Published by: Ministry of Health and Population, Government of Nepal
Prepared by: Epidemiology and Disease Control Division (EDCD) with WHO Support
Year: 2019
🐍 Introduction: A Critical Public Health Concern
Snakebite is a significant medical emergency and a major occupational hazard in rural Nepal, particularly for farmers, herders, plantation workers, and children sleeping on the ground. The Terai region, with its favorable climate and ecosystem, sees the highest incidence.
Annually, approximately 20,000 snakebites occur in Nepal, resulting in over 1,000 deaths, most of which are preventable. The delay in accessing trained healthcare providers and misuse of harmful traditional treatments contribute heavily to this toll.
🔍 Snakes of Medical Importance in Nepal
Nepal hosts 89 snake species, of which 17 are highly venomous, belonging to two main families:
1. Elapidae Family (Neurotoxic)
- Cobra species: Common Cobra, Monocellate Cobra
- Kraits: Common, Banded, Himalayan, Lesser & Greater Black Krait, Wall’s Krait
- King Cobra
- MacClelland’s Coral Snake
2. Viperidae Family (Hemotoxic)
- Russell’s Viper (most dangerous)
- Pit Vipers: Himalayan, Tibetan, Mountain, White-lipped, Kramer’s
🧬 Clinical Manifestations of Envenomation
1. Local Effects
- Cobra: Pain, swelling, necrosis
- Krait: Often painless, no swelling
- Viper: Pain, swelling, bleeding, necrosis
2. Systemic Effects
- Elapids: Neurotoxicity (ptosis, paralysis, respiratory failure)
- Vipers: Hematotoxicity (bleeding, coagulopathy, AKI)
3. Syndromes by Species
- Cobra: Paralysis with local swelling
- Krait: Nocturnal bite, neuroparalysis, abdominal pain
- Russell’s Viper: Bleeding, shock
- Pit Vipers: Local swelling, rarely bleeding
🩺 Diagnosis and Tests
- 20-minute Whole Blood Clotting Test (20WBCT) – to detect coagulopathy.
- Kidney function tests, BT/CT, INR.
- No lab test for neurotoxicity – clinical diagnosis is key.
🛟 Management: Steps for Snakebite Care
1. First Aid
- Reassurance and immobilization
- Avoid tourniquets, cutting, suction, or traditional remedies
- Transport rapidly to the nearest treatment center
2. Rapid Clinical Assessment
- Use ABCDE approach: Airway, Breathing, Circulation, Disability, Exposure
3. Antivenom Administration
- Polyvalent antivenom used in Nepal targets: Cobra, Krait, Russell’s Viper (not pit vipers)
- Indications: Neurotoxicity, coagulopathy, shock, AKI
- Dose: Initial 10 vials; maximum recommended: 20 vials
- Pre-treatment with adrenaline to prevent reactions
4. Managing Antivenom Reactions
- Early Anaphylactic Reaction (EAR)
- Pyrogenic Reaction (PR)
- Late (serum sickness-like) Reaction
5. Supportive Treatment
- Ventilation for neurotoxicity-induced paralysis
- Fluids and blood for hypovolemia or bleeding
- Dialysis for AKI from viper bites
📉 When No Antivenom is Available
- Provide supportive care
- Ensure airway management and oxygenation
- Early referral is crucial
🚑 Community and Health System Role
- Motorcycle volunteer programs have saved lives by providing rapid transport.
- Strengthening primary care training, antivenom distribution, and public education is essential.
🛡️ Prevention Strategies
- Avoid sleeping on the ground
- Use mosquito nets tucked into beds
- Wear boots and gloves in fields
- Keep surroundings clean to deter rodents/snakes
- Raise community awareness
📌 Conclusion
Snakebite management in Nepal is a critical yet solvable public health issue. With proper implementation of the national guidelines, timely use of antivenom, and community education, Nepal aims to meet the WHO target of reducing snakebite deaths and disabilities by 50% by 2030.
Let us ensure that knowledge, preparedness, and timely response save every life threatened by a snakebite.
For full clinical protocols and management algorithms, healthcare professionals are encouraged to consult the official PDF of the National Guidelines.
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