Exploring The Impact of Bite-to-Needle Time on Snakebite Complications: Insights from a Study at Tertiary Care Hospital

Dr. Meenakshi Bhattacharya et al. Exploring the Impact of Bite-to-Needle Time on Snakebite Complications: Insights
from a Study at Tertiary Care Hospital. Int. J Med. Pharm. Res., 6 (4): 680‐699, 2025
690
Int. J Med. Pharm. Res.
P-ISSN: 2958-3675 | E-ISSN: 2958-3683
Available on: https://ijmpr.in/
International Journal
of Medical and
Pharmaceutical Research
Exploring The Impact of Bite-to-Needle Time on Snakebite
Complications: Insights from a Study at Tertiary Care Hospital
Dr. Meenakshi Bhattacharya1
, Dr. Sunil Bothara2
, Dr. Akash Aher3
, Dr. Adesh Chavan3
, Dr. Shivani Bhagore3
, Dr. Prerna
Sarode3
1 Professor and Head, Department of Medicine, Government Medical college and Hospital, Aurangabad, India.
2 Professor, Government College of Pharmacy, Aurangabad, India.
3 Pharm.D., Government College of Pharmacy, Aurangabad, India.
OPEN ACCESS
Corresponding Author
Dr. Akash Aher
Pharm.D., Government
College of Pharmacy,
Aurangabad, India
Received: 20-06-2025
Accepted: 27-07-2025
Available Online: 16-08-2025
©Copyright: IJMPR Journal
A B S T R A C T
Background: Snakebite envenoming is an acute life-threatening time-limiting medical
emergency necessitating prompt intervention. Timely treatment is often hindered by delayed
hospital arrival, delayed treatment, and initial reliance on traditional healers, exacerbating
adverse outcomes. This study was conducted to assess whether the bite-to-needle time
impacts on complications in snakebite patients, reasons behind the delay in Anti Snake
Venom administration, clinico-epidemiological profiles and first aid awareness in victims.
Methods: A hybrid study enrolled 124 snakebite patients admitted between January 2022
and April 2023. Statistical analysis using Chi-square and Pearson's correlation tests
evaluated the impact of BNT on complications.
Results: The study revealed higher snakebite incidence in males 53.22%, mostly 74% in 21
to 50 years of age group, farmers 78.22%, from rural areas 77%. A significant positive
correlation between BNT and complications is revealed. Notably, 100% of patients with
BNT exceeding 8 hours, 96.66% with BNT between 4–8 hours, and 65.58% with BNT
within 0–4 hours developed complications. Delayed ASV administration was attributed to
various factors, including transportation issues (28.2%), delay after primary health center
(PHC) (13.7%), unavailability of personnel for help at incidence place (11.3%), distant
hospitals (10.5%), patient ignorance (7.3%), and no sense of damage (6.5%).
Conclusion: This study underscores the critical importance of prompt ASV administration
in preventing complications. The direct correlation between BNT and complications
highlights the need for enhanced public awareness of snakebite ASV, first aid and timely
medical intervention to mitigate morbidity, mortality and to improve the quality of life.
Keyword: Bite-to-needle time, Snakebite Envenoming, Complications, First Aid, ASV,
Adverse Events.
INTRODUCTION:
The World Health Organization (WHO) estimates that 5 million snakebites occur worldwide each year, resulting in up to 2.7
million envenomed. Published reports indicate that between 81,000 and 138,000 people die each year worldwide, snake bites
cause up to 400,000 amputations and other permanent disabilities.[1,2,3,4]
It is a preventable public health hazard often faced by
rural populations in tropical and subtropical countries with heavy rainfall and humid climate, mainly those involved in
subsistence farming activities.[5]
It's an important cause of morbidity and mortality, especially in sub-Saharan Africa, south to
Southeast Asia, Papua New Guinea, and the Latin Republic.[6,7,8]
At least 46,000 of deaths occur in India alone considering the
worldwide snakebites deaths, the published reports says, India had 1.2 million snakebite deaths from 2000 to 2019 (an average
of 58,000 per year), almost half of the victims are aged 30-69 and more than a quarter are children under 15 years of age, the
largest number of deaths reported in India are from Bengal, Uttar Pradesh (up), Tamil Nadu, and Bihar.[6,9]
ORIGINAL ARTICLE OPEN ACCESS

691
Approximately 3,500 snake species exist globally, with less than 350 being venomous. In India, venomous snakes pose a
significant threat, particularly the "Big Four" 1. Common krait (Bungarus caeruleus) 2. Common cobra (Naja naja) 3. Saw-
scaled viper (Echis carinatus) 4. Russell's viper (Daboia russelii). Snakebites envenoming is an acute life-threatening time
limiting medical emergency, and these species are responsible for most snakebite envenoming related morbidity and mortality
in India.[5,10]
Anti-snake venom (ASV) is the first line treatment and should be given as soon as it is indicated, it neutralizes
circulating venom only and no amount of ASV neutralizes once the venom is attached or adsorbed to the target organ. ASV
does not eliminate venom from the body, does not reverse anything or nor it make the patient better, it just neutralizes the snake
venom.[5,11]
In previously conducted studies, [12,13,14,15,16]
it is observed that many snakebite victims fail to reach hospitals in time or seek
medical care after a considerable delay, resulting in high morbidity and mortality. The present study aimed to assess the
relationship between timing of ASV administration and complications in snakebite patients, factors reasonable for delay in
receiving ASV, clinico-epidemiological profile, clinical management, first aid awareness and clinical outcomes of snake bite
patients. By exploring these aspects, the study seeks to provide valuable insights to reduce morbidity and mortality, ultimately
improving the quality of life for snakebite victims.
