Sasidharan et al.

International Journal of Emergency Medicine (2025) 18:50 International Journal of

https://doi.org/10.1186/s12245-024-00796-x
Emergency Medicine

RESEARCH Open Access

Clinical and demographic profiling

of snakebite envenomation in a tertiary care
centre in northern India
Parvathy Sasidharan1, Nidhi Kaeley1*, Prakash Mahala1, Jewel Rani Jose1, Takshak Shankar1, Silpa Santhalingan2,
Ankit Sharma1, Balwant Kumar1, Mallapu Ajay Kumar1 and Minakshi Dhar1

Abstract
Background Snake bites are a major cause of emergency visits in tropical countries like India, with actual mortality
and morbidity likely higher due to underreporting. The aim of the study was to analyze the clinical and demographic
profiles of snake bites at the Department of Emergency Medicine, AIIMS Rishikesh, over two years (July 2021 to July
2023).
Methods Patients aged over 18 with witnessed or suspected snake bites were included. Data on demographics,
clinical history, laboratory parameters, treatment, and outcomes were collected.
Results Most patients were male (68.3%) and aged 31–50 years (35.6%). Farmers made up 57.4% of the cohort.
Bites occurred mostly in the evening (46.5%) and during the monsoon (71.3%). Symptoms varied: 48.5% were
asymptomatic, 31.7% had hemotoxic symptoms, and 15.8% experienced neurotoxic symptoms, including ptosis.
Hemotoxic bites frequently involved bleeding at the bite site (93.8%) and gum bleeding (46.9%). Local complications
were noted in 7.9% of cases. Neuroparalytic bites required ventilatory support in 62.5%. Blood products were
administered to 31% of patients with hemotoxic bites, hemodialysis to 19%, and plasmapheresis and hyperbaric
oxygen therapy to 6.3%. Out of the 69 symptomatic patients (68.3%) who received anti-snake venom (ASV), 28
(40.6%) patients developed adverse reactions.
Conclusion This study provides a detailed analysis of suspected snakebites in Uttarakhand and surrounding areas,
highlighting the importance of early recognition, prompt treatment, and timely referral to prevent fatalities. The
administration of anti-snake venom (ASV) is identified as the most critical intervention, though lack of awareness in
rural areas complicates management. The study calls for targeted public health campaigns to educate communities
about early snakebite recognition and the role of ASV. It also stresses the need for region-specific protocols
and improved healthcare access, emphasizing the importance of referral systems for advanced interventions
like hemodialysis and intubation. Overall, the study advocates for enhanced public awareness and healthcare
infrastructure to reduce snakebite incidence and mortality in rural populations.
Keywords Snake bite, Hemotoxic, Neurotoxic, ASV, Plasmapheresis, HBOT

*Correspondence:
Nidhi Kaeley
[email protected]
1
All India Institute of Medical Sciences, Rishikesh, India
2
All India Institute of Medical Sciences, New Delhi, India

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Sasidharan et al. International Journal of Emergency Medicine (2025) 18:50 Page 2 of 9

Background bites, diagnosis relied on history and clinical features,

Reptile bites, particularly snakebites, are a major cause after excluding other differentials such as neuromuscu-
of emergency visits in tropical countries like India, lar diseases, myasthenia gravis, botulism, Lambert-Eaton
with the WHO estimating 81,000 to 138,000 deaths syndrome, hemolytic anemia, or acute febrile illness.
and 400,000 amputations annually in the Indian sub- Demographic data, clinical history, biochemical and
continent [1]. However, underreporting due to limited hematological parameters, treatment, and outcomes (e.g.,
healthcare access and reliance on alternative treatments mortality, blood product use, hemodialysis, vasopres-
means the true burden is likely higher. The “big four” sor need, complications, mechanical ventilation) were
snakes responsible for envenomation in India—Russell’s recorded.
viper, saw-scaled viper, common krait, and cobra—are
targeted by anti-snake venom (ASV), though increasing Results
cases of humped-nosed pit viper bites lack specific ASV. Of the 101 patients, 69 (68.3%) were male, with most
Snakebites can lead to hematotoxicity, neurotoxicity, and (36, 35.6%) aged 31–50 years. The majority were farm-
myotoxicity, with delayed treatment resulting in life- ers (58, 57.4%). Bites typically occurred between 4 p.m.
threatening complications like hypotension, paralysis, and 7 p.m. (47, 46.5%) and were most common during
bleeding, acute kidney injury, and severe tissue destruc- the monsoon season (June–September) (72, 71.3%). Most
tion. Underreporting hampers public health efforts, mak- patients (47, 46.5%) were from Uttarakhand, with oth-
ing it crucial to raise awareness and improve access to ers from Uttar Pradesh (36, 35.6%), Himachal Pradesh
timely treatment. (12, 11.8%), and Haryana (6, 5.9%). Eighty-seven patients
(86.1%) had lower limb bites, and 12 (11.8%) had upper
Methodology limb bites. Most patients arrived at the hospital 12–24 h
This retrospective-prospective observational study, after the bite (87, 86.1%) (Table 1).
conducted in the Department of Emergency Medicine Pre-hospital treatments varied: 40 patients (39.6%)
at AIIMS, Rishikesh, aimed to analyze the clinical and received no treatment, 11 (10.8%) received 10 vials of
demographic profiles of snakebite cases over two years. anti-snake venom (ASV), 9 (8.9%) received 2–5 vials,
Variables studied included age, sex, occupation, bite loca- and 27 (26.7%) underwent traditional practices such as
tion, time of occurrence, seasonal variations, complica- cutting the bite site or applying irritants. At our center,
tions, snake species, clinical manifestations, treatment 56 patients (55.4%) received ASV, with up to 20 vials for
modalities, and outcomes. The two-year timeframe was neurotoxic bites and about 30 vials for hemotoxic bites.
chosen following the establishment of a toxicology fel- Among those with a history of snakebite, 49 (48.5%)
lowship at the institution in 2022, which included a were asymptomatic, 32 (31.7%) hemotoxic, and 16
dedicated ICU for toxicology patients, enhancing special- (15.8%) neurotoxic. Neurotoxic symptoms included
ized care for snakebite victims. The retrospective por- ptosis, ophthalmoplegia (14, 87.5%), respiratory paraly-
tion used electronic records (e-hospital@NIC) from July sis (10, 62.5%), dysphagia (10, 62.5%), limb paralysis (6,
2021 to July 2022, including patients aged 18 years and 37.5%), and unconsciousness with a GCS < 8 (2, 12.5%).
older with a snakebite history. Their clinical and demo- Hemotoxic symptoms included subconjunctival hemor-
graphic details will be obtained from the electronic medi- rhage, ecchymosis, and intracranial bleed (1 case each,
cal records of the hospital (e-hospital@NIC). The details 3.1%), gum bleeding (15, 46.9%), hematuria (12, 37.5%),
regarding site of bite, timing of bite, time of presentation hematemesis (9, 28.1%), and local bleeding (30, 93.8%).
to the ED, details of the pre hospital treatment, clinical Renal dysfunction occurred in 17 (53.1%) hemotoxic
features were noted. The treatment given as well as out- cases, with 7 (21.8%) having acute kidney injury and 10
come of all the patients were documented. The details (31.2%) experiencing oliguria with metabolic acidosis.
of the relevant blood investigations were obtained from Six (18.8%) needed hemodialysis, and two (6.3%) under-
the records. The prospective portion, covering July 2022 went plasmapheresis. Local complications included
to July 2023, included patients with witnessed snakebites cellulitis (5, 4.9%), necrotizing fasciitis (2, 1.98%), and
or clinical signs of hemotoxic or neurological envenom- compartment syndrome (1, 0.99%) (Table 2A, 2B). Of the
ation. Exclusion criteria included patients without con- 8 patients with local complications, 5 (62.5%) required
sent, those who absconded or discharged against medical surgical intervention, including fasciotomy or debride-
advice, and those with incomplete medical records. ment, while 3 (37.5%) needed skin grafting.
Convenience sampling was used, screening all patients All patients with hemotoxic snakebites exhibited ele-
with a possible history of snakebite for neurological vated bleeding time (BT) and clotting time (CT) and a
symptoms (e.g., diplopia, dysphagia, dysarthria, ptosis) mean activated partial thromboplastin time (APTT) of
or hemotoxic manifestations (e.g., bleeding, hematuria, 33.65 s and a PT/INR of 25.19/2.45 s (Table 3).
hemoptysis, hematemesis, purpura). For unwitnessed
Sasidharan et al. International Journal of Emergency Medicine (2025) 18:50 Page 3 of 9

