 Snakebite  Syndromes definition  Severity  Treatment variables  Clinical outcomes

 Patient presenting with snake bite -snake seen -snake brought  Unknown bite with characteristic clinical envenomation responding to ASV therapy

1. No envenomation 2. Local swelling only 3. Haemotoxicity with / without local swelling 4. Neurotoxicity only 5. Neurotoxicity with Local swelling 6. Haemotoxicity + Neurotoxicity with / without local swelling 7. Haemotoxicity + Neurotoxicity +renal failure with / without local swelling 8. Neurotoxicity + myoglobinuria 9. Neurotoxicity + renal failure + muscle pain+ no local swelling + no Haemotoxicity + bite in the sea

Non-venemous bite No 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 calculation Using MDRD formula

 Local swelling in the absence of a tourniquet  Enlarged tender lymph node draining the bitten limb  Necrosis, blistering  Necrotising fascitis  Compartment 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

 Haemotoxicity Time to normalisation of CT or PT/PTT  Neurotoxicty Time to regaining normal power (except ptosis) Time to extubation  Dose of anti-snake venom  Duration of ICU care  Duration of hospitalisation  Allergic reactions Minor-itching,urticaria,wheals Major-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