MATERIAL AND METHODS:
A hybrid observational study, integrating prospective and retrospective design, was conducted at the Department of Medicine,
Government Medical College and Hospital, Aurangabad. Following approval from the Institutional Ethics Committee, 124
snakebite patients admitted between January 2022 and April 2023 were included in the study. Patients were eligible for
enrollment if they met the inclusion criteria, which included being willing to participate in the study (with consent forms
applicable for prospective patients), being over 12 years of age, having a confirmed snakebite, and having received ASV
treatment. Pregnant and breastfeeding females were excluded. Data collection utilized a Case Report Form (CRF) that captured
demographic information, including gender, age, geographical location, and occupation, as well as first aid, identified bitten
snake, bite-to-needle time (BNT), type of complications with bitten snake, victims had complications and no-complications
with respective BNT, ASV administration, adverse events (AE), reasons for delay in receiving ASV, and clinical outcomes.
Case files of the patients were reviewed and discussed with respective ward treating physicians, and the study required data
were recorded in CRF. In some patients, missing information, such as reasons for delay in receiving ASV and first aid, was
gathered through telephonic contact with the patients or their relatives. The CRF data were transferred to MS Excel for data
analysis and appropriate statistical tests, including Chi-square and Pearson correlation were used.
RESULTS:
This study analyzed 124 snakebite victims, revealed, a male predominance 53.22% compared to females 46.78%. The most
affected victims were in the age groups 21-50 years 74%, from rural areas 77%, with occupation as a farming 78.22%. And the
large number of victims, 42.60% had not received any first aid (Table 1).
Table 1: Snakebite patients’ demographic, epidemiological, and first aid profile.
Parameter Frequency (100%, n=124)
Gender
Male 53.22%
Female 46.78%
Age
<21 Years 13%
21-50 Years 74%
>50 Years 13%
Geographical
Rural 77%
Urban 23%
Occupation
Farmers 78.22%
Servants 12.91%
Students 8.87%

692
First Aid
No first aid received 42.60%
First aid at PHC 34%
Tourniquet 23.40%
Among the study population, most of the victims 62.90% had BNT 0-4 hrs., and least of those 0.80% had BNT over 24 hrs. Of
these victims vasculotoxic snake bites were most common 46.77%, followed by mixed type 42.74% and neuroparalytic bites
10.48%. No myotoxic case was observed (Table 2).
Table 2: Cases distribution based on bitten snake and bite-to-needle time.
Bitten Snake 0 to 4 (Hrs) 4 to 8 (Hrs) 8 to 12 (Hrs) 12 to 24 (Hrs) >24 (Hrs)
Viper 36 15 1 5 1
Russell’s viper 28 9 2 3 0
Cobra 8 4 2 0 0
Krait 6 2 1 1 0
Grand Total 62.90%, n=78 24.19%, n=30 4.84%, n=6 7.25%, n=9 0.80%, n=1
*Categorywise: Vasculotoxic (46.77%, n= 58), mixed type (42.74%, n=53), neuroparalytic (10.48%, n=13) and myotoxic (0%,
n=0).
Amongst the study population, with proportionate to BNT from 0-4 hrs. to more than 24 hrs., the frequency of complications
were increased, cellulitis (14.10% to 100%), anemia (12.82% to 100%), uremia (10.26% to 22.22%), hypotension (1.28% to
22.22%), hematuria (3.85% to 11.11%), Lower Respiratory Tract Infection (LRTI) (6.67% to 16.67%), neutrophilia (50% to
100% and then to 55.56%), leukocytosis (47.44% to 83.33% and then to 66.67%), respiratory failure (7.69% to 50% and then
to 11.11%), thrombocytopenia (12.82% to 50% and then to 33.33%), acute kidney injury (AKI) (1.28% to 10%), and
progressive swelling (15.38% to 33.33%) (Table 3).
Table 3: Cases distribution based on complications with bitten snake and bite-to-needle time.
Complication in cases (%,
n) and Bitten snakes (n)
0-4 hrs. 4-8 hrs. 8-12 hrs. 12-24 hrs. >24 hrs.
