1. Number of Snake bites from January to December 2012 has been 47. Snake bite syndromes were 24.

2. Cases of Snake bite were reported from the months of April to November. There were no reported bites in January, February, March and December.

3. Of all the snake bite syndromes 21 had only neurological presentation 1 had hematotoxic presentation Only 2 had combination of hematotoxic and neurological presentation Only 2 dead snakes were brought to the hospital that also after a lot of insistance

4. Of these patients only 4 required mechanical ventilation No one required dialysis 1 died

5. Facilities available at the centre ICU care 1 mechanical ventilator Blood components for transfusion available from Blood Bank about 35 km away from Dehradun Laboratory tests like Prothrombin time and Partial Thromboplastin test and other biochemical tests

6. Protocol for Snake bite management Paediatric department follows CMC, Vellore and Secondary hospitals mordified version of W.H.O protocol Medicine department projected 2 different versions of care

7. 2 different versions of treatment Version 1 – according to senior resident Version 2 – according to other residents Lab tests at presentation BT/CT, Bld. Urea, S. Creatinine, WBCT, Urine microscopy Lab tests at presentation not mentioned

8. Indications for ASV Version 1 Version 2 Mild/moderate signs and symp – lymph edema, lymphangitis, enlarged lymph nodes, blister and edema at site of bite, bleeding from sight of bite. Sever / generalised signs and symptoms – hemolysis, ptosis, respiratory depression, head lag, prolonged WBCT Mild/moderate symp and signs – cellulitis involving half of bitten limb, rapid progression of edema, bleeding from site of bite, lymphadenopathy, 20 min WBCT Severe signs/ symp – DIC, Hypotension, ARF, Neurotoxicity

9. Treatment of mild/moderate symptoms Version 1 Version 2 For both hematotoxic and neurological bites – 5 vials ASV over 1 hour. Repeat 20 min. WBCT in 30 min. after the dose If WBCT is pronged or if neurological signs/ symp. Repeat 5 vials in 6 hours 5 vials are continued every time for 6 hours if WBCT is pronged or if there are signs of neurotoxicity. For both types of bites a maximum of 20 vials ASV are given For mild/moderates toxicity – 3 vials loading dose over 1 hour. Reassess and repeat WBCT. Then 3 vials are repeated over 4 hours. Repeat 20 min WBCT and reassess. Again 3 vials ASV are repeated over 4 hours. Maximum 12 vials are given.

10. Treatment contd.. Version 2 For sever signs and symptoms – 10 vials ASV are given over 4 hours. Reassessment in neurotoxic bites is done immediately whereas WBCT for hematotoxic bite is repeated in 6 hours. 5 vials of ASV is repeated over 4 hours. The same dose is continued in repeats if required. For neurological bites maximum 20 vials are given. For hematotoxic bites maximum of 30 vials ASV are given

11. Treatment contd.. For neurotoxic snake bites 2 mg neostigmine i.m and 0.6 mg atropine i.v are given. If there is improvent 0.5 mg neostigmine every 30 mins. And atropine 0.6 mg i.v every8hourly Intubate if there is respiratory paralysis and o2 saturation decreased