Table 1 Socio demographic profile of patients with snake bite

Age < 19 years 13 12.9%
19–30 24 23.8%
31–50 36 35.6%
> 50 28 27.7%
Gender Male 69 68.3%
Female 32 31.7%
Occupation Farmer 58 57.4%
Student 8 7.9%
Home maker 10 9.9%
Snake charmer 3 2.97%
Others 22 21.8%
Time of bite Morning (6 am to 12 pm) 18 17.8%
Afternoon (12pm to 4pm) 8 7.9%
Evening (4pm to 7pm) 47 46.5%
Night (7pm to 6 am) 25 24.8%
Not known 4 3.96%
Season Monsoon (June to September) 72 71.3%
Winter (October to February) 20 19.8%
Summer (march to may) 9 8.9%
Geographical area Uttarakhand 47 46.5%
Uttar Pradesh 36 35.6%
Haryana 6 5.94%
Himachal Pradesh 12 11.9%
Site of bite Upper extremity 12 11.9%
Lower extremity 87 86.1%
Trunk 1 0.99%
Others 1 0.99%
Time of presentation < 12 h 7 6.9%
12 to 24 h 87 86.1%
> 24 h 7 6.9%
Local treatments False beliefs Local application of substances like chilli/ turmeric/local herbs 12 11.9%
Attempts at sucking the venom 5 4.9%
Washing the site of bite 7 6.9%
Placing incision over the site of bite 3 2.97%
Torniquet 14 13.9%
ASV 11 10.9%
Incomplete ASV (2 to 5 vials) 9 8.9%
No treatment 40 39.6%

Among 16 neurotoxic patients, 10 (62.5%) needed adverse reactions. The most common reactions included
mechanical ventilation, with 2 (12.5%) developing ven- fever, chills, and rigor (64.2%), followed by nausea and
tilator-associated pneumonia and 3 (18.8%) undergo- vomiting (46.4%) and itching (42.9%). Severe reactions
ing tracheostomy. The remaining were successfully included respiratory distress (17.9%) and anaphylactic
extubated. (Table 4). Hemotoxic snake bite patients (32, shock (10.7%).
31.7%) required blood products (10, 31.2%), 6 (18.8%)
required hemodialysis and 2 (6.3%) required plasmapher- Discussion
esis. Hypotension with vasopressor support occurred in India accounts for nearly half of the world’s snakebite-
6 patients (19%), while 3 (9.4%) had local reactions, and 2 related deaths, a critical issue often overlooked in global
(6.3%) required mechanical ventilation. 2(6.3%) patients health discussions. In 2017, the WHO recognized snake-
were given hyperbaric oxygen therapy for the manage- bite envenomation as a neglected tropical disease and
ment of the local wound necrosis. (Table 5). The mortal- launched a strategy to reduce deaths and disabilities by
ity was similar in both the groups. (Table 6). 2023 [2, 3]. Timely access to antivenom (ASV) is crucial
In our study, 69 symptomatic patients (68.3%) received to preventing fatalities [4]. Uttarakhand, with its hilly
anti-snake venom (ASV), with 28 (40.6%) developing terrain and forests, is home to over 30 snake species,
Sasidharan et al. International Journal of Emergency Medicine (2025) 18:50 Page 4 of 9

