The management principles are the same as in a tertiary care hospital. But one must know the limitations and facilities at the local hospital level and the correct decisions should be taken when transferring a patient to major institutions. The following facts should be considered:
(1) Infrastructure and the facilities avilable:
Availability of resuscitation facilities, antivenom, endotracheal tubes, ventilators, intensive care facilities, trained manpower, ability for continuous monitoring, ambulance, life support systems in the ambulance.
(2) Severity of envenoming and the species of the offending snake.
1. All krait bites with definitive envenoming (abdominal pain, blurring and double vision could be the earliest signs of envenoming)
2. Hump-nosed viper bite with following complications:
2.1. Severe local effects (blisters and necrosis)
2.2. Acute renal failure (oliguria)
2.3. DIC (bleeding into venepuncture sites is the first sign).
Uncomplicated positive WBCT20 is not an indication
3. Cobra bites with neurotoxicity or significant local swelling
Very often local tissue necrosis needs surgical intervention.
4. Russell’s viper bites with the following complications:
4.2 Acute renal failure,
4.3. Persistently positive WBCT20 or bleeding tendency despite antivenom therapy,
4.4. Intracranial haemorrhage as suggested by altered level of consciousness, focal neurological signs, meningism,
4.5. Paralysis of respiratory muscles,
4.6 Severe local effects.
Uncomplicated local effects, neurotoxicity and coagulopathy can be managed in the local hospital
1. Respiratory paralysis: Development or worsening of respiratory muscles paralysis could occur during transfer. It is recommended to intubate early and to be ready with Ambu bag for assisted ventilation when required. The patient should be accompanied by a Medical Officer and nurse with facilities such as endotracheal tubes, mouth gag, suckers and emergency medications.
2. Pneumothorax: This could happen especially in children due to forceful Ambu ventilation. Hence, a trained and knowledgeable person should do the ventilation under supervision of the doctor.
3. Intubation of right bronchus and collapse of left lung: Accidental slipping of endotracheal tube to right main bronchus might occur during transfer. To avoid this proper anchoring of the endotracheal tube to the face is important. Ausculatation of both lungs should be done at frequent intervals.
4. Allergic reactions to antivenom: Antivenom should be started before transfer under cover of premedications and allergic reactions should be managed accordingly. However, medications should be available in the ambulance during transfer to manage anaphylaxis. In a very urgent transfer such as respiratory paralysis due to krait bite, it is advisable to postpone antivenom administration until the patient reaches a tertiary care unit. However, if the journey is long antivenom should be given in the ambulance.
5. Aspiration of vomitus: The patient should be kept in left lateral position to prevent aspiration of vomitus to the lungs
It is strongly recommended that the specimen of the offending snake, if available should be sent to tertiary care unit along with the patient, preferably in diluted formalin for identification and diagnosis.