Snakebite EnvenomationICU / resuscitation

Farmer bitten on the foot while harvesting at night 3 h ago; swelling to the knee, bleeding gums; 20-minute whole-blood clotting test (20WBCT) — blood not clotted (viper); or painless bite, ptosis and difficulty swallowing (krait/cobra)

• 20WBCT not clotted / spontaneous bleeding
• Ptosis, bulbar weakness, falling SpO₂
• Oliguria, dark urine
• Hypotension
• Swelling crossing a joint within hours

• Dry bite / anxiety
• Scorpion sting (autonomic storm, pulmonary oedema)
• Other bites (rodent, insect)
• Guillain–Barré or myasthenia (painless krait neurotoxicity)
• Other causes of coagulopathy

• Admit: Every snakebite for ≥24 h observation
• ICU: Neurotoxic paralysis, shock, AKI needing dialysis, severe bleeding
• Intubate: Bulbar failure, respiratory weakness, falling SpO₂
• Dialysis: AKI with AEIOU indications (often Russell's viper)

• India has the world's highest snakebite mortality — the "Big Four": Russell's viper, saw-scaled viper (haemotoxic), common krait, cobra (neurotoxic).
• 20WBCT is the bedside test that drives ASV — use a new, clean, dry glass tube.
• Early ventilation keeps krait victims alive until the neurotoxicity wears off (days).

• Apply a tourniquet, incise, suck or apply herbs to the bite
• Give ASV to an asymptomatic bite with normal 20WBCT (dry bite)
• Give routine premedication or a test dose of ASV
• Discharge a painless night-time bite before 24 h (krait)
• Give IM injections or NSAIDs to a coagulopathic patient

• Tourniquets and cuts
• Premedication/test dose delaying ASV
• Early discharge of krait bites
• Waiting for ASV to reverse paralysis instead of ventilating

Ward/ICU with ventilator and dialysis access; transfer early if unavailable. Follow-up for AKI recovery and hypopituitarism.