Neutrophilia 50%, n=39 56.67%, n=17 100%, n=6 55.55%, n=5 -
Bitten snakes
Russell’s viper-
22, viper-12,
Cobra-5
Viper-9, Russell’s
viper-4, Cobra-3,
Krait-1
Russell’s viper-
2, Cobra-2,
Viper-1, Krait-1
Viper-2,
Russell’s viper-2,
Krait-1
-
Leukocytosis 47.44%, n=37 53.33%, n=16 83.33%, n=5 66.66%, n=6 -
Bitten snakes
Russell’s viper-
22, Viper-11,
Cobra-4
viper-4, Cobra-3
Russell’s viper-
2, Cobra-2,
Krait-1
Viper-3,
Krait-1
-
Thrombocytopenia 12.82%, n=10 36.67%, n=11 50%, n=3 33.33%, n=3 -
Bitten snakes
Russell’s viper-
4, Viper-3,
Cobra-3
viper-3, Cobra-2
Russell’s viper-
2, Cobra-1
Viper-1
-
Progressive swelling 15.38%, n=12 33.33%, n=10 - - -
Bitten snakes
Viper-6,
Russell’s viper-
5, Cobra-1
viper-2
- - -
Cellulitis 14.10%, n=11 16.67%, n=5 16.67%, n=1 44.44%, n=4 100%, n=1
Bitten snakes
Russell’s viper-
6, Viper-4,
Cobra-1
viper-2
Russell’s viper-1
Viper-2
Viper-1

693
Anemia 12.82%, n=10 30%, n=9 50%, n=3 11.11%, n=1 100%, n=1
Bitten snakes
Russell’s viper-
6, Viper-2,
Cobra-2
Viper-7, Cobra-1,
Krait-1
Cobra-2,
Russell’s viper-1
Viper-1 Viper-1
RF 7.69%, n=6 10%, n=3 50%, n=3 11.11%, n=1 -
Bitten snakes
Cobra-4, Krait-
2
Cobra-2, Russell’s
viper-1
Cobra-2,
Russell’s viper-1
Krait-1 -
Uremia 10.26%, n=8 6.67%, n=2 - 22.22%, n=2 -
Bitten snake
Russell’s viper-
4, Cobra-2,
Viper-1, Krait-1
Viper-1
- Viper-1, Krait-1 -
Hypotension 1.28%, n=1 13.33%, n=4 - 22.22%, n=2 -
Bitten snakes
Russell’s viper-
1
viper-1, krait-1
- Viper-2 -
Hematuria 3.85%, n=3 6.67%, n=2 - 11.11%, n=1 -
Bitten snakes
Russell’s viper-
1, Viper-1,
Cobra-1
Cobra-1
- Russell’s viper-1 -
DIC - 6.67%, n=2 - 11.11%, n=1 -
Bitten snakes -
Viper-1
- Viper-1 -
AKI 1.28%, n=1 10%, n=3 - - -
Bitten snakes Cobra-1
Viper-1
- - -
LRTI - 6.67%, n=2 16.67%, n=1 - -
Bitten snakes -
Cobra-1,
Russell’s, viper-1
Cobra-1 - -
HIE - 3.33%, n=1 - - -
Bitten snakes - Cobra-1 - - -
Septic shock - - 16.67%, n=1 - -
Bitten snakes - - Cobra-1 - -
Septicaemia - 3.33%, n=1 - - -
Bitten snakes - Viper-1 - - -
ARDS - 33.33%, n=1 - - -
Bitten snakes - Russell’s viper-1 - - -
In this study, the relationship between BNT and complications was statistically analyzed using “Chi-square and Pearson’s
coefficient tests”. Patients receiving ASV within 0-4 hours had a complication rate of 65.58% (n=51), whereas those receiving
ASV within 4-8 hours, 8-12 hours, and beyond 12 hours had complication rates of 96.66% (n=29), 100% (n=6), and 100%
(n=10), respectively. Statistical analysis using the Chi-Square test revealed a significant association between BNT and
complications (p=0.0015, 95% CI, p<0.05). Furthermore, Pearson Correlation analysis showed a strong positive correlation
between BNT and complications (r=0.665, significant between 0 to +1). These findings indicate a significant association
between delayed ASV administration and increased risk of complications in snakebite patients. The increased BNT indicates
the increased duration of venom stay in the body of victims and thus, the complications occurred. Therefore, this finding
highlights the importance of timely administration of ASV in reducing the complications (Table 4).
Table 4: Cases distribution based on complications and no-complications with bite-to-needle time.
BNT (Hrs.) Total
complicated
cases (n)
Total
complicated
cases (%)
Total uncomplicated
cases (n)
Total uncomplicated
cases (%)
Total cases
within
respective
BNT (n)

694
0-4 51 65.38% 27 34.62% 78
4-8 29 96.67% 1 3.33% 30
8-12 6 100% 0 0% 6
12-24 9 100% 0 0% 9
>24 1 100% 0 0% 1
*P value=0.0015, Confidence Interval (CI)=95%, p<0.05).
In the present study, it is noted that most patients (41.94%, n=52) required 11-20 vials of ASV. The ASV adverse events were
observed, with the most common being mild hypotension (8.06%, n=10), fever (5.65%, n=7), hypertension (6.45%, n=8), and
rigors (4.3%, n=5). Moderate adverse events included tachycardia (4.83%, n=6), tachypnea (3.23%, n=4), and bradycardia
(0.81%, n=1). Other less frequent adverse events were itching, urticaria, and abdominal pain, each of which occurred in 0.81%
(n=1) of patients. Transportation issues (28.2%, n=35) and delays after PHC (13.7%, n=17) were identified as the most common
contributing factors to delayed ASV treatment (Table 5).
Table 5: Distribution of snakebite cases by Anti Sanke Venom administration, adverse events, and delay reasons.
