IMMEDIATE FIRST AID
for bites by
(Vipera russelli pulchella
Vipera russelli siamensis)
In the event of an actual or probable bite from a Vipera russelli, execute the
following first aid measures without delay.
- Make sure that the responsible snake or snakes have been appropriately
and safely contained, and are out of danger of inflicting any additional
- Immediately call for transportation.
- Keep the victim calm and reassured. Allow him or her to lie flat and
avoid as much movement as possible. If possible, allow the bitten limb to
rest at a level lower than the victim's heart.
- Identify the bite site, looking for fang marks, and apply the Sawyer Pump
extractor with the largest cup possible over the bite site. If there are two
or more fang marks noted on the limb, apply the pump extractor over at least
one fang mark. If more than one pump extractor is available, they may be
applied to the additional fang marks.
(See the attached copy from "First Aid for Snakebite", by Dr. S.K.
- Immediately wrap a large constricting band snugly about the bitten limb
at a level just above the bite site, ie. between the bite site and the heart.
The constricting band should be as tight as one might bind a sprained ankle,
but not so tight as to constrict blood flow.
- DO NOT remove the constricting band until the victim has reached the
hospital and is receiving antivenom.
- Have the Haffkine Bio-Pharmaceutical Corporation Polyvalent Antivenom
ready for the emergency crew to take with the victim to the hospital. Give
them the following:
- the available antivenom (at least 10 vials)
- the accompanying instruction (Protocol) packet
- the victim's medical packet (if available)
DO NOT cut or incise the bite site.
DO NOT apply ice to the bite site.
Summary for Human Bite
(Vipera russelli pulchella
Vipera russelli siamensis)
The bite of Vipera russelli can be fatal. In Sri Lanka, Burma and India it is
responsible for the majority of snakebite incidents. It is a very dangerous
snake. Large members of some species can easily deliver a lethal dose in
humans. Victims will usually complain of pain at the bite site, and swelling
may be evident. Substantial coagulopathy and acute renal failure may ensue.
Unique to certain subspecies, there has been reported symptoms indicative of a
neurotoxic and myotoxic venom including ptosis, dysarthrias, and generalized
weakness. Prompt medical therapy avoids these problems. Please read the
attached and respond appropriately.
- First Aid:
- Apply a constricting band if not already present, proximal to the bite site
on arms, legs, hands, or feet. Apply suction with the Sawyer Pump extractor
for 10-20 minutes. Rest the extremity below the patient's heart.
- Transport to a medical center emergency or trauma service.
- Medical Management:
- Call your local Poison Control Center or the San Diego Regional Poison
Control Center (800 876-4766). They should locate a consultant to help you
treat this patient.
- Observe for Signs and Symptoms of Envenomation.
- If signs or symptoms are present, perform the following:
- Apply intradermal skin test.
- Administer Lactated Ringers intravenously at a rate of 200 cc/hour.
Obtain appropriate blood and urine laboratory data.
- Wait 20 minutes.
- Reconstitute the contents of 2 vials of Haffkine Bio-Pharmaceutical Corp.
Polyvalent Antivenom with Lactated Ringers solution (10 cc/vial).
- If there is no reaction to the intradermal skin test, administer antivenom
by intravenous infusion over 20 minutes at a rate of 1 vial (10 cc) per 10
minutes. The constricting band can be removed after the first two vials have
been infused. One should anticipate using 2-8 vials or more for minor to
- Monitor signs, symptoms, and laboratory data and administer additional
antivenom in 1 vial (10 cc) increments at a rate of 1 vial per 10 minutes (1
cc/min) as necessary to control the progression of symptoms. Ideally one
should wait 2 hours or less from the first two vials before giving the third
- If the patient is allergic to horse serum, administer 1 gram Solu-Medrol
IV push, wait 30-45 minutes, and then begin intravenous antivenom. Be prepared
to administer Benadryl and epinephrine.
for bites by
(Vipera russelli pulchella
Vipera russelli siamensis)
This person has received a bite and probable envenomation from a Vipera
russelli. This is a dangerous snake, as it can strike with great force and
speed, and deliver greater than the lethal dose in humans. This snake
accounts for the majority of snakebites in southeast Asia. Envenomation
presents predominately with edema, pain, and hematologic manifestations. Unique
to a certain subspecies (Vipera russelli pulchella), there has been reported
symptoms indicative of neurotoxic and myotoxic venom including ptosis,
dysarthrias, and generalized weakness. Vomiting, drowsiness, and epigastric
pain can also be present. In severe envenomations, peripheral circulatory
collapse and acute renal failure may manifest.