Table 2 Clinical profile of patients with snake bite Table 5 Treatment modalities used in patients with hemotoxic
A snake bites neurotoxic snake bites
Asymptomatic 49 48.5% Modality Hemotoxic bites Neuro-
Neurotoxic 16 15.8% (32) toxic
bites (16)
Hemotoxic 32 31.7%
Anti Snake Venom 32 (100%) 16 (100%)
Local reaction 8 7.9%
Blood product transfusion 10(31%) 0
B
Vasopressor support 6 (19%) 0
Neurotoxic Ptosis 16 100%
Dialysis 6 (19%) 0
16(15.8%) Dysphagia 10 63%
plasmapheresis 2 (6%) 0
Ophthalmoplegia 14 88%
HBOT 2(6%) 0
Limb paralysis 6 38%
Surgical intervention 3 (9%) 2 (13%)
Unconsciousness 2 13%
Mechanical ventilation 1 (3%) 10 (62.5%)
Respiratory paralysis 10 62.5%
Hemotoxic Ecchymosis 1 3%
including venomous ones like the cobra, krait, viper, and
32 (31.7%) Gum bleeding 15 47%
Local bleeding 30 94%
king cobra [5]. Our hospital also treats patients from
Subconjunctival haemorrhage 1 3%
neighboring regions of western Uttar Pradesh and south-
Haematuria 12 38%
ern Himachal Pradesh.
Hematemesis 9 28% Our study found that snakebites were more common
Intracranial bleed 1 3% among males (68.3%), consistent with Bhalla et al. (66%)
Acute renal failure 17 53% and Bhat et al. (70%) [6, 7]. Unlike Russell et al. (1979)
Shock 10 31% [8] and Bhalla et al. (2014) [6], who identified the 14–30
Local reactions Cellulitis 5 63% age group as most affected, we observed the highest
8(7.9%) Necrotizing fasciitis 2 25% incidence in the 31–50 age group, likely due to regional
Compartment syndrome 1 13% differences. Most patients (57.43%) were farmers, fol-
lowed by homemakers (9.9%), students (7.92%), and
Table 3 Lab profile of patients with hemotoxic snake bite snake charmers (2.97%), in line with findings by Bhat et
Parameter Mean value Standard deviation al. [7], Saini et al. [9], and Sarangi et al. [10]. The male
aPTT (21–30) 33.65 5.08 predominance and higher vulnerability among farmers
PT (12.3 s) 25.19 3.42 are consistent with studies by Satyanarayan et al. [11] and
INR (0.97) 2.45 0.67 Patil et al. [12]. Additionally, 21.78% of bites occurred
Total bilirubin (0.3–1.2 mg/dl) 1.55 0.81 during outdoor activities like walking through forests or
Haemoglobin (13–17 g/dl) 10.41 2.02 trekking.
Platelet (1.5-4.5lakh/uL) 1.76 0.80 Lower extremity bites accounted for 86.1% of cases,
Urea (17–43 mg/dl) 99.25 89.48 similar to Anurekha et al. [13], as accidental stepping on
Creatinine (0.72–1.18 mg/dl) 2.52 1.2 snakes is common in tropical countries. This contrasts
with non-tropical regions, where snake handling inju-
Table 4 Duration of mechanical ventilation in patients with ries are more frequent [14]. In rural India, where bare-
neuroparalytic snake bites foot walking in the dark is common, over 90% of bites
Duration No of cases Percentage result from accidental encounters. Most bites occurred
Less than 24 h 3 18.8% in the evening (46.5%), followed by night (24.8%), morn-
24–48 h 2 12.5% ing (17.8%), and afternoon (7.9%), aligning with studies
> 48 h 5 31.3% by Bhat et al. [7], Virmani et al. [15], and Vora et al. [16],
indicating that evening bites are linked to agricultural
Table 6 Outcomes of patients with snake bite activities and reduced visibility in tall grass.
Outcome Neurotoxic Hemo- India’s tropical climate causes seasonal variations in
(16) toxic (32) snakebites. In our study, 71.3% of bites occurred during
Need for mechanical ventilation 10 (62.5%) 2 (6.25%) the monsoon (June–September), 19.8% in winter (Octo-
Need for hemodialysis/ plasmaphersis - 7(21.9%) ber–February), and 8.9% in summer (March–May). The
Need for blood product administration - 10(31.3%) monsoon peak aligns with Banarjee et al. [17] and Vora
Need for surgical interventions 2(12.5%) 3(9.4%) et al. [16], while Bhat et al. (2014) reported 51.3% in sum-
ICU admission 10 (62.5%) 14 (43.8%) mer [7]. Neuroparalytic bites peaked at the end of sum-
Death 1 (6.3%) 2(6.3%) mer and beginning of monsoon, with hemotoxic bites
more common in winter [6]. The monsoon peak is likely
Sasidharan et al. International Journal of Emergency Medicine (2025) 18:50 Page 5 of 9

