Reapply

95. Snake Bite Management
Haemolytic Type
• When oedema becomes severe ,Skin
becomes bluish black ,Circulation of toes
is diminished ---
• Then to save the limb ,emergency
Faciotomy incisions must be taken

96. Snake Bite Management
Haemolytic Type
• In advanced cases ,we must look for
Haematuria, Bleeding from other sites like
nose, skin, check urine output.

97. Snake Bite Management
Haemolytic Type --
• In cases of bleeding –
• BT is given
• When possible – Platelet Transfusion is given
• Inj Fibrinogen 300 to 600 mg IV
• Inj Heparin –if DIC [ New Thought in 2014 -
Heparin is ineffective against venom induced
Thrombin and should never be used]

98. Snake Bite Management
Haemolytic Type
• When urine out put reduces –
• Inj Mannitol 300 ml IV
• Inj Lasix 2 amp IV stat & repeat sos
• Inj Decadron 2cc IV – 6 hrly
• In Renal failure ( Urea & Creatinine level
increases) – Peritoneal Dialysis is done

99. Snake Bite Management
In Paralytic Type –
• If Ptosis or Dysphagia develops ,take
immediate action
• If GP & do not have ASV – shift to
appropriate hospital
• Respiratory Paralysis is an Emergency

100. Snake Bite Management
• ASV vial contains powder. Dissolve in 10 ml of sterile
water for injection.
• Give ½ cc IV as Test Dose .Watch for 2 min for Urticaria
• If no allergy ,inject Full dose
• New Thought in 2019 -- Sensitivity tests are no longer
recommended because they are unreliable and may
even lead to sensitisation of patient before the actual
therapeutic dose.

101. Snake Bite Management
• Inj ASV 1 to 4 vials ,slow IV
• Then 1 vial ,every 15 to 30 min ,till the
signs start reversing
• Inj Atropine 2 amp IV ,to control excess
salivation
• Inj Neostigmine 4 amp IV

102. Snake Bite Management
• Symptomatic treatment:
• 1) Inj. Pethidine (not morphine) 50 mg.
I.M. or Inj. Largactil 25 mgm. I.M. is given
for pain.
• 2) Inj. Streptopenicillin
• 3) Inj. Tetanus Toxoid

103. Snake Bite Management
• 4) I.V. steroid is given in massive doses
e.g. in serious patients, 300mgm. Efcorlin
I.V. to start and 200 mgm. as slow I.V. drip
later.
• 5) If B.P. is falling, Inj. Lomodex or glucose
saline with two ampoules of Noradrenaline
or 100 mgm. Inj. Mephentine is added to
the bottle

104. Snake Bite Management
• Associated Treatment – Pain – Paracetamol
• Aspirin or other NSAIDS should not be given –
can excerbate bleeding
• For severe pain – mild opiates – Tramodol 50
mg
• Neostigmine is Anti cholinesterase drug –
prolongs the action of Acetylcholine – revert
respiratory failure & Neurotoxic symptoms – 0.5
mg IM ,half hourly + 0.6 mg of Atropine IV ,over
an 8 hour period by continuous infusion

105. Snake Bite Management
• In Dysphagia – Continuous throat suction
• In Respiratory Paralysis – Endotracheal
Intubation, Artificial Respiration
• Total 10 to 15 vials of ASV may be
required in Respiratory Paralysis

106. Snake Bite Management
• After giving adrenaline 1:1000 solution I.M.
½ c.c. and antihistaminic, 30 c.c. of the
serum should be added to 300 c.c. or
normal saline and given as I.V. drip in 1 to
2 hours.
• [ New Thought in 2019 - Prophylactic
Adrenaline should not be given as a
routine]

107. Snake Bite Management
• Assurance – Relieve fear & Anxiety
• Clean the bite area with soap & water
• Symptomatic & General Treatment --
• Wait & watch – First just give Inj TT+ IV DNS +
Antibiotics, Anti histaminics, Analgesics,
Steroids, Blood Transfusion, Artificial respiration,
Haemodyalysis etc .If absolute No symptoms
except fear & Patient is alright ,not necessary to
give ASV