Parameter Frequency (100%, n=124)
Total ASV vials used
<10 vials 3.23%
10 vials 23.38%
11-20 vials 41.93%
>20 vials 31.44%
Adverse Events
Hypotension 8.06%
Hypertension 6.45%
Fever 5.65%
Tachycardia 4.83%
Rigors 4.03%
Tachycardia 3.23%
Bradycardia 0.81%
Itching 0.81%
Urticaria 0.81%
Abdominal Pain 0.81%
Reason for delay to receive ASV
Transportation 28.20%
Delayed after PHC 13.70%
No one available for help at incidence place 11.30%
Hospital far away 10.50%
Patient ignorance 7.30%
No sense of damage 6.50%
In our study, it is observed that 96.78% of patients recovered and discharged, while 1.61% left against medical advice (DAMA)
and 1.61% succumbed to mortality (Figure 1).

695
Figure 1: Clinical outcomes of snakebite victims.
DISCUSSION:
This study found a slightly higher incidence of snakebites among males (53.22%) than females (46.78%), with most victims
74% were in the age group 21 to 50 years followed 13% each below 21 years and more than 50 years. Of these, farmers 78.22%,
servants 12.91%, and students 8.87%. Farmers being the most affected. Most cases were reported from peripheral areas of
Aurangabad city, with rural areas (77%) having a higher incidence than urban areas (23%). The higher incidences among males
and farmers with age group of 21-50 years are likely due to occupational exposure, these findings are consistent with the study,
identifying snakebite as an occupational hazard among 54.4% farmers and 30.5% plantation workers,[17]
mostly, people working
in the rural areas with barefoot walking.[18]
The work environment and timing of agricultural activities increase the risk of
encounters with snakes.
Our study revealed that 34.7% of snakebite patients received first aid at PHCs, while 23.4% used tourniquets and 42.7%
received no first aid. Notably, none of the patients applied the WHO recommended pressure immobilization technique.[5]
These
findings indicate a significant knowledge gap, consistent with a North Kerala study, which found 86% of participants had poor
understanding of snakebite first aid and 93.6% used tourniquets, despite WHO warnings against their use.[19]
These highlights
indicate the need for public education on proper snakebite first aid measures.
Snakebite cases were identified and categorized based on clinical features and complications into vasculotoxic, neuroparalytic,
and mixed-type envenoming. This study found vasculotoxic snakebites to be the most common (46.77%), followed by mixed
type (42.74%), and neuroparalytic (10.48%). Based on the identified snake species, Viper bites accounted for 46.77% of cases,
followed by Russell's viper (33.87%), Cobra (11.29%), and Krait (8.06%) bites, with Viper bites and Russell’s Viper bites
being the most prevalent. Similarly, the study conducted at Maharashtra noted most of the victims were bitten by Viper,[20]
in
rural Maharashtra reported regional variations in snakebite incidence, with Echis carinatus (saw-scaled Viper) prevalent in
humid coastal regions and Russell's viper, Cobra, and Krait more common in dry and hot climates.[21]
The climate and
geography of Aurangabad, Marathwada, Maharashtra, likely contribute to the higher incidence of Viper (vasculotoxic) and
Russell's viper and Cobra (mixed type) and Krait (neuro paralytic) bites.
It was observed that amongst our study population, with proportionate to BNT the frequency of complications were increased
cellulitis (14.10% to 100%), anemia (12.82% to 100%), uremia (10.26% to 22.22%), hypotension (1.28% to 22.22%),
hematuria (3.85% to 11.11%), LRTI (6.67% to 16.67%), neutrophilia (50% to 100% and then to 55.56%), leukocytosis (47.44%
to 83.33% and then to 66.67%), respiratory failure (7.69% to 50% and then to 11.11%), thrombocytopenia (12.82% to 50%
and then to 33.33%), AKI (1.28% to 10%), and progressive swelling (15.38% to 33.33%). The neutrophilia (54.03%) with
leukocytosis (51.61%), anemia (19.35%), thrombocytopenia (21.77%), cellulitis 21.57%), and progressive swelling (21.57%
were the most prevalent manifestations than the AKI (3.22%), respiratory failure (10.48%), ARD (0.8%), HIE (0.8%) aligning
with findings of the study, which reported significant complications including cellulitis (26.2%), acute kidney injury (20.9%),
respiratory paralysis (4%), and ARDS (2%), among others the cerebrovascular events were noted in (n=9) patients,[22]
whereas
in our study the orthopedic (osteomyelitis at bite site) and gangrene complications were not observed this might because of our
most of the study population had BNT less than 8 hrs. Similar findings where noted in previously conducted, the renal failure,
leukocytosis, neurotoxicity, severe coagulopathy and adverse outcomes were observed in patients with prolonged BNT.[23]
In
our study, the frequent hematological complications were observed mainly due to most of the victims were bitten by
vasculotoxic (Viper) and mixed type (Russell’s viper and Cobra) snakes. In this study, it was observed that neuroparalytic
Recovered and
discharged,
96.78%
Decision Against
Medical Advise
(DAMA), 1.61%
Death, 1.61%

696
complications such as respiratory failure and ARDS were initiated in the victims within very short duration due to Cobra and
Krait bites.