due to increased agricultural activity and heightened patients, 49 (48.5%) were asymptomatic, 32 (31.7%)
snake movement from heat and rainfall [18, 19]. had hemotoxic symptoms, and 16 (15.8%) exhibited
Patients presented within three time categories: under neurotoxic symptoms. This aligns with studies where
12 h, 12–24 h, and over 24 h. The majority (86.1%) arrived hemotoxic bites were most common (Biju et al. [22],
within 12–24 h. Delays in treatment were due to remote Gopalakrishnan et al. [23]), though Patel et al. [24]
locations, inadequate transportation, patient negligence, reported more neurotoxic bites. The higher rate of
lack of awareness, and referral delays. Despite 67 primary asymptomatic cases may reflect regional species differ-
health centers (PHCs) and 50 community health cen- ences or better identification of non-venomous bites.
ters (CHCs) in Uttarakhand, 39.6% of patients received Consistent with Bhalla et al. [6], ptosis (16 cases,
no prior treatment, often relying on local remedies that 100%) was the most common neurotoxic symptom, fol-
worsen conditions, leading to complications like celluli- lowed by ophthalmoplegia (14 cases, 88%), dysphagia,
tis, compartment syndrome, and gangrene. and respiratory paralysis (10 cases, 62.5%). Limb paraly-
Tourniquet use was seen in 14 (13.9%) of patients. sis occurred in 6 cases (38%), and 2 patients (13%) had
Tight torniquets can cause reperfusion injury and acute a Glasgow Coma Scale (GCS) < 8. Respiratory paralysis
kidney injury [20]. But in our study, we didn’t come was identified by a breath count under 20, breath-hold-
across any cases of reperfusion injury, possibly because ing time under 30 s, or inability to hold the neck against
they were removed cautiously. Standard protocols were gravity. Krait bites in northern India have been linked to
followed for controlled removal, with a pulse distal to locked-in syndrome [25], and neurotoxicity from cobra
the tourniquet checked before removal. For venomous and krait bites affects muscles involved in eye movement,
bites, a loading dose of ASV was given to reduce venom swallowing, and breathing. Our study did not categorize
surge risk. Nonvenomous bites had tourniquets removed envenomation severity, and no cases of delayed neurotox-
after an IV line was established. Multiple ligatures were icity were observed. Venom toxins cause neuromuscular
released in the emergency room, except for the most blockade through presynaptic (beta-neurotoxins) and
proximal, which was removed upon hospital admission. postsynaptic (alpha-neurotoxins) mechanisms, depleting
Blood pressure cuffs used for venom release were inflated acetylcholine vesicles or inhibiting acetylcholine bind-
20–30 mmHg above the patient’s systolic blood pressure ing [26, 27]. While regional variations in neurotoxic and
(SBP) to occlude venous return while maintaining arterial hemotoxic bites have been reported, our findings do not
flow, then deflated slowly over 10–15 min with continu- support this pattern [28].
ous monitoring. Immediate interventions were initiated In our study, hemotoxic bites were the most common,
if distress signs, such as hypotension or respiratory dif- accounting for 32 cases (31.7%). These bites, primar-
ficulty, occurred, ensuring patient safety. ily from viper envenomation, presented with symptoms
While some primary hospitals administered anti-snake such as local bleeding (94%), gum bleeding (47%), hema-
venom (ASV), 8.9% of patients received incomplete turia (38%), hematemesis (28%), subconjunctival hemor-
doses, highlighting the need for standardized protocols. rhage (3%), ecchymosis (3%), and intracranial bleeding
Prolonged bite-to-needle time increases the risk of sys- (3%), consistent with previous studies [6]. Hemotoxic
temic envenomation, raising morbidity and mortality venoms disrupt coagulation, leading to venom-induced
[21]. The high percentage of untreated patients in Utta- consumption coagulopathy (VICC) and depleting fibrin-
rakhand underscores the urgent need for improved pub- ogen and coagulation factors II, V, VIII, and X. C-type
lic health campaigns and infrastructure to ensure timely lectins, disintegrins, and metalloproteinases contribute
access to antivenom and life-saving treatments. to thrombocytopenia [29].
In our study, all hemotoxic snakebite patients had ele- Treatment followed the National Health Mission
vated bleeding time (BT) and clotting time (CT), consis- (NHM) guidelines [30], with up to 30 vials of anti-snake
tent with Bhalla et al., Saini et al. [6, 9], and Anurekha et venom (ASV) for hemotoxic bites and 20 vials for neuro-
al. [13]. These parameters normalized within 3–4 days toxic bites. Patients with severe hemotoxic envenomation
after receiving full doses of ASV and blood transfusions, received 30 vials. We conducted clinical assessments and
with Anurekha et al. reporting quicker CT normaliza- laboratory investigations, including coagulation tests,
tion (8.1 to 18 h). Hemotoxic bites also caused abnormal CBC, renal function, and electrolyte evaluations, in line
prothrombin time (PT), with an average activated partial with NHM protocols. Polyvalent ASV was adminis-
thromboplastin time (APTT) of 33.65 s and PT/INR of tered intravenously, adjusted based on clinical response.
25.19/2.45 s. Supportive care included blood products (fresh frozen
Our study categorized snakebites based on symp- plasma, platelets, cryoprecipitate), pain management,
toms rather than snake species, as many patients could and fluid resuscitation.
not identify the snake, and in several cases, the bite was For neurotoxic cases, treatment followed NHM guide-
unwitnessed or could not be identified. Among 101 lines, including ASV and measures for neuromuscular
Sasidharan et al. International Journal of Emergency Medicine (2025) 18:50 Page 6 of 9

