STANDARD TREATMENT GUIDELINES Management of Snake Bite Full Background Document (Draft) January 2016 Ministry of Health & Family Welfare Government of India Management of Snakebite – Full Background Document Ver. 4.0 Contents Introduction ........................................................................................................................................... 4 The Need for the STG ........................................................................................................................ 4 The purpose of the STG ..................................................................................................................... 5 Declaration of Interest ....................................................................................................................... 5 The funding source ............................................................................................................................ 5 3. The Scheduled review .................................................................................................................... 5 4. Scope of the STG ............................................................................................................................ 5 5. List of all recommendations .............................................................. Error! Bookmark not defined. 6. Methodology ..................................................................................................................................... 6 How the relevant guideline(s) were selected as source of recommendation .................................. 7 How recommendations were selected, adopted or adapted ........................................................... 9 Recommendations ................................................................................................................................ 9 Stages of management (WHO) ............................................................................................................ 10 First Aid Treatment Guidelines (Bystanders/victim) ........................................................................... 11 Treatment in the dispensary or hospital ............................................................................................. 17 Signs and symptoms of snakebite .................................................................................................... 17 Asymptomatic Arrival (A2) ............................................................................................................... 18 Symptomatic Patients (A2) .............................................................................................................. 19 CRITICAL ARRIVAL ............................................................................................................................ 24 Non critical arrival and critical arrival after stabilization .................. Error! Bookmark not defined. Diagnosis: Signs and Symptoms of Envenoming .............................. Error! Bookmark not defined. ANTI SNAKE VENOM (ASV) .................................................................................................................. 32 ASV dosage forms ............................................................................................................................... 34 What Can ASV Do and more importantly what can it NOT Do? (A2) .............................................. 34 Swelling and ASV .............................................................................................................................. 38 ASV Safety ........................................................................................................................................ 38 ASV Administration Criteria .............................................................. Error! Bookmark not defined. Inappropriate use of antivenom (WHO) .......................................................................................... 32 How long after the bite can antivenom be expected to be effective? ............................................ 38 How to administer ASV ..................................................................... Error! Bookmark not defined. ASV Dosage ...................................................................................................................................... 35 Initial Dosing Exceptions (A2) .......................................................................................................... 36 Late Administration of ASV ............................................................... Error! Bookmark not defined. ASV and Pregnancy .......................................................................................................................... 39 Paediatric ASV Dosing ...................................................................................................................... 40 Repeat Bites ..................................................................................................................................... 40 Adverse Anti Snake Venom Reactions ................................................................................................. 41 Mechanism of the Reaction ............................................................................................................. 42 Prediction of Adverse Reactions ...................................................................................................... 42 Preventing Adverse Reactions ......................................................................................................... 42 Treatment of Adverse Reactions ..................................................................................................... 43 Contraindications to antivenom: Prophylaxis of high risk patients (WHO) ......................................... 45 Observation of the response to antivenom ......................................................................................... 45 Haemotoxic Envenomation, Blood Products and Renal Impairment .................................................. 52 Hypotension ...................................................................................... 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Persistent or Severe bleeding .......................................................................................................... 53 Management of Snakebite – Full Background Document Ver. 4.0 Role of Anticoagulants ..................................................................................................................... 54 Renal Failure and ASV .......................................................................................................................... 55 Pain, Wound Management and the Surgical Aspects of Snakebite .................................................... 58 Snake Venom Ophthalmia ................................................................................................................... 59 Surgery and Snakebite ......................................................................................................................... 60 Snakebite & Life Threatening Conditions Requiring Surgery .......................................................... 60 Debridement of Necrotic Tissue ...................................................................................................... 60 Compartment Syndrome ................................................................................................................. 61 Conservative treatment when no antivenom is available ................................................................... 63 Follow-up ............................................................................................................................................. 64 Rehabilitation ....................................................................................................................................... 64 Snakebite Management in Basic or Primary Care Facilities ................................................................ 65 At the community or village level (WHO) ............................................................................................ 65 At the rural clinic, dispensary or health post ........................................ Error! Bookmark not defined. At the district hospital .......................................................................... Error! Bookmark not defined. D. At the referral (specialized) hospital ................................................ Error! Bookmark not defined. Conditions and Equipment Accompanying Neurotoxic Referral ......................................................... 65 Equipping a Basic Hospital for Effective Snakebite Management (A2) ............................................... 71 Holding Quantities of ASV/ Stocks of ASV........................................................................................ 71 Snakebite Prevention & Occupational Risk ......................................................................................... 72 Management of Snakebite – Full Background Document Ver. 4.0 Introduction The Need for the STG Snakebite is an acute life threatening time limiting medical emergency. It is a preventable public health hazard often faced by rural population in tropical and subtropical countries with heavy rainfall and humid climate. There is a huge gap between the number of snakebite deaths reported from direct survey and official data. Only 7.23% snakebite deaths