The Chinese guideline for management of snakebites

doi:10.5847/wjem.j.1920-8642.2024.076

World Journal of Emergency Medicine ›› 2024, Vol. 15 ›› Issue (5): 333-355.doi: 10.5847/wjem.j.1920-8642.2024.076

The Chinese guideline for management of snakebites

Rongde Lai¹(), Shijiao Yan², Shijun Wang³, Shuqing Yang⁴, Zhangren Yan⁵, Pin Lan⁶, Yonggao Wang⁷, Qi Li⁸, Jinlong Wang⁹, Wei Wang¹⁰, Yuefeng Ma¹¹(), Zijing Liang¹²(), Jianfeng Zhang¹³(), Ning Zhou¹⁴(), Xiaotong Han¹⁵(), Xinchao Zhang¹⁶(), Mao Zhang¹⁷(), Xiaodong Zhao¹⁸(), Guoqiang Zhang¹⁹(), Huadong Zhu²⁰(), Xuezhong Yu²⁰(), Chuanzhu Lyu²¹^,²²()

¹Emergency Department, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
²School of Public Health, Hainan Medical University, Haikou 571199, China
³Surgery Department of Traditional Chinese Medicine, the Affiliated People’s Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou 350004, China
⁴Emergency Department, Chongqing University Central Hospital/Chongqing Emergency Medical Center, Chongqing 400014, China
⁵Department of Surgery of Traditional Chinese Medicine, Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang 330006, China
⁶Department of Emergency Medicine, the Fifth Affiliated Hospital of Wenzhou Medical University/Lishui Central Hospital, Lishui Hospital of Zhejiang University, Lishui 323000,China
⁷General Surgery Department, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, China
⁸Emergency Department, Shengli Clinical Medical College of Fujian Medical University, Fuzhou 350001, China
⁹Emergency Department, Chongqing University Fuling Hospital, Chongqing University, Chongqing 408000, China
¹⁰Emergency Department, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
¹¹Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
¹²Emergency Department, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
¹³Emergency Department, Wuming Hospital of Guangxi Medical University, Nanning 530021, China
¹⁴Emergency Department, Central People's Hospital of Zhanjiang, Zhanjiang 524037, China
¹⁵Emergency Department, Hunan Provincial People's Hospital, Changsha 410005, China
¹⁶Emergency Department, National Geriatrics Center of Beijing Hospital, Beijing 100020, China
¹⁷Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
¹⁸Emergency Department, the Fourth Medical Center of the PLA General Hospital, Beijing 100048, China
¹⁹Emergency Department, China-Japan Friendship Hospital, Beijing 100029, China
²⁰Emergency Department, Peking Union Medical College Hospital, BeiJing 100730, China
²¹Emergency Department, Sichuan Academy of Medical Sciences/Sichuan Provincial People's Hospital, Chengdu 610072, China
²²Research Unit of Island Emergency Medicine, Chinese Academy of Medical Sciences (No. 2019RU013), Hainan Medical University, Haikou 571199, China

Received:2024-06-06 Online:2024-09-09 Published:2024-09-01
Contact: Rongde Lai, Email: lairongde@163.com; Yuefeng Ma, Email: 2193017@zju.edu.cn; Zijing Liang, Email: 13719337897@163.com; Jianfeng Zhang, Email: zhangjf.gxmu@163.com; Ning Zhou, Email: zjzhou121@163.com; Xiaotong Han, Email: 744953695@qq.com; Xinchao Zhang, Email: xinchaoz@163.com; Mao Zhang, Email: z2jzk@zju.edu.cn; Xiaodong Zhao, Email: zxd63715@126.com; Guoqiang Zhang, Email: zhangchong2003@vip.sina.com; Huadong Zhu, Email: zhuhuadong1970@126.com; Xuezhong Yu, Email: yxzpumch@126.com; Chuanzhu Lyu, Email: lvchuanzhu677@126.com

Abstract

Abstract:

In 2009, the World Health Organization included snakebite on the list of neglected tropical diseases, acknowledging it as a common occupational hazard for farmers, plantation workers, and others, causing tens of thousands of deaths and chronic physical disabilities every year. This guideline aims to provide practical information to help clinical professionals evaluate and treat snakebite victims. These recommendations are based on clinical experience and clinical research evidence. This guideline focuses on the following topics: snake venom, clinical manifestations, auxiliary examination, diagnosis, treatments, and prevention.

Key words: Snakebite, Envenomation, Management, Prevention

Rongde Lai, Shijiao Yan, Shijun Wang, Shuqing Yang, Zhangren Yan, Pin Lan, Yonggao Wang, Qi Li, Jinlong Wang, Wei Wang, Yuefeng Ma, Zijing Liang, Jianfeng Zhang, Ning Zhou, Xiaotong Han, Xinchao Zhang, Mao Zhang, Xiaodong Zhao, Guoqiang Zhang, Huadong Zhu, Xuezhong Yu, Chuanzhu Lyu. The Chinese guideline for management of snakebites[J]. World Journal of Emergency Medicine, 2024, 15(5): 333-355.