paralysis. Symptoms such as ptosis, diplopia, difficulty 8 patients with local complications, 5 (62.5%) required
swallowing, and respiratory distress were managed with surgical intervention, including fasciotomy or debride-
atropine (0.5–1 mg IV) for bradycardia and secretions, ment, and 3 (37.5%) needed skin grafting. Compartment
and neostigmine (0.5–1 mg IV) to reverse neuromus- syndrome was identified by signs such as pale skin, weak
cular blockade, adjusted based on paralysis severity. In pulses, tight swelling, severe pain, and loss of move-
suspected krait bites, calcium gluconate (10–20 mL of ment. Necrotizing fasciitis presented with flu-like symp-
10% solution IV) was given to stabilize the neuromuscu- toms, progressing to tissue redness, swelling, death, and
lar junction. Supportive care included continuous moni- sepsis [42, 43]. Imaging with ultrasound and CT scans
toring of vital signs, respiratory and renal function, and facilitated early diagnosis. For persistent swelling, broad-
mechanical ventilation for severe muscle weakness or spectrum antibiotics and magnesium sulfate compresses
respiratory failure. Fluid management, electrolyte correc- (2–3 times/day for 5–7 days) were used. Limb elevation
tion, and pain relief with analgesics were also provided. showed uncertain effectiveness. Antivenom reversed
Acute kidney injury (AKI) was diagnosed in 17 patients coagulopathy and reduced edema, while corticosteroids
(53%) using AKIN criteria [31]. Patients presented with were avoided. Severe cases required surgical referral for
oliguria and metabolic acidosis, with 7 (19%) requiring debridement and fasciotomy [44, 45].
hemodialysis and 2 (6.3%) undergoing plasmapheresis. Venom enzymes like hyaluronidase and phospholipase
The correlation between AKI and the timing of ASV A2 cause edema, blistering, and tissue necrosis, with
administration remains debated, though some studies viper bites leading to bruising, blistering, and delayed
suggest dark urine may indicate AKI [32]. Hemodialy- necrosis. Incorrect practices, such as pressure bandages
sis decisions followed National Health Mission guide- or irritants, can worsen damage. Timely surgical inter-
lines [30]. Thrombotic microangiopathy (TMA), seen in vention is essential to prevent infection and preserve
patients with venom-induced consumption coagulopathy limb function. Hyperbaric oxygen therapy, used in 2 (6%)
(VICC), resulted in microangiopathic hemolytic ane- patients with hemotoxic bites, improved tissue oxygen-
mia and thrombocytopenia. TMA treatment typically ation and healing, potentially reducing the need for fas-
involves hemodialysis, with recent studies suggesting ciotomy [46].
plasmapheresis may offer additional benefits [33, 34]. The In our study, 69 symptomatic patients (68.3%) received
use of hemodialysis (19%) and plasmapheresis (6.3%) in anti-snake venom (ASV), with 28 (40.6%) develop-
our study aligns with Dhikav et al. [35], underscoring the ing adverse reactions. The most common were fever,
importance of tertiary care. Plasmapheresis, a category chills, and rigor (64.2%), followed by nausea and vomit-
III, grade 2 C recommendation by the American Soci- ing (46.4%) and itching (42.9%). Severe reactions, such
ety for Apheresis (ASFA), was used for snakebite-related as respiratory distress (17.9%) and anaphylactic shock
TMA and diffuse alveolar hemorrhage [36–38]. (10.7%), were less frequent. High-risk individuals were
In our study, 10 (62.5%) patients with neurotoxic snake- closely monitored and given prophylactic hydrocortisone
bites required mechanical ventilation, with 5 (31.3%) (200 mg) and chlorpheniramine (22.75 mg) before ASV,
needing it for over 48 h and 3 (18.8%) undergoing tra- with 2 h of observation and epinephrine on standby. In
cheostomy. One patient died from aspiration pneumo- case of adverse reactions, ASV infusion was stopped, and
nia, sepsis, and multiorgan dysfunction. These findings treatment with epinephrine (0.5 mg IM), chlorphenira-
are consistent with Bhalla et al. [6], who reported a 71% mine (10 mg IV), and hydrocortisone (100–200 mg IV)
mechanical ventilation rate, mostly for less than 24 h. was initiated. If no improvement occurred in 8 min, a
Spontaneous bleeding in hemotoxic envenomation second dose of epinephrine was given. ASV was slowly
was managed with FFP, RDP, or cryoprecipitate. Of 32 reinitiated once symptoms resolved. For severe anaphy-
hemotoxic cases, 10 (31%) required blood components, laxis, a desensitization protocol was followed, and for
including 4 (12.9%) with thrombotic microangiopathy pyrogenic reactions, chlorpheniramine and paracetamol
who received packed red blood cells and platelets. One were administered with close monitoring.
patient died from cerebral venous sinus thrombosis, and Given the critical nature of snakebite management in
another succumbed to coagulopathy, sepsis, and septic rural areas, our institution has focused on strengthen-
shock after 5 days, consistent with previous studies [6]. ing peripheral healthcare by training medical officers in
Hypotension occurred in 10 (31%) patients, with 6 (19%) community health centers (CHCs) to manage snakebites
requiring vasopressors. The causes of shock in snake bite effectively. We organize annual Continuing Medical Edu-
include blood loss, septic shock, or rarely hypopituita- cation (CME) programs in alignment with International
rism, which respond to glucocorticoid treatment [39–41]. Snakebite Awareness Day to update medical officers on
Local complications, including cellulitis [5], necrotizing the latest treatment protocols, particularly timely anti-
fasciitis [2], and compartment syndrome [1], were found snake venom (ASV) administration. These sessions cover
in 8 (7.9%) patients, lower than in other studies. Of the snake identification, symptom assessment, and early
Sasidharan et al. International Journal of Emergency Medicine (2025) 18:50 Page 7 of 9