In the present study, almost 62.9% (n=78) of the total study population (n=124) comprised BNT 0-4 hours. Of these, 65.38%
(n=51) of patients experienced complications, which included, cellulitis (14.10%, n=11), anemia (12.82%, n=10), uremia
(10.26%, n=8), hypotension (1.28%, n=1), hematuria (3.85%, n=3), neutrophilia (50%, n=39), leukocytosis (47.44%, n=37),
respiratory failure (7.69%, n=6), thrombocytopenia (12.82%, n=10), AKI (1.28%, n=1), progressive swelling (15.38%, n=12).
The snakebite types in this BNT category were, Viper bites (29.03%, n=36), Russell’s viper bites (22.58%, n=28), Cobra bites
(6.45%, n=8), and Krait bites (4.84%, n=6). These findings are consistent with previous studies, which reported similar clinical
manifestations and bitten snake species.[24,25,26]
The hematological toxicity of Viper and Russell's viper bites led to adverse
outcomes, including neutrophilia, leukocytosis, anemia, and thrombocytopenia. Respiratory failure was observed in 7.69% of
cases, likely due to the lower number of Cobra and Krait bites in this BNT category. According to previous research, Cobra
and Krait venom can cause respiratory failure due to neuromuscular blocking action.
In the present study, almost 24.19% (n=30) of the total study population (n=124) comprised BNT 4-8 hours. Of these, 96.67%
(n=29) of patients experienced complications, which included, cellulitis (16.67%, n=5), anemia (30%, n=9), uremia (6.67%,
n=2), hypotension (13.33%, n=4), hematuria (6.67%, n=2), LRTI (6.67%, n=2), HIE (3.33%, n=1), septicemia (3.33%, n=1),
neutrophilia (56.67%, n=17), leukocytosis (53.33%, n=16), respiratory failure (10%, n=3), ARDS (3.32%, n=1), DIC (6.67%,
n=2), thrombocytopenia (36.67%, n=11), AKI (10%, n=3) and progressive swelling (33.33%, n=10). The snakebite types in
this BNT category were, Viper bites (12.09%, n=15), Russell's viper bites (7.26%, n=9), Cobra bites (3.23%, n=4), Krait bites
(1.61%, n=2).These findings are consistent with the study, which reported similar critical complications, including AKI, DIC,
sepsis, progressive swelling, respiratory failure, and ARDS, in patients with prolonged BNT.[14, 24]
The present study suggests
that vasculotoxic snake bites are frequently associated with critical complications, such as AKI, progressive swelling,
septicemia, and DIC, while neuroparalytic bites can lead to respiratory failure and ARDS, as the BNT rises, likewise findings
were revealed in a previously conducted study.[27]
In the present study, almost 4.84% (n=6) of the total study population (n=124) comprised BNT 8-12 hours. Of these, 100%
(n=6) of patients experienced complications, which included cellulitis (16.67%, n=1), anemia (50%, n=3), LRTI (16.67%, n=1),
neutrophilia (100%, n=6), leukocytosis (83.33%, n=5), respiratory failure (50%, n=3), thrombocytopenia (50%, n=3). The
snakebite types in this BNT category were, Viper bites (0.8%, n=1), Russell’s viper bites (1.61%, n=2), Cobra bites (1.61%,
n=2), and Krait bites (0.8%, n=1). The complications were more frequent and severe in this BNT category. Previously
conducted studies, revealed that the delayed recognition and management can lead to life-threatening complications,[28,29}
which
aligned with the present study, the respiratory failure were observed among 50% amongst victims of this BNT category, this
might be due to the Cobra and Krait bites with prolonged BNT, management of such cases were very difficult, as the
complications turned in to the critical stages, many respiratory failure victims went through intubation, ventilator for oxygen
support due to respiratory muscle paralysis. Moreover, it was observed that such patients had received medical intensive care
services with closely clinical monitoring, consistent with findings reported by Patil et al. larger proportion of patients with
delayed treatment required interventions such as fasciotomy, dialysis, and ventilator support. Notably, the need for dialysis and
ventilator support was significantly (p<0.05) associated with delayed treatment.[13]
In the present study, almost 7.26% (n=9) of the total study population (n=124) comprised BNT 12-24 hours. Of these, 100%
(n=9) of patients experienced complications, which included, cellulitis (44.44%, n=4), anemia (11.11%, n=1), uremia (22.22%,
n=2), hypotension (22.22%, n=2), neutrophilia (55.56%, n=5), leukocytosis (66.67%, n=6), respiratory failure (11.11%, n=1),
thrombocytopenia (33.33%, n=3). The snakebite types in this BNT category were, Viper bites (4.03%, n=5), Russell’s viper
bites (2.42%, n=3), and Krait bites (0.8%, n=1). These findings align with the previous study, an exacerbated systemic
complication due to delayed treatment reported.[30]
The hematological toxicity and neurotoxicity worsened the victims'
conditions due to delayed treatment, particularly due to Viper, Russell's viper, and Krait bites. Managing such cases is
challenging, required interventions such as blood transfusions, dressings, higher antibiotics, and prolonged ventilator support.