Please read and execute the following procedures without delay.
- A constricting band should be in place proximal to the bite site. If
present, leave in place, if not apply a penrose drain as if for venipuncture.
This retards venom absorbtion. DO NOT remove until the patient has
arrived at the hospital and is receiving the antivenom.
- Make sure that at least 10 vials of Haffkine Bio-Pharmaceutical Corp.
Polyvalent Antivenom are present with the patient. This antivenom contains the
necessary fractions to neutralize the venoms of all southeast Asian subspecies
of Vipera russelli.
- If the patient has been envenomated, the initial treatment is 2 vials of
intravenous antivenom. Envenomation is diagnosed by the presence of
characteristic signs and symptoms. Necessary information follows and is
organized in sections:
- Signs and Symptoms of Envenomation
- Medical Management
- General Considerations
- Special Considerations
Signs and Symptoms of Envenomation:
- These signs and symptoms will usually manifest earliest, though their
development will vary considerably from case to case. Not all of these will
necessarily occur, even with severe envenomation.
|Local pain at bite site
|Pain in regional lymph nodes
|Bleeding from distant sites
|Lower back pain
|Tender, enlarged lymph nodes
|Bleeding at bite site
|Local blistering and necrosis
- Systemic envenomation
|Spontaneous systemic bleeding
|Bleeding from gums
|Bleeding from venipuncture sites
|Bleeding from incisions
- General: The above symptoms can manifest within 5 hours after
envenomation. Pain and local bleeding (if present) usually begins within the
first few minutes after the bite. Pain may persist for two weeks or longer.
Swelling is usually greatest 1-4 days after the bite. Unlike the rattlesnakes
and other New World pit vipers, tissue necrosis and local blister formation is
Neurological muscle signs:
||(up to 86%)
|(up to 86%)
Generalized muscle pain & tenderness
|(up to 77%)
Neurological signs generally occur during the first 24-48 hours. Neurological
manifestations gradually improve and disappear by 5-7 days. Myalgias disappear
usually within a few days.
- Hematology: Generally Vipera russelli venom shows both procoagulant (Factor
V, IX, & X activation) enzyme activity and direct fibrinolytic activity.
This presents as a DIC-type coagulopathy, and results in non coagulating blood
Fibrinogen, platelet counts, and hemoglobin levels are generally decreased.
Fibrin microthrombi to renal glomeruli is seen, along with a greater than 50%
occurrence of leucocytosis (11,000-29,000) with 70-90% PMNs. A fall in albumin
may also be expected secondary to a generalized increase in capillary
- Urinary Symptoms and Renal Failure:
||14 - 68%
|Proteinuria (>1 gm/liter)
Oliguria develops rapidly; usually after 1-3 days in systemic envenomations.
Renal-angle tenderness precedes the onset of oliguria in greater than 85% of
the patients, and can be used as a valuable clinical sign of impending renal
failure. Renal failure is usually secondary to acute tubular necrosis (from
fibrin microthrombi), and is often the main cause of death in Russell's Viper
snake bites in Burma.
- Fang Marks: Fang marks may be present as one or more well defined
punctures, as a series of small lacerations, or scratches, or there may not be
any noticeable or obvious markings where the bite occurred. The absence of
fang marks does not preclude the possibility of a bite (especially if a
juvenile snake is involved). The presence of fang marks does not always imply
that envenomation occurred. Multiple bites inflicted by a single snake are
also possible, and should be noted if present. WATCH THE PATIENT CLOSELY.