intervention strategies. Additionally, we collaborate with which often require advanced interventions like intu-
the Uttarakhand State Council for Science and Technol- bation, hemodialysis, and blood transfusions. Given
ogy (UCOST) to host a toxicology conference, bringing the resource constraints in rural areas, it is essential for
together healthcare professionals, public health officials, healthcare systems to strengthen referral pathways to
and experts to discuss best practices and recent treat- facilitate the quick transfer of patients to higher-level
ment advances. These initiatives aim to empower rural facilities equipped with appropriate resources, accompa-
medical officers with the necessary skills to improve nied by thorough referral documentation.
patient outcomes and support healthcare infrastructure. In conclusion, the findings from this study could serve
In Uttarakhand, healthcare workers are crucial in as a foundation for the development of region-specific
managing snake envenomations due to the region’s geo- public health strategies aimed at reducing both the
graphical challenges. Many remote areas lack advanced incidence and mortality associated with snakebites. By
medical facilities, and trained professionals often serve enhancing public awareness, improving access to treat-
as the first line of defense. The National Action Plan for ment, and strengthening referral systems, healthcare sys-
Snake Envenoming (NAPSE) highlights the importance tems can significantly reduce the burden of snakebites in
of specialized training for healthcare workers in snake- rural populations, ultimately improving health outcomes
bite recognition, ASV administration, and management in these vulnerable communities.
of complications like coagulopathy and respiratory dis-
tress. NAPSE training is essential in Uttarakhand, where Limitations of the study
delayed treatment and low public awareness are com- Our study has several limitations. Being single-cen-
mon. Healthcare workers must also understand the tered, the findings are specific to a tertiary care hospital
region’s terrain and transportation challenges to make and may not be fully representative of other regions or
informed decisions about patient transfers. By integrat- healthcare settings. The lack of snake species identifica-
ing NAPSE training, Uttarakhand can develop a network tion limits venom-specific management insights, and
of skilled professionals capable of providing optimal care, variability in pre-hospital treatments, such as inconsis-
regardless of location. tent tourniquet use and traditional practices, was noted
but not evaluated for its impact. Many patients presented
Conclusion 12–24 h post-bite, potentially influencing outcomes
This study provides a detailed analysis of the clinical and and underestimating the benefits of early intervention.
demographic patterns of suspected snakebites in Uttara- The study’s limited sample size also restricted subgroup
khand and surrounding areas, offering valuable insights analyses, particularly between neurotoxic and hemotoxic
into local practices and response strategies. The findings bites. Additionally, long-term outcome assessments were
highlight the critical importance of early recognition of not conducted, preventing insight into chronic compli-
envenomation, prompt initiation of treatment, and timely cations. Generalizability is limited due to ecological and
referral to advanced medical facilities to prevent fatali- institutional differences, and patient recall may introduce
ties. The administration of anti-snake venom (ASV) is bias. Preventive measures, like public education, were
identified as the most crucial intervention for saving not thoroughly explored, which are essential in reducing
lives. However, the widespread lack of awareness about snakebite incidents. Further, the lack of comparison with
the severity of snakebites and the urgency of timely treat- lower-level hospitals, such as Community Health Cen-
ment complicates effective management, particularly in ters (CHCs), is another limitation. The study focused on
rural areas with limited healthcare access. cases treated at our tertiary center, which tends to handle
The study emphasizes the urgent need for targeted more severe cases, leading to a higher venomous rate
public health initiatives in remote communities, where compared to peripheral settings, where less severe cases
treatment delays are most prevalent. Public aware- are managed initially. The limited transport facilities and
ness campaigns that focus on the early recognition of underreporting of cases in remote areas of Uttarakhand
snakebites, the importance of seeking immediate medi- further complicate drawing conclusive evidence regard-
cal attention, and the critical role of ASV in preventing ing the clinicoepidemiological profile. These limitations
fatalities could significantly improve patient outcomes. suggest the need for larger, multicenter studies to validate
Additionally, developing community-specific treatment and expand upon our findings.
protocols could equip local healthcare workers to man-
age snakebites more effectively, reducing the need for Take home message
unnecessary referrals to distant medical centers. This study underscores the critical need for early recog-
Furthermore, the study sheds light on the potential nition and prompt treatment of snake bites, particularly
complications of snake envenomation, such as respira- in rural areas where healthcare access is limited. The
tory paralysis, acute kidney injury, and coagulopathy, timely administration of anti-snake venom (ASV) is vital
Sasidharan et al. International Journal of Emergency Medicine (2025) 18:50 Page 8 of 9