In the present study, almost (0.81%, n=1) of the total the study population (n=124) comprised BNT >24 hrs. Of these (100%,
n=1) patients had cellulitis and anemia complications. The victims falling in this BNT were, Viper bites (0.8%, n=1). The
cellulitis was a common complication that increased from 14.10% to 100% in victims bitten by Viper, consistent with the study,
which found cellulitis across all BNT categories, increasing in frequency with longer BNT, especially >24 hours.[30]
This study found a significant correlation between the timing of ASV administration and the development of complications in
snakebite patients. Patients who received ASV within 0-4 hours of the bite had a lower incidence of complications (65.58%)
compared to those who received ASV at later time intervals (96.66% for 4-8 hours, 100% for 8-12 hours, 12-24 hours, and >24
hours). Statistical analysis using the Chi-Square test revealed a significant correlation between BNT and complications (P-

697
value = 0.0015, 95% CI, p<0.05). Furthermore, Pearson Correlation analysis showed a strong positive correlation (r = 0.665)
between BNT and complications. These findings are consistent with previous studies, which have also demonstrated a direct
relationship between delayed ASV administration and increased risk of complications in snakebite patients,[31,32]
The delayed
ASV administration indicates the increased BNT which reflects increased duration of venom stay in the body of the victims
and thus proportionately enhances the risk of development of complications.
In our study, it is observed that, the majority of patients (41.64%) received 11-20 vials of ASV, with a recovery rate of 96.77%,
however the majority of our study patients had BNT 0-8 hrs. Notably, starting with a low dose of ASV (minimum 10 vials)
resulted in better patient improvement, suggesting that subsequent doses should be tailored to individual clinical conditions
and response to ASV. These findings are consistent with previous research, including a study, they found no significant
difference in outcomes between low-dose (<50 ml or ≤5 vials) and high-dose (>50 ml or >5 vials) ASV groups, with most
patients surviving with low doses when treated promptly. [33]
As in present study most of the patients received ASV within 0-
8 hrs. with <10 and 10-20 vials, though patients had many complications however the recovery rate was good. A review of 5
randomized controlled trials, also suggested that low-dose ASV may be equivalent to or better than high-dose ASV in treating
venomous snakebites, depending on patient clinical status.[34]
although the evidence quality was graded as "very low".
This present study found that adverse events after ASV administration were mostly mild to moderate, including hypotension
(8.06%), hypertension (6.45%), fever (5.65%), tachycardia (4.83%), tachypnea (3.23%), and rigors (4.3%). Less common
events included bradycardia, itching, urticaria, and abdominal pain. All adverse events were resolved with medications such as
adrenaline, hydrocortisone, phenylephrine, and paracetamol, whereas a study revealed, chills, nausea, and vomiting as common
adverse reactions, with some patients had severe reactions like hypotension and respiratory arrest.[35]
Prophylactic use of
medications may have contributed to the low incidence of adverse events in the present study.
In this study, reasons for delayed to reach at hospital for ASV treatment and supportive management were observed as
transportation in 28.2 % (n=35) of patients, delayed after PHC in 13.7 % (n=17) of patients, no one available for help at the
time of incidence place in 11.3 % (n=14) of patients, hospital far away in 10.5 % (n=13) of patients, patient ignorance in 7.3 %
(n=9) of patients and no sense of damage in 6.5 % (n=8) of patients. Transportation and delayed after PHC were the two major
reasons in most of the patients, similar findings align with the study, revealed ASV treatment delay due to lack of awareness
of snakebite hazards, lack of transportation and referral facilities,[36,37]
another study noted that snake bite victim died on the
way due to poor access to nearest hospital,[21]
in one of the previously conducted study, the 3 patients were died out of 18
patient snake bite envenomation because of lacking prompt medical facilities and inadequate antivenom,[38]
these findings
indicating, it is essential to have availability of ASV at PHCs and nearby hospitals to get it promptly by snake bite victims. A
retrospective chart review study of 533 snakebite victims in India, found that pre-hospital delays over 24 hours resulted in 18%
mortality,[39]
compared to 5% mortality for those hospitalized within a shorter timeframe, this study concluded that
complications and mortality are directly related to the timing of ASV administration. In the present study, the higher recovery
rate of 96.78% and least death rate 1.61% are probably due to most of the victims 62.90% and 24.19% having received ASV
with supportive medical management within 0-4 hrs. and 4-8 hrs. respectively, however the large number of victims had
complications. The victims who received ASV within 0-4 hrs. had lower complication rate (34.4% without complications)
compared to those who received ASV within 4-8 hours (3.33% without complications) and for those whose ASV receiving
time delayed over 8 hrs., 100% of patients had complications. Timely administration of anti-snake venom (ASV) can
significantly reduce mortality and morbidity associated with snakebites. Integrating snake antivenoms into primary healthcare
systems is crucial in regions prone to snakebites. Delayed medical care often stems from diverse factors, including geographical
disparities, snake species diversity, inadequate reporting, reliance on traditional remedies, and limited healthcare access.[40]
These findings highlight the importance of prompt ASV administration and public awareness to minimize delays, reduce
complications thus, reduce morbidity, mortality, and save lives.
CONCLUSION:
This study concluded that, despite being preventable, snakebites envenoming remains a life-threatening medical emergency,
particularly affecting rural agricultural and farming communities. Snakebite envenoming complication rises in proportionately
to the BNT, as the statistically significant, strong positive correlation exists between BNT and complications. Thus, this study
highlights the imperative role of timely ASV administration in preventing complications and reducing morbidity and mortality
associated with snakebites and underscores the need for public awareness on appropriate first aid measures, prompt ASV and
supportive medical intervention, ultimately enhancing patient outcomes and quality of life.