108. Wait & Watch for min 6 hours
• Look following signs of Poisoning
• 1) Ptosis
• 2) Local swelling
• 3) Dysphagia
• 4) Difficulty in breathing

109. Treatment of absorbed venom
• 1) In Elapids – Alternate 0.6 mg Inj.
Atropine & 0.5 mg Neostigmine
• In paralytic cases – Inj.Adrenaline – s/c &
Inj Calcium chloride – I/M

110. Treatment of absorbed venom
• 2) In Vipers –
• 30,000 to 40,000 Units Inj Heparin
• [Heparin not to be used]
• 300 to 600 gms – Inj Fibrinogen
• Also used are fresh whole blood, Platelets
or Fresh frozen plasma(FFP).

111. Indications for Antivenom
• Signsof systemic envenomation(ARF,Dark
color urine,GeneralizedRhabdomyolysis)
• Haemostatic abnormalities (20WBCT)
• SpontaneusBleeding
• Neurotoxic signs

112. SnakeVenom Antiserum
•
•
•
Only specific antidote to snakevenom
most important decision in themanagement
IVImmunoglobulin (IgG)
•
•
“polyvalent anti-snake venomserum”
CoversCobra,Krait, Russell’sviper, Saw-
scaledviper.
Not againstHumpnosed viper.•

113. Snake Venom Antiserum
• Manufactured by Vins Bioproducts Limited
Survey no 117 Thimmapur (V)
509325,Kothur (Mandal) ,Mahaboobnagar
( Dist) ,Andhra Pradesh,India

114. Snake Venom Antiserum
• Each 1 ml of has capacity of specifically
neutralising the venom of following
species of Snake
• O.60 mg of dried Indian Cobra venom
• 0.45 mg of dried common Krait Venom
• 0.60 mg of dried Russell’s viper venom
• 0.45 mg of dried Saw scaled Viper

115. Snake Venom Antiserum
• Reconstituted antivenin is administered as
soon as possible ,if clear cut signs or
symptoms of envenomation are evident

116. Snake Venom Antiserum
• It can be administered in 2 ways
• 1) Intravenous injections – Reconstituted
antivenin is administered by slow
intravenous injection ( 1 to 2 ml per
minute)
• 2) Infusion – Reconstituted antivenin is
diluted in isotonic saline or glucose
solution ( 5 to 10 ml per kg body weight)

117. Snake Venom Antiserum
• At present there is no simple method to
measure the amount of circulating venom
in the body.
• So dose of Antivenin can not be accurately
recommended
• The dose also depends on the type of
snake bite & severity of envenomation

118. Snake Venom Antiserum
• Presentation – Snake venom antiserum IP
is supplied as freeze dried powder in glass
vials .Sterile water for Injection IP is
supplied in 10 ml vials
• The antivenin is also supplied as 10 ml
liquid in glass vials

119. Snake Venom Antiserum
• Disposal – Left over antivenin & used
empty vials should be discarded as
biomedical waste

120. Snake Venom Antiserum
• 2 vials are usually injected directly by IV
route slowly ( 1 to 2 ml per minute) &
taking care of sensitivity reaction
• 2 more vials are given after half an hour to
one hour ,if the symptoms of
envenomation persists.
• Further dose can be given with IV fluids,till
envenomation symptoms subside

121. Snake Venom Antiserum
• The patient should be closely monitored
for 2 hours
• Local administration of antivenin in or
around the bite site is ineffective ,painful &
may raise intra compartmental pressure
particularly in digits .So not recommended

122. Snake Venom Antiserum
• Antivenin Reactions – Anaphylaxis is life
threatening .
• Anaphylaxis can be rapid onset & can
deteriorate into a life threatening
emergency very quickly
• Patient should be monitored closely & at
the first sign of any of the following ,anti
venin should be discontinued

123. Snake Venom Antiserum
• Anaphylaxis –
• Indicating signs & symptoms – Urticaria,
Itching, fever, chills or rigors, vomiting,
diarrhoea, abdominal cramps,
Tachycardia, Hypotension,
Bronchospasm, angioedema.