4. Gutiérrez JM, Casewell N, Laustsen AH. Progress and challenges in the

in preventing fatalities, but widespread lack of aware- field of snakebite envenoming therapeutics. Annu Rev Pharmacol Toxicol.
ness complicates effective management. Targeted public 2024;64:1–19. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​1​4​6​​/​a​​n​n​u​​r​e​v​​-​p​h​a​​r​m​​t​o​x​-​1​2​1​6​2​3​-​0​9​2​4​4​2.
health interventions, including education on snakebite 5. Mongabay-India. Mapping snakes in Uttarakhand for safer coexistence with
humans. Available from: ​h​t​t​p​​s​:​/​​/​i​n​d​​i​a​​.​m​o​​n​g​a​​b​a​y​.​​c​o​​m​/​2​​0​2​0​​/​0​5​/​​m​a​​p​p​i​​n​g​-​​s​n​a​
identification and treatment, as well as improved refer- k​​e​s​​-​i​n​​-​u​t​​t​a​r​a​​k​h​​a​n​d​​-​f​o​​r​-​s​a​​f​e​​r​-​c​o​e​x​i​s​t​e​n​c​e​-​w​i​t​h​-​h​u​m​a​n​s​/. Accessed August 21,
ral systems, are essential to improving outcomes in these 2024.
underserved communities. Strengthening local health- 6. Mhaskar D, Agarwal A, Bhalla G. A study of clinical profile of snake bite at a
tertiary care centre. Toxicol Int. 2014;21(2):203–8. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​4​1​0​3​​/​0​​9​7​
care practices and creating accessible treatment proto- 1​-​6​5​8​0​.​1​5​1​6​5​8.
cols will be key in reducing snakebite-related mortality 7. Bhat RN, Singh AB, Gupta S, Kumar R, Sharma P, Patel J. Viperine snake bite
and morbidity. poisoning in Jammu. J Indian Med Assoc. 1974;63(12):383–92. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​
/​​1​0​.​​1​0​3​8​​/​s​​4​1​5​9​8​-​0​1​9​-​5​6​6​6​2​-​5.
Abbreviations 8. Russell FE, Emery JA. Effects of corticosteroids on lethality of Ancistrodon
ASV Anti Snake Venom contortrix venom. Am J Med Sci. 1961;241:507–11.
HBOT Hyper Baric Oxygen Therapy 9. Saini RK, Sharma S, Singh S, Pathania NS. Snake bite poisoning: a preliminary
DIC Disseminated Intravascular Coagulation report. J Assoc Physicians India. 1984;32(2):195–7.
APTT Activated Partial Thromboplastin Time 10. Sarangi A, Jana I, Das JP. Clinical profile of snake bite poisoning. J Assoc Physi-
BT Bleeding Time cians India. 1977;25:55–60.
CT Clotting Time 11. Satyanarayan B, Panda SK, Sunder A, Kumari S. Clinical and epidemiological
profile of snakebite cases – A study from an industrial teaching hospital at
Acknowledgements Jamshedpur, Jharkhand, India. J Family Med Prim Care. 2022;11(12):7652–6. ​h​t​
Not applicable. t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​4​1​0​3​​/​j​​f​m​p​c​.​j​f​m​p​c​_​8​9​0​_​2​2.
12. Patil V, Patil H, Patil A, Agrawal V. Clinical Profile and outcome of envenomous
Author contributions snake-bite at tertiary care centre in western Maharashtra. Int J Med Public
Conceptualization: N.K., M.D. Data curation: P.S., J.J., T.S., S.S., A.S., B.K, M.K.,P.M. Health. 2011;1(4):28–38. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​5​5​3​0​​/​i​​j​m​e​d​p​h​.​4​.​2​0​1​1​.​7.
Formal analysis: N.K., M.D. Methodology: N.K., M.D., P.S., P.M. Writing – original 13. Anurekha N, Paranthakan. A study of clinical profile of snake bite at a tertiary
draft: P.S. Writing – review & editing: P.S., N.K., M.D., J.J., T.S., S.S., A.S., B.K, M.K., care centre. Panacea J Med Sci. 2024;14(1):255–9. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​8​2​3​​1​/​​j​.​p​
P.M. j​m​s​.​2​0​2​4​.​0​4​5.
14. Reid HA, Theakston RD. The management of snake bite. Bull World Health
Funding Organ. 1983;61(6):885–95.
There are no sources of funding to declare. 15. Virmani SK, Dutt OP. A profile of snake bite poisoning in Jammu region. J
Indian Med Assoc. 1987;85(5):132–4.
Data availability 16. Vora DH, Vora JH. An Epidemiological Study of Venomous Snake Bites: a
No datasets were generated or analysed during the current study. Hospital based analysis. Natl J Community Med. 2019;10(8):474–8.
17. Banerjee RN. Venomous snakes of India, their venoms, symptomatology and
treatment of envenomation. Prog Clin Med India. 1978;2:136–79.
Declarations 18. Rahman R, Faiz MA, Selim S, Rahman B, Basher A, Jones A. Annual incidence
of snake bite in rural Bangladesh. PLoS Negl Trop Dis. 2010;4(10). ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​
Ethics approval and consent to participate r​g​/​​1​0​.​​1​3​7​1​​/​j​​o​u​r​​n​a​l​​.​p​n​t​​d​.​​0​0​0​0​8​6​0.
The study was approved by the Institutional Ethics Committee, All India 19. Lal P, Dutta S, Rott SB, Dhanabalam M, Kumar A. Epidemiologicalprofile
Institute of Medical Sciences, Rishikesh (Reference number- No. 286/IEC/IM/ of snakebite.cases admitted in JIPMER hospital. Indian J CommunityMed.
NF/2022). 2001;26:36–8.
20. Watt G, Padre L, Tuazon ML, Theakston RD, Laughlin LW. Tourniquet applica-
Consent to participate tion after cobra bite: delay in the onset of neurotoxicity and the dangers of
All patients enrolled in the study signed an informed written consent for sudden release. Am J Trop Med Hyg. 1988;38(3):618–22. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​4​2​
the use and publication of their medical records for academic and research 6​9​​/​a​​j​t​m​h​.​1​9​8​8​.​3​8​.​6​1​8.
purposes. 21. Jayaraman T, Dhanasinghu R, Kuppusamy S, Gaur A, Sakthivadivel V. Bite-
to-needle time – an extrapolative indicator of repercussion in patients with
Consent for publication snakebite. Indian J Crit Care Med. 2022;26(11):1175–8. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​5​0​0​5​​
Not applicable. /​j​​p​-​j​​o​u​r​​n​a​l​s​​-​1​​0​0​7​1​-​2​5​6​6​7.
22. Biju AP, Krishnan J. Clinical and laboratory profile of snake bite envenomation:
Competing interests a crosssectional observational study at a tertiary care center. J Evid Based
The authors declare no competing interests. Med Healthc. 2018;5(40):2860–4. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​8​4​1​​0​/​​j​e​b​m​h​/​2​0​1​8​/​5​8​5.
23. Gopalakrishnan M, Saurabh S, Dutta TK. Clinical profile of viper enven-
Received: 15 October 2024 / Accepted: 20 December 2024 omations in Kerala, India: some unanswered questions. Int J Gen Med.
2018;11:391–2. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​2​1​4​7​​/​i​​j​g​m​.​s​1​7​7​5​0​9.
24. Patel S, Patel A, Ganjiwale J, Patel D, Nimbalkar S. The study of clinical profile
and outcome of patients with snakebite in a rural community. J Family Med
Prim Care. 2021;10(4):1661–5. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​4​1​0​3​​/​j​​f​m​p​​c​.​j​​f​m​p​c​​_​1​​9​7​6​_​2​0.
References 25. Chauhan V, Thakur S. The north-south divide in snake bite envenomation in
1. World Health Organization. Snakebite envenoming India. Available from: ​h​t​t​p​​ India. J Emerg Trauma Shock. 2016;9(4):151–4. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​4​1​0​3​​/​0​​9​7​4​-​2​
s​:​/​​/​w​w​w​​.​w​​h​o​.​​i​n​t​​/​i​n​d​​i​a​​/​h​e​​a​l​t​​h​-​t​o​​p​i​​c​s​/​s​n​a​k​e​b​i​t​e. Accessed August 21, 2024. 7​0​0​.​1​9​4​1​1​0.
2. Chippaux JP, Massougbodji A, Habib AG. The WHO strategy for prevention 26. Prasarnpun S, Walsh J, Awad SS, Harris JB. Envenoming bites by kraits:
and control of snakebite envenoming: a sub-saharan Africa plan. J Venom the biological basis of treatment-resistant neuromuscular paralysis. Brain.
Anim Toxins Incl Trop Dis. 2019;25. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​1​8​6​​/​s​​4​1​1​2​0​-​0​1​9​-​0​1​2​ 2005;128(Pt 12):2987–96. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​0​9​3​​/​b​​r​a​i​n​/​a​w​h​6​4​2.
8​-​2. 27. Nirthanan S, Selvanayagam M, Charpantier E, Gopalakrishnakone P, Gwee
3. Suraweera W, Warrell D, Whitaker R, Menon G, Rodrigues R, Fu SH, Begum R, M, Khoo HE. Candoxin, a novel toxin from Bungarus candidus, is a reversible
Sati P, Piyasena K, Bhatia M, Brown P, Jha P. Trends in snakebite deaths in India antagonist of muscle (alpha, beta, gamma, delta) but a poorly reversible
from 2000 to 2019 in a nationally representative mortality study. eLife. 2020;9. ​ antagonist of neuronal alpha 7 nicotinic acetylcholine receptors. J Biol Chem.
h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​7​5​5​4​​/​e​​L​i​f​e​.​5​4​0​7​6. 2002;277(20):17811–20.
Sasidharan et al. International Journal of Emergency Medicine (2025) 18:50 Page 9 of 9