RECOMMENDATION:
Providing health education on snakebites at rural and urban areas, their toxic effects, importance of prompt hospitalization,
ASV therapy, right first aid and preventive measures can significantly reduce the incidence and complications of snakebites.

698
ACKNOWLEDGEMENT:
Our sincere thanks to all medical faculty, hospital management and staff of Government Medical College and Hospital,
Aurangabad for helping in completion of this study and to all participants.
FUNDINGS: Nil.
CONFLICT OF INTEREST: Nil declared.
ETHICAL APPROVAL: This study approved by Institutional Ethics Committee (IEC).
CONTRIBUTION: MB and SB had equal contribution and are co-authors as the first author. MB and SB: concept, design,
literature search, data acquisition, data analysis and manuscript review; AA, AC, SB, PS: design, approval process, conduct,
data acquisition, statistical analysis, manuscript preparation, manuscript writing, manuscript review and submission process.
ABBREVIATIONS:
%: Percentages.
AE: Adverse Event.
ARDS: Acute Respiratory Distress Syndrome.
ASV: Anti-Snake Venom.
BNT- Bite-to-Needle tile.
CI: Confidence Interval.
CRF: Case Report Form.
DAMA: Discharged Against Medical Advice.
DIC: Disseminated Intravascular Coagulopathy.
HIE: Hypoxic Ischemic Encephalopathy.
PHC: Primary Health Centre.
IEC: Institutional Ethics Committee.
LRTI: Lower Respiratory Tract Infection.
MS Excel: Microsoft Excel.
n: Frequency of cases.
RF: Respiratory Failure.
WHO: World Health Organization.
REFERENCES:
1. World Health Organization. Snakebite [Internet].2024 [Accessed 10 Apr 2024]; Available from:
https://www.who.int/india/health-topics/snakebite.
2. World Health Organization: Study estimates more than one million Indians died from snakebite envenoming over past two
decades [Internet]. 2020 Jul 10 [ Accessed 02 Jul 2025]; Available from: https://www.who.int/news/item/10-07-2020-
study-estimates-more-than-one-million-indians-died-from-snakebite-envenoming-over-past-two-decades..
3. Chippaux JP. Snakebites: Appraisal of the global situation. Bull World Health Organ. 1998;76(5):515-24.
4. Kasturiratne A, Wickremasinghe AR, De Silva N, Gunawardena NK, Pathmeswaran A, Premaratna R, et al.: The global
burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med.
2008 Nov;5(11):e218. doi: 10.1371/journal.pmed.0050218.
5. Ministry of Health and Family Welfare, Government of India: Management of Snake Bite. Version 4. 2016.
6. Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, et al.: Snakebite mortality in India: a nationally
representative mortality survey. PLoS Negl Trop Dis. 2011 Apr 12;5(4):e1018. doi: 10.1371/journal.pntd.0001018.
7. Chippaux JP: Estimate of the burden of snakebites in sub-Saharan Africa: a meta-analytic approach. Toxicon. 2011
Mar;57(4):586-99. doi: 10.1016/j.toxicon.2011.02.003.
8. Harrison RA, Hargreaves A, Wagstaff SC, Faragher B, Lalloo DG: Snake envenoming: a disease of poverty. PLoS Negl
Trop Dis. 2009 Dec 8;3(12):e569. doi: 10.1371/journal.pntd.0000569.
9. Wilson S, Warrell D, Romulus W, Geetha M, Rashmi R, Size HF, et al. Trends in snakebite deaths in India from 2000 to
2019 in a nationally representative mortality study. eLife. 2020 Jan 28;9:e54076. doi: 10.7554/eLife.54076.
10. Pillay VV: Modern Medical Toxicology. 4th ed. New Delhi: Jaypee Brothers Medical Publishers; 2013. p. 137-56.
11. Balachandran A: Principles of Forensic Medicine and Toxicology. 1st ed. Jaypee Brothers Medical Publishers; 2011. 477-
487.
12. Mahendra M, Mujtaba M, Mohan CN, Ramaiah M: Study of Delayed Treatment Perspective of Snake Bites and Their
Long-Term Effects in a Tertiary Care Hospital in Balgalkot District of Karnataka. Journal of Internal Medicine. 2021 Jul-
Sep;9(3):153-158. doi: 10.4103/ajim.ajim_78_20.

699
13. Silva A, Hlusicka J, Siribaddana N, Waiddyanatha S, Pilapitiya S, Weerawansa P, et al. Time delays in treatment of
snakebite patients in rural Sri Lanka and the need for rapid diagnostic tests. PLoS Negl Trop Dis. 2020;14: e0008914.
14. Suchithra N, Pappachan JM, Sujathan P. Snakebite envenoming in Kerala, South India: Clinical profile and factors
involved in adverse outcomes. Emerg Med J. 2008;25:200-4. doi: 10.1136/emj.2007.051136.
15. Kulartane SA. Common Krait (bungarus caeruleus) bite in Anuradhapura, Sri Lanka: A prospective clinical study. 1996-
98. Postgrad Med J 2002; 78:276-80. doi: 10.1136/pmj.78.919.276.
16. Kalantri S, Singh A, Joshi R, Malamba S, Ho C, Ezoua J, et al. Clinical predictors of in-hospital mortality in patients with
snakebite: A retrospective study from a rural hospital in central India. Trop Med Int Health. 2006; 11:22-30. doi:
10.1111/j.1365-3156.2005.01535.x.