- Severe Envenomation: One or more of the following clinical pictures can
- Hypotension and increased heart rate secondary to peripheral circulatory
- Acute Renal Failure secondary to acute tubular necrosis.
- Internal bleeding secondary to DIC.
- Neurological symptoms including ptosis, external ophthalmoplegia, and
- Admit patient to an emergency or trauma service, and call the consultant
identified by the Poison Control Center.
- Begin a peripheral intravenous infusion (18 gauge catheter) of Lactated
Ringers Solution at the rate of 250 cc/hr.
- Draw blood from the contralateral arm, and collect urine for the following
laboratory tests. Mark STAT.
- Type and Cross Match TWO units of whole blood.
- CBC with differential and platelets.
- Coagulation Parameters:
- Prothrombin Time (PT)
- Partial Thromboplastin Time (PTT)
- Fibrinogen levels
- Fibrin Degradation Products
- Serum Electrolytes, BUN/Creatinine, Calcium, Phosphorus.
- Lactate Dehydrogenase (with Isoenzyme analysis). Isoenzyme analysis may
indicate multiple targets of venom components which may dictate further
- Urinalysis (Macroscopic and Microscopic Analysis). Must include analysis
- Free Protein
- Electrocardiogram. Place patient on continuous cardiac monitoring.
- Intermittent or indwelling Foley Catheter to monitor urine output may be
necessary in the conscious impaired patient.
- Additional tests as needed or indicated by the patient's hospital
- It may be necessary or practical to repeat some of the above serum and
urine tests periodically over the hospital course to monitor the effects of
antivenom therapy or to detect late changes in laboratory values.
- OBSERVE PATIENT CLOSELY for signs and symptoms of envenomation which
usually manifest between 15 minutes and two hours after the bite occurred.
- If NONE of the signs or symptoms have been noted after two hours, there is
a possibility that the patient received a dry bite (no venom injected).
- Remove the constricting band, watching carefully for any changes in the
patient's status. If any changes occur, assume the patient has been
envenomed, and prepare to give antivenom immediately (as directed below).
- If signs and symptoms still fail to manifest, continue CLOSE observation of
the patient for an additional 12 to 24 hours.
- IF ANY SIGN OR SYMPTOM becomes apparent or has been noted during the course
of treatment, begin antivenom therapy as follows:
- Patients manifesting severe symptoms or are suspected of having an
intravenous injection of venom should be treated immediately with antivenom and
should not undergo skin testing. Corticosteroid adjuncts may facilitate the
delivery of rapid infusion.
- If the patient is exhibiting minor to moderate signs of envenomation, or
has a prior history of anaphylactic or anaphylactoid response to antivenom,
inject intracutaneously the skin test sample included in the antivenom package,
sufficient to raise a small weal.
- The skin test should be read after 15 minutes, but it is wise to check the
test area and observe the patient constantly during the period following the
injection. If there is no evidence of erythema or vesicular response, the test
should be considered negative.
- A positive test IS NOT a contraindication to giving antivenom, but should
alert the clinician that the rate at which the antivenom is delivered and/or
the use of corticosteroids may need to be adjusted to control potential
- Assuming that the above skin testing precautions have been done,
reconstitute the contents of 2 vials of Haffkine Institute Polyvalent
Antivenom. Each vial is packaged as a lyophilized dry preparation in a glass
vial with an accompanying vial of sterile water (to reconstitute the
antivenom). It is preferable to reconstitute the antivenom in Lactated Ringers
solution. The contents of TWO vials of antivenom are to be used as the initial
dose. CAREFULLY score both vials and break open. Withdraw 20ml of room
temperature Lactated Ringers solution into a sterile syringe, and then transfer
10ml to each antivenom vial.
- Carefully mix and reconstitute the antivenom in each vial by covering the
open ends with several thicknesses of sterile gauze sponges, and then shaking
each vial vigorously for one minute or longer. Allow the vials to stand still
for one minute to clear. Withdraw the CLEAR solution into a clean sterile
syringe (leaving froth and undissolved particles behind), and prepare to
transfer to an intravenous piggyback set-up.