28. Sharma R, Dogra V, Sharma G, Chauhan V. Mass awareness regarding snake 39. Gopalakrishnan M, Vinod KV, Dutta TK, Shaha KK, Sridhar MG, Saurabh S.
bite induced early morning neuroparalysis can prevent many deaths in North Exploring circulatory shock and mortality in viper envenomation: a prospec-
India. Int J Crit Illn Inj Sci. 2016;6(3):115–8. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​4​1​0​3​​/​2​​2​2​9​-​5​1​5​1​.​ tive observational study from India. QJM: Monthly J Association Physicians.
1​9​0​6​5​2. 2018;111(11):799–806. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​0​9​3​​/​q​​j​m​e​d​/​h​c​y​1​7​5.
29. Slagboom J, Kool J, Harrison RA, Casewell NR. Haemotoxic snake venoms: 40. Bhattacharya S, Krishnamurthy A, Gopalakrishnan M, Kalra S, Kantroo V,
their functional activity, impact on snakebite victims and pharmaceutical Aggarwal S, Surana V. Endocrine and metabolic manifestations of snakebite
promise. Br J Haematol. 2017;177(6):947–59. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​1​1​1​​/​b​​j​h​.​1​4​5​9​ envenoming. Am J Trop Med Hyg. 2020;103(4):1388–96. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​4​2​
1. 6​9​​/​a​​j​t​m​h​.​2​0​-​0​1​6​1.
30. Management of Snake Bite [Internet]. National Health Mission.[cited 2024 41. Rajagopala S, Thabah MM, Ariga KK, Gopalakrishnan M. Acute hypopituita-
Dec 26]. Available from: ​h​t​t​p​​s​:​/​​/​n​h​m​​.​g​​o​v​.​​i​n​/​​i​m​a​g​​e​s​​/​p​d​​f​/​g​​u​i​d​e​​l​i​​n​e​s​​/​n​r​​h​m​-​g​​u​i​​ rism complicating Russell’s viper envenomation: case series and systematic
d​e​l​​i​n​e​​s​/​s​t​​g​/​​S​n​a​k​e​b​i​t​e​_​F​u​l​l​.​p​d​f review. QJM: Monthly J Association Physicians. 2015;108(9):719–28. ​h​t​t​p​​s​:​/​​/​d​o​
31. Harshavardhan. A study on the acute kidney injury in snake bite victims in a i​​.​o​​r​g​/​​1​0​.​​1​0​9​3​​/​q​​j​m​e​d​/​h​c​v​0​1​1.
tertiary care centre. J Clin Diagn Res. 2013;7(10):2248–51. 42. Sartelli M, Guirao X, Hardcastle TC, Kluger Y, Boermeester MA, Raşa K, Ansaloni
32. Paul J, Dasgupta S. Early prediction of acute kidney injury by clinical features L, Coccolini F, Montravers P, Abu-Zidan FM, Bartoletti M, Bassetti M, Ben-Ishay
of snakebite patients at the time of hospital admission. North Am J Med Sci. O, Biffl WL, Chiara O, Chiarugi M, Coimbra R, De Rosa FG, De Simone B, Catena
2012;4(5):216–20. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​4​1​0​3​​/​1​​9​4​7​-​2​7​1​4​.​9​5​9​0​3. F. (2018). 2018 WSES/SIS-E consensus conference: recommendations for the
33. Prasad H, Kaeley N, Jose JR, Ajun, Shankar T, Salam A, Shukla K. (2024). The role management of skin and soft-tissue infections. World Journal of Emergency
of plasmapheresis in snake envenoming: a systematic review. In medRxiv. ​h​t​t​ Surgery, 13(1), 58. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​1​8​6​​/​s​​1​3​0​1​7​-​0​1​8​-​0​2​1​9​-​9
p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​1​0​1​​/​2​​0​2​4​​.​0​9​​.​2​7​.​​2​4​​3​1​4​4​7​6 43. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJC, Gorbach
34. Fouad MM, Zawilla NH, Abdelsamie AA, Manawil M, Shehata RSA, Moham- SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC, Infectious Diseases
med RS, Khalifa EM, Ramadan A, M., Mourad BH. Successful management of Society of America. Practice guidelines for the diagnosis and management
severe unresponsive snake bite envenomation using plasmapheresis and of skin and soft tissue infections: 2014 update by the Infectious Diseases
corticosteroid at Egyptian national environmental and clinical toxicology Society of America. Clin Infect Diseases: Official Publication Infect Dis Soc Am.
research center: a case report. Wilderness Environ Med. 2024;35(1):82–7. ​h​t​t​p​​s​ 2014;59(2):e10–52. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​0​9​3​​/​c​​i​d​/​c​i​u​4​4​4.
:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​1​7​7​​/​1​​0​8​0​6​0​3​2​2​3​1​2​2​5​1​0​2. 44. Afroz A, Siddiquea BN, Chowdhury HA, Jackson TNW, Watt AD. Snakebite
35. Dhikav V, Gupta R, Saini J, Mandani P, Upadhyay P, Shakeel K, Menon J. Snake- envenoming: A systematic review and meta-analysis of global morbidity and
bites in three districts of rural areas of Western India during winter. Indian J mortality. PLoS Neglected Tropical Diseases. (2024);18(4):e0012080. ​h​t​t​p​​s​:​/​​/​d​o​
Med Specialities. 2024. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​4​1​0​3​​/​i​​n​j​m​s​.​i​n​j​m​s​_​5​7​_​2​4. i​​.​o​​r​g​/​​1​0​.​​1​3​7​1​​/​j​​o​u​r​​n​a​l​​.​p​n​t​​d​.​​0​0​1​2​0​8​0
36. Padmanabhan A, Connelly-Smith L, Aqui N, Schulman S, Knovich MA, Reddy 45. (N.d.-c). Health.Mil. Retrieved December 26, 2024, from ​h​t​t​p​​s​:​/​​/​j​t​s​​.​h​​e​a​l​​t​h​.​​m​i​l​/​​a​
V, et al. Guidelines on the use of therapeutic apheresis in clinical practice s​​s​e​t​​s​/​d​​o​c​s​/​​c​p​​g​s​/​​G​l​o​​b​a​l​_​​S​n​​a​k​e​​_​E​n​​v​e​n​o​​m​a​​t​i​o​​n​_​M​​a​n​a​g​​e​m​​e​n​t​_​3​0​_​J​u​n​_​2​0​2​0​
- evidence-based approach from the writing committee of the American _​I​D​8​1​.​p​d​f
Society for Apheresis: the eighth special issue. J Clin Apher. 2019;34:171–354. ​ 46. Korambayil PM, Ambookan PV, Abraham SV, Ambalakat A. A multidisciplinary
h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​0​0​2​​/​j​​c​a​.​2​1​7​0​5. approach with hyperbaric oxygen therapy improves outcome in snake bite
37. Mohan G, Guduri PR, Shastry S. Role of therapeutic plasma exchange in snake injuries. Toxicol Int. 2015;22(1):104–9. ​h​t​t​p​s​:​​​/​​/​d​o​​i​.​​o​r​​g​​/​​1​0​​.​4​1​​​0​3​​/​0​​9​7​1​-​6​​5​8​0​.​1​7​2​2​
bite associated thrombotic microangiopathy: a case report with review of 8​7.
literature. J Clin Apher. 2019;34:507–9. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​0​0​2​​/​j​​c​a​.​2​1​7​1​2.
38. Sakhuja V, Aggarwal A, Arora P, Soni KD, Gulia A, Rajeshwari. Plasmapheresis
for pulmonary hemorrhage following viperine snakebite: case report with Publisher’s note
review of literature. Indian J Crit Care Med. 2020;24(10):986–90. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​ Springer Nature remains neutral with regard to jurisdictional claims in
g​/​​1​0​.​​5​0​0​5​​/​j​​p​-​j​​o​u​r​​n​a​l​s​​-​1​​0​0​7​1​-​2​3​5​3​3. published maps and institutional affiliations.