Figures/Tables 3

Table 1.

Table 2.

Modified snakebite severity scale

Position	Symptoms/Signs	Score
Lungs	No symptoms/signs	0
	Difficulty in breathing, mild chest tightness, mild discomfort, breathing 20-25 times/min	1
	Moderate respiratory distress (dyspnea, 26-40 breaths/min, use of auxiliary respiratory muscles)	2
	Cyanosis, feeling of insufficient air, severe shortness of breath, or respiratory distress/failure	3
Cardiovascular	No symptoms/signs	0
	Heart rate 100-125 beats/min, palpitations, general fatigue, benign arrhythmia or hypertension	1
	Heart rate 126-175 beats/min or hypotension (systolic blood pressure <100 mmHg)	2
	Heart rate >175 beats/min or hypotension (systolic blood pressure <100 mmHg), malignant arrhythmia, or cardiac arrest	3
Local trauma	No symptoms/signs (swelling or erythema around the teeth mark <2.5 cm)	0
	Pain, swelling or bruising of the bite area <5.0-7.5 cm	1
	Pain, swelling or bruising of the bite area not extending beyond half of the limb (7.5-50.0 cm)	2
	Pain, swelling or bruising of the bite area extending over half of the limb (50-100 cm)	3
	Pain, swelling or bruising beyond the limb (> 100 cm from the bite site)	4
Gastrointestinal tract	No symptoms/signs	0
	Abdominal pain, tenesmus, or nausea	1
	Vomiting or diarrhea	2
	Repeated vomiting, diarrhea, hematemesis, or hematochezia	3
Hematology	No symptoms/signs	0
	Mild changes in coagulation parameters (PT < 20 s, APTT < 50 s, platelet count (100-150) × 10⁹/L, fibrinogen 100-150 mg/dL)	1
	Significantly abnormal coagulation parameters (PT 20-50 s, APTT 50-75 s, platelet count (50-100)×10⁹/L, fibrinogen 50-100 mg/dL)	2
	Significantly abnormal coagulation parameters (PT 50-100 s, APTT 75-100 s, platelet count (20-50)×10⁹/L, fibrinogen <50 mg/dL)	3
	Significantly abnormal coagulation parameters, accompanied by severe bleeding or spontaneous bleeding risk; PT or APTT undetectable, platelet < 20×10⁹/L, fibrinogen undetectable, other laboratory results with severe abnormalities such as abnormal venous blood coagulation time	4
Nervous system	No symptoms/signs	0
	Mild anxiety or fear, headache, fatigue, dizziness, coldness, or abnormal sensation	1
	Moderate anxiety or fear, headache, fatigue, dizziness, chills, confusion or blurring of consciousness, muscle tremors or fasciculations in the bite area, ptosis of the upper eyelid, and difficulty swallowing	2
	Severe confusion, lethargy, weakness, paralysis, convulsions, coma, mental disorders, or generalized muscle fasciculations	3
Kidney	Normal creatinine and urine volume	0
	Creatinine 1.5-1.9 times the baseline, or creatinine increases by ≥26.5 μmol/L, or urine volume <0.5 mL/(kg·h)for >6 h	1
	Creatinine 2.0-2.9 times the baseline, or urine volume less than 0.5 mL/(kg·h) for > 12 h	2
	Creatinine ≥3 times the baseline, creatinine ≥353.6 µmol/L, urine volume <0.3 mL/(kg·h) for >24 h, or anuria ≥12 h, or requiring renal replacement therapy	3

Table 2.

Figure 1.

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Severity	Clinical manifestations
No poisoning	Only teeth marks (“dry bite”) without any other symptoms and signs
Light	Only local symptoms around the wound, such as pain, bleeding from the wound, skin bruising, non-progressive limb swelling not exceeding the elbow or knee, and no progress in 12 h after the bite; local sensory abnormalities, numbness, neuropathic pain, muscle spasm, and fasciculation
Moderate	Progressive swelling, purpura, or ecchymosis away from the wound, not exceeding half of the limb; non-fatal systemic symptoms or signs, such as nausea, vomiting, hematemesis/melena; mild perioral numbness, mild fatigue, respiratory muscle weakness resulting in dyspnea or other respiratory discomfort, language barriers, diplopia, hearing or taste abnormalities, and difficulty swallowing; slight changes in laboratory results (<2 times the upper limit of normal), mild abnormalities in coagulation function but no systemic bleeding
Severe	Local symptoms such as widespread swelling, erythema, or ecchymosis rapidly progressing beyond more than half of the body, or bites on the head, neck, or trunk; obvious symptoms and signs such as fatigue or progressive muscle weakness, blurred vision, ptosis, altered consciousness, tachycardia, shortness of breath or distress, or the need for mechanical ventilation support, hemodynamic instability (such as hypotension or shock), suspected or confirmed intracranial or abdominal bleeding; laboratory results showing significant abnormalities, such as severe coagulopathy with bleeding in areas other than the wound, thrombocytopenia, significant abnormalities in muscle enzymes (≥2 times the upper limit of normal)

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The Chinese guideline for management of snakebites

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