Intended for healthcare professionals

Practice Clinical Update

Managing snakebite

BMJ 2022; 376 doi: (Published 07 January 2022) Cite this as: BMJ 2022;376:e057926
  1. Ravikar Ralph, professor1,
  2. Mohammad Abul Faiz, professor of medicine (retired)2,
  3. Sanjib Kumar Sharma, professor and head3,
  4. Isabela Ribeiro, scientific lead4,
  5. François Chappuis, professor5
  1. 1Department of Internal Medicine, Christian Medical College, Vellore, Tamil Nadu, 632004, India
  2. 2Dev Care Foundation, Dhaka-1209, Bangladesh
  3. 3Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, 76500, Nepal
  4. 4Dynamic Portfolio, Drugs for Neglected Diseases initiative (DNDi), 15 Chemin Louis-Dunant, 1202, Geneva, Switzerland
  5. 5Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 6, Geneva, CH 1211, Switzerland
  1. Correspondence to: R Ralph ravikar_ralph{at}

What you need to know

  • Bites from venomous snakes can result in bleeding, paralysis, long term disability, and death

  • Immobilise the bitten limb when transporting the patient to a medical facility; the universal use of pressure immobilisation is controversial, and tourniquets are not recommended

  • The 20-minute whole blood clotting test is a simple bedside test to screen for and monitor coagulopathy in resource-limited settings

  • Assess vital parameters and initiate resuscitation measures if the patient is clinically unstable with signs of bleeding, shock, paralysis, or respiratory distress

  • Intravenous antivenom is recommended in patients with systemic symptoms; the dose and type depend on likely snake species, local guidelines, and availability

Snakebite affects between 1.8 to 2.7 million people worldwide each year, and it is estimated to cause between 80 000 and 138 000 deaths.12 A mixture of toxins (venom) is injected into the body following bite by a venomous snake.3 Envenoming can be a highly dynamic clinical event. Symptoms can progressively worsen to a life-threatening emergency. Snakebites can have long term physical sequelae such as amputation, paralysis and disability, and psychological health consequences.4567

Snakebite envenoming is more common in South and South-East Asia (2 million annually), sub-Saharan Africa (420 000) and Latin America (150 000).12 These regions also report a high burden of deaths from snakebite (100 000, 32 000, and 5000 deaths respectively) possibly due to poor access to medical aid.12 Delayed diagnosis and treatment can worsen prognosis.891011 The World Health Organization recognised snakebite as a neglected tropical disease in 2017 and called for concerted global action to reduce deaths and disability.12

In this clinical update, we present an approach to evaluation and management of snakebites for primary care providers in resource-limited settings in endemic regions. The principles of management are broadly similar, but it is …

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