- Administer the reconstituted antivenom intravenously over a period of 20
minutes at a rate of 1 vial per 10 minutes (1cc/minute).
- Should any signs of ALLERGY/ANAPHYLAXIS develop (e.g. coughing, dyspnea,
urticaria, itching, increased oral secretions, etc.), immediately discontinue
the administration of antivenom and treat symptoms with Corticosteroids,
Epinephrine, Benadryl, Atarax, and/or other Antihistamines as necessary. As
soon as the patient is stabilized, continue the antivenom infusion at a slower
- After 20 minutes of antivenom administration, the constricting band may be
- If the patient's condition worsens, reapply the constricting band and
immediately infuse a third vial at 1.0cc/minute for 10 minutes. Additional
vials can be administered as above until symptoms/signs are stabilized.
- If the patient's condition persists but is not worsening, a third dose at
1.0cc/minute can be administered 1-2 hours after the initial two vial dose.
Additional vials can be administered as above until the patient's condition is
stabilized. The dose range for mild to severe bites is 2-8 vials.
- Antivenom Therapy is the mainstay of treatment for Vipera envenomation.
Many of the symptoms are ameliorated or entirely eliminated by the antivenom
alone. Other symptoms will require additional specific therapy to correct.
- Acute Renal Failure is seen in systemic envenomation. It may necessitate
- Cardiovascular symptoms are usually seen only in systemic envenomation.
They usually present as hypotension and increased heart rate. Patients should
be treated for peripheral circulatory collapse by continuing peripheral I.V.
infusion of Lactated Ringers at 250 cc/hr and administering vasopressors and
- Hematologic symptoms may present as a Disseminated Intravascular
Coagulopathy, and are treated as other DICs.
- Neurological symptoms are usually mild and transient. Often these are
improved by the antivenom. If breathing becomes impaired, provide respiratory
assistance. Secretions may become copious, necessitating suctioning.
- If severe muscle paralysis develops and persists, administer 0.6 mg of
Atropine IV. Follow by giving 0.5 mg of Neostigmine IV.
- If significant limb swelling occurs, orthopaedic evaluation with
intracompartment and subcutaneous tissue pressure measurements can be obtained.
Surgical debridement or fasciotomy is very rarely if ever indicated.
- It is important to keep venom neutralization current and continuous. The
best method to accomplish this is to keep a close watch on the patient's
status. If the present condition does not improve, or should it worsen for any
reason, additional antivenom should be administered. Give all additional
antivenom in 1 vial increments. Again, dilute the antivenom 1 to 10 in
Lactated Ringers, transfer the solution to an IV piggyback setup, and deliver
over a period of 10 minutes per vial. One should anticipate using 2-8 vials
for minor to severe bites.
- It is advisable to check periodic serum and urine analyses during therapy
as outlined above.
- It is always best to keep the patient in an Intensive Care setting until
free of major symptoms for 24 hours. The patient should be observed in the
hospital for at least 24 hours after the major symptoms abate.
- It is important that the patient be placed at rest, kept warm, and avoid
- Symptom variability: As noted above, the variability of symptoms in viper
envenomation can be great. It is important to note the continual progression
of symptoms throughout the course of therapy, and give additional antivenom as
necessary to titrate these symptoms.
- Fluid management is very important in snakebite cases. The patient
should be well hydrated and a brisk urine output maintained.
- Morphine is CONTRAINDICATED because of its tendency to suppress respiration.
Alcohol should also be avoided.
- In cases where Circulatory Shock remains uncorrected by antivenom
therapy, plasma volume expanders and/or vasopressor agents may be given with
- If the patient remains oligoanuric, peritoneal dialysis should be considered
- Tetanus prophylaxis should be current.
- Antibiotics are NOT recommended prophylactically.