124. Snake Venom Antiserum
• Anaphylaxis – 0.5 mg of 1: 1000
Adrenaline IM
• Children – Adrenaline IM – 0.01 mg/kg
body weight

125. Snake Venom Antiserum
• Anaphylaxis – To provide longer term
protection against Anaphylactoid reaction
,100 mg of Hydrocortisone & 10 mg of H1
antihistamine ,IV
• Children – 0.2 mg/kg of Anti histamine IV
& 2 mg /kg of Hydrocortisone IV

126. Snake Venom Antiserum
• Anaphylaxis – If the condition is worsening
,a second dose of 0.5 mg of Adrenaline
1:1000 IM ,may be given

127. Administration of antivenom
Serum
• 3 IV lines
• Keepadrenaline ready in a
syringe 0.5mg (1:1000)
• 10 ampoules of AVS
• Eachdissolved in 10ml of
water
• 100mlAVSinto 200mlof
Normal Saline
• Slow IV infusion for 1hour

128. • Watch for any reaction suchas,
– Fever ,Chills
– Itching,Urticaria
– Bronchospasms
• If aEarlyAnaphylactoid reaction occurs???

129. • StopAVSinfusion
• Giveadrenaline 0.5mg (1:1000) IM
• IV Chlorpheniramine 5mg
• IV Hydrocortisone200mg
• RestartAVSafter the reaction settled
• In Shock----> SublingualAdrenaline

130. More Antivenom??
• Persistant or Recurrent Incoagulability by
20WBCTafter 6 hours
• Further Deterioration

131. How to Administer ASV ?
• 1) Old Thought -- Test Dose – 0.01 ml by
Insulin Syringe s/c --- New Thought --
Not Recommended as unreliable.
• If No Allergic reactions –
• 10 ml Liquid ASV in 500 ml DNS .Speed
30 drops per min
• Constant watch in the Improvement of
Symptoms or Toxic or Side effects of ASV

132. Anti Snake Venom
• 1) Powder form – ASV – By Serum
Institute of India ( SII) –This is PAVS =
Polyvalent Anti snake Venom Serum
.Price – Rs 400/- for Powder to form 10 ml
solution
• Also available Powder by Haffkine Bio
Pharma ,Mumbai .10 ml .Rs 400/-

133. Anti Snake Venom
• 2) Liquid Form – By Bharat
Company,Thane ,Mumbai.For IV – 10 ml
vial .Rs.400/-

134. Snake Bite
• Tab Pinak – Herbal Tablet

135. Investigations
• 20 WBCT
• FBC
• SC& BU
• SE
• SGOT/SGPT
• Blood Grouping
• IPOPchart
ASV & Blood Test
• 1) PT,BT,CT – For
Viperidae ( Ghonas & Phurse )
Haemotoxic

136. 20 minsWhole BloodClotting Test
Incoagulableblood is diagnostic of aviperbite
and rules out an elapidbite

137. Blood Tests
• 20 WBCT : 2ml fresh venous blood collected in Glass
bulb.Keep undisturbed for 20 minutes.Slightly tilt the bulb
and check for clotting.
Normally the blood should have clotted by the end of 20
minutes. Repeat test after 6 hours.
• BT/CT
• Platelet count : May be decreased in viper bite.
• PT : Normal is 12-14 seconds.
• TLC/DLC : May show neutrophil predominant
leucocytosis.

138. Supportive/ancillary treatment
• In severely envenomedpatients
– Assisted ventilation.
– renal dialysis.
– Wound Debridement.
– Fasciotomy.

139. Rehabilitation
• Restoration of normal function in the bitten
part.
• Conventional physiotherapy.

140. LongTerm Complications
• Chronic Ulceration
• Osteomyelitis
• Chronic RenalFailure
• Chronic Neurological deficit

141. CHEMICAL ANALYSIS:
 SKIN ,UNDERLYING TISSUES
SURROUNDING THE FANG
PUNCTURES
 WOUNDS AND BLISTER
ASPIRATE
MEDICOLEGAL ASPECT:
 ACCIDENTAL CASES ARE
SEEN OFTEN .
 FOR SUICIDAL
PURPOSE,NOT YET
REPORTED.
 HOMICIDAL-FOUND N
ANCIENT TIMES,NOW-A-
DAYS ITS VERY RARE.

142. ThankYou…!!