Venom types (regional) (**Hemotoxic (viperids):** local swelling, bleeding, coagulopathy · **Neurotoxic (elapids):** ptosis, paralysis, respiratory weakness · **Cytotoxic:** tissue necrosis — species and geography determine syndrome (WHO, AAP, national poison centers))
Dry bite vs mimic (~25–50% of venomous snake bites are **dry bites** (fang marks without envenomation) — distinguish from spider bite, cellulitis, trauma, or insect sting; absence of progression over observation supports dry bite (WHO, AAP))
First-line therapy
Paracetamol • p.o. • 10–15 mg/kg/dose • 4×/day
Max 1000 mg/dose · Max 4000 mg/day · Duration: PRN · 10–15 mg/kg/dose q4–6 h PRN — max 60 mg/kg/day or 4 g/day; **avoid NSAIDs early** with hemotoxic venom (bleeding risk) (WHO, AAP)
• **Initial assessment (ABCDE):** time of bite, species if known, geography (viper vs elapid, neurotoxic vs hemotoxic); document fang marks, local pain/swelling, bleeding, neuro symptoms (ptosis, diplopia, respiratory weakness); distinguish snake bite from mimics (spider, cellulitis, dry bite) (WHO, AAP, ERC).
• **First aid (pre-hospital):** move away from snake; reassure, minimize movement; remove jewelry/tight clothing before swelling; rapid transport to hospital with antivenom capability; **pressure immobilization bandage (PIB)** — region-specific (effective for neurotoxic elapids in some regions; NOT universal for all snakes — follow local WHO/national guidelines) (WHO, ERC).
• **Immobilization:** splint limb at heart level or slightly below; avoid unnecessary movement; **do NOT** apply arterial tourniquet; contraindicated measures: NO incision/suction, NO mouth suction, NO electric shock, NO ice/cryotherapy, NO routine prophylactic antibiotics (WHO, AAP).
• **Local envenomation management:** limb elevation, wound care, monitor for compartment syndrome (rare — fasciotomy only after correcting coagulopathy if indicated); **NO NSAIDs early** (bleeding risk with hemotoxic venom) — use paracetamol for pain; opioids if severe pain per local protocol (WHO, AAP).
• **Laboratory monitoring:** coagulation (PT/INR, fibrinogen, D-dimer), FBC, renal function, CK; urinalysis for myoglobin/hemoglobinuria; repeat per clinical course — escalate to systemic variant if coagulopathy, progressive swelling crossing joint, or systemic signs develop (WHO, poison center).
Enter weight on Kids to calculate doses
Escalate to antivenom pathway • procedure
Duration: If progression · Switch to systemic envenomation variant if coagulopathy, neurotoxicity, hypotension, renal failure, or progressive local swelling crossing joint — do not wait for severe symptoms if systemic signs present (WHO, poison center)
• Progressive local swelling crossing joint or involving whole limb — region-specific criteria; antivenom may be indicated even without systemic signs in some protocols (WHO, national toxicology guidelines).
• Laboratory evidence of envenomation: coagulopathy (prolonged PT/INR, low fibrinogen, elevated D-dimer), hemolysis, or myoglobinuria — give antivenom as soon as indicated (WHO).
• Observation period inadequate: elapid bites may require longer observation (24–48 h+ per regional protocol); pit vipers typically 12–24 h minimum (WHO, poison center).
• Tetanus prophylaxis: assess vaccination status at presentation — update Tdap/Td and give TIG if tetanus-prone wound with incomplete primary series (AAP Red Book, WHO wound management).
Clinical notes
• Initial assessment: ABCDE; document time of bite, species/geography, fang marks, local and systemic signs; distinguish dry bite, local envenomation, and mimics (spider, cellulitis) — ~25–50% of venomous bites are dry bites without envenomation (WHO, AAP).
• First aid: minimize movement, remove jewelry, rapid transport to antivenom-capable facility; PIB only per **local** guidelines (effective for some neurotoxic elapids; not universal); NO tourniquets (except trained PIB), incision, suction, ice, or electric shock (WHO, ERC).
• Hospital admission: all suspected venomous bites in endemic areas until envenomation excluded — observe 12–24 h for pit vipers, longer for some elapids per regional protocol; serial exams and labs (WHO, poison center).
• Analgesia: paracetamol first-line; avoid NSAIDs early with hemotoxic venom (bleeding risk); opioids for severe pain; do NOT give prophylactic antibiotics routinely (WHO, AAP).
• Discharge criteria: no progression after adequate observation; stable coagulation (prolonged recovery possible); educate on wound care and return precautions for bleeding, neuro worsening, or swelling — tetanus prophylaxis updated (WHO, AAP).
• WHO — Guidelines for the management of snakebites (2016)
• WHO Pocket Book of Hospital Care for Children — Poisoning and envenomation principles (2022)
• AAP Red Book — Venomous snakebite management (2024)
+ 2 more
• ERC — Paediatric first aid and envenomation principles (2021)
• National poison center / toxicology service protocols (region-specific antivenom and PIB guidance) (2024)