- Local Necrosis: Prompt delivery of antivenom following the bite may lessen
the extent of local tissue damage, although some evidence suggests that certain
antivenoms have less efficacy in ameliorating or protecting against the local
action of Vipera venom. This latter statement should not be held as a
contraindication to the use of antivenom in those Vipera bites in which local
- Multiple Bites: It is possible for Vipera to deliver more than one bite in
a single attack and thus may inject a large volume of venom. If there is
evidence that such an attack occurred (i.e. history or multiple bite sites),
twice the initial dose of antivenom should be given (i.e. 4 vials over 40
minutes at the rate of one vial per 10 minutes). Always watch closely for
signs of allergic response; if they occur, treat appropriately and with a
slower infusion rate. Give all subsequent doses in one vial increments at a
rate of 1 vial per 10 minutes as necessitated by the presence of continued
signs and symptoms.
- Severe Envenomations: If the patient shows severe signs of envenomation,
particularly if early after the bite, treat as a multiple bite, administering 4
vials of antivenom over the first 40 minutes. Give all subsequent doses in one
vial increments at a rate of 1 vial/10 minutes as necessitated by the presence
of continued signs and symptoms.
- Neurological Manifestations: The onset of neurotoxic symptoms can be rapid
and subtle, but usually mild and transient. It may be necessary to wake the
patient and perform a brief neurological check every hour or so to assure that
breathing and other neurological functions are not impaired. Carefully note
the progress of any paralysis which may be present.
If the patient should develop difficulties in breathing or airway management,
respiratory support will be required. If the tongue, jaw, or pharynx become
paralyzed, insert an oral airway; intubation may be required. Make sure
adequate suction equipment is available and operative.
If any signs of Oropharyngeal paralysis or impaired swallowing exist, give
NOTHING BY MOUTH, and keep patient on his side with head down. Watch for
airway compromise and aspiration.
The following references are recommended for further in depth reading. This
material includes case histories, guidelines, and recent findings in snake bite
literature. These should be read only after treatment has begun and the
patient is in stable status.
- Buckley, E.E. and Porges, N.: Venoms, 1956. The American Association for
the Advancement of Science, Washington, D.C.
- Chugh, K.S., Pal, Y., et al.: Acute Renal Failure Following Poisonous
Snakebite. American Journal of Kidney Diseases, IV(1): 30-38, July 1984.
- Date, A. and Shastry, J.C.M.: Renal Ultrastructure in Acute Tubular Necrosis
Following Russell's Viper Envenomation. J. Pathology, 137:225-241, 1982.
- Haffkine Bio-Pharmaceutical Corporation Ltd.: Lyophilized Polyvalent
Anti-Snake-Venom serum (package insert). Parel, Bombay, 400012, India.
- Indraprusit, S. and Boonpucknavig, V.: Acute Interstitial Nephritis after a
Russell's Viper Snake Bite (letter). Clin. Nephrol., 25(2):111, February
- Jeyerajah, R.: Russell's Viper Bite in Sri Lanka: A Study of 22 Cases. Am.
J. Trop. Med. Hyg. 33(3):506-510, 1984.
- Minton, S.: Snake Venoms and Envenomation. Marcel Dekker, Inc. New York,
- Myint, L., Warrell, D., et al.: Bites by Russell's Viper (Vipera russelli
siamensis) in Burma: Hemostatic, Vascular and Renal Disturbances and Response
to Treatment. Lancet, 2(8467):1250-64, Dec. 7, 1985.
- Moore, G., Dewling, H., Minton, S., and Russell, F.: Poisonous Snakes of the
World. U.S. Government Printing Office, Washington, D.C., 1968.
- Pe, T., and Cho, K.A.: Amount of Venom Injected by Russell's Viper (Vipera
russelli) Toxicon, 24(7):730-733, 1986.
- Russell, F.: Snake Venom Poisoning, 2nd. Edition, 1983. Scholium
International, Great Neck, New York.
- Sitprija, V, Suvanpha, R., et al.: Acute Nephritis in Snake Bite. Am. J.
Trop. Med. Hyg. 31(2):408-410, 1982.
- Tu, A.: Chemistry and Molecular Biology, 1st. Edition, 1977. John Wiley
and Sons, New York.
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