SnakebiteSyndromes definitionSeverityTreatment variablesClinical outcomes

Patient presenting with snake bite -snake seen -snake broughtUnknown bite with characteristic

clinical envenomation responding to ASV therapy

1. No envenomation2. Local swelling only3. Haemotoxicity with / without local swelling 4. Neurotoxicity only 5. Neurotoxicity with Local swelling6. Haemotoxicity + Neurotoxicity with / without

local swelling7. Haemotoxicity + Neurotoxicity +renal failure with

/ without local swelling8. Neurotoxicity + myoglobinuria   9. Neurotoxicity + renal failure + muscle pain+ no

local swelling + no Haemotoxicity + bite in the  sea

• Non-venemous biteNo signs of envenomation after 24 hour observation

• Haemotoxicity Hemorrhagic manifestations or Whole blood clotting time › 20 minutes or Deranged PT/PTT

• Neurotoxicity- (any of the below) Ptosis or Opthalmopegia Limb muscle weakness grade 4 or less Respiratory paralysis-paradoxical breathing /

Type 2 respiratory failure/need for intubation

Renal failure- AKIN using RIFLES criteria

Estimated baseline creatinine to be calculated using GFR calculationUsing MDRD formula

Local swelling in the absence of a tourniquet

Enlarged tender lymph node draining the bitten limb

Necrosis, blisteringNecrotising fascitisCompartment syndrome –absent

pulses

• Coagulopathy 1. CT/PT/PTT abnormal- no clinical

bleeding 2. CT/PT/PTT abnormal- clinical bleeding• Paralysis 1. Paralysis not requiring mechanical

ventilation 2. Paralysis requiring mechanical

ventilation/intubation and face mask ventilation

• Renal failure 1. Renal failure not requiring dialysis 2. Renal failure requiring dialysis• Local complication 1. Local complication not requiring

surgical intervention 2. Local complication requiring surgical

intervention• Shock 1. Present 2. Absent

• Local measures-tourniquet ,pressure immobilisation• Antibiotics• Anti-snake venom dose Total dose administered to patient including

dose administered in outside hospital(preparation-company)

• Adrenaline/hydrocortisone• Neostigmine• Ventilation /bagging• Dialysis• Transfusion• ICU care• Referral to higher centre

HaemotoxicityTime to normalisation of CT or PT/PTT NeurotoxictyTime to regaining normal power (except ptosis)Time to extubation Dose of anti-snake venom Duration of ICU care Duration of hospitalisation Allergic reactionsMinor-itching,urticaria,whealsMajor-angioedema,anaphylactic shock,death Mortality

• Proportion of venomous and non-venomous bites

• Proportion of different syndromes• Severity grading of syndromes• Syndrome- species correlation (where

snakes are identified)• Mean anti-snake venom dose according to

(a) syndrome; (b) severity; (c) protocol variations; (d) ASV preparations; (e) geographic location