17. Halesha BR, Lokesh AJ. Clinico-epidemiological profile and outcomes in snake bite victims. J Clin Diagn Res.
2013;7(1):122-126. doi: 10.7860/JCDR/2012/4842.2685.
18. Denker BM, Brenner BM: Azotemia and urinary abnormality In: Fauci AS, Kasper DL, Longo DL, Braunwald E, Hauser
SL, Jameson JL, et al.: editors. Harrison's Principles of Internal Medicine. 17th ed. New Delhi: McGraw Hill; 2008. p. 271.
19. Thomas B, Induja H, Rajendra G, Bhosle SB: Cross-Sectional Study on the Awareness, Perceptions and First Aid Measures
of Snakebite among Adult Population in Calicut, South India. International Journal of Medical Research and Health
Science 2021;10(4):51-55.
20. Punde DP: Management of snakebite in rural Maharashtra: A 10-year experience. Natl Med J India. 2005; 18:71-5.21.
21. Bawaskar HS, Bawaskar PH, Punde DP, Dongre RB, Boite RR: Profile of snake bite envenoming in rural Maharashtra,
India. J Assoc Physicians India. 2008; 56:88-95.
22. Menon JC, Joseph JP, Jose MP, Dhananjaya BL, Oomen OV: Clinical profile and laboratory parameters in 1051 victims
of snake bite. J Assoc Physicians India. 2016;64(12):22-29.
23. Kumar S, Prabhakaran P: Clinical profile and outcome in patients with snake bites in a tertiary care Centre in Kerala. J
Evid Based Med Health. 2021; doi: 10.18410/jebmh/2021/646.
24. Siddique FS, More KS, Bhandare M, Bolke M, Jadhao K: Hematological profile in vasculotoxic snake bites. Eur J
Cardiovasc Med. 2025; 15:562-567.
25. Agrawal A, Gupta A, Khanna A: What dose of anti-snake venom should be given in severe neuroparalytic snake bite? Ann
Thorac Med. 2011;6(1):47-48.
26. Indian National Snakebite Protocols: Indian National Snakebite Protocol Consultation Meeting, Delhi. Neurotoxic
Envenomation. 2007.
27. Mao YC, Liu PY, Chiang LC, Lai CS, Lai KL, Ho CH, et al.: Naja atra snakebite in Taiwan. Clin Toxicol (Phila). 2018;
56:273-280.
28. Maduwage K, Isbister GK: Current treatment for venom-induced consumption coagulopathy resulting from snakebite.
PLoS Negl Trop Dis. 2014;8:e3220. doi: 10.1371/journal.pntd.0003220.
29. Tasoulis T, Isbister GK: A review and database of snake venom proteomes. Toxins 2017; 9:290. doi:
10.3390/toxins9090290.
30. Lakkappan V, Vyas PK, Sivakumar MN, Palekar SP, Uchil A: To study clinical presentation, management and outcomes,
in snake bite patients. Ann Med Med Res. 2023;6: Article 1058.31.
31. Narvencar K: Correlation between timing of ASV administration and complications in snake bites. J Assoc Physicians
India. 2006; 54:717-719. PMID: 17212020.
32. Rabadiya M, Ganvir A, Sinha S, Bhusare D: Impact of time interval on snake bite treatment outcomes: Insights from Anti
Snake Venom Administration. Int J Toxicol Pharmacol Res. 2024;14(5):86-92.
33. Borkar MS, Lahane CG, Kashid AA, Chavan SU, Uppod SC: Effect of low dose ASV with supportive care in poisonous
snake bites in Marathwada region, Aurangabad, Maharashtra, India. Int J Sci Rep. 2015;1(8). doi: 10.18203/issn.2454-
2156.IntJSciRep20151500.
34. Das S, Sankar J, Dev N: High-dose versus low-dose antivenom in the treatment of poisonous snake bites: a systematic
review. Indian J Crit Care Med. 2015;19(6):340-349. doi: 10.4103/0972-5229.158275.
35. Deshpande RP, Motgare VM, Padwal SL, Pore RR, Bhamare CG, Deshmukh VS, et al.: Adverse drug reaction profile of
anti-snake venom in a rural tertiary care teaching hospital. J Young Pharm. 2013;5(2):41-45. doi:
10.1016/j.jyp.2013.02.003.
36. Reddy KS: Essentials of forensic medicine and toxicology. 27th ed. Hyderabad: Laxmi Printers; 2008. p. 487-99.
37. Gaitonde BB, Bhattacharya S: An epidemiological survey of snake-bite cases in India. Snake. 1980; 12:129-33.
38. Hung DZ: Snake bite in Taiwan. Toxicon. 2002;40(2):96-101.
39. David S, Matathia S, Christopher S: Mortality predictors of snake bite envenomation in southern India. J Med Toxicol
2012;8(2):118-123. doi: 10.1007/s13181-011-0204-0.
40. World Health Organization: Snakebite Envenoming Fact Sheets [Internet]. 12 Sep 2023 [Accessed on 2024 Jul 10].
Available from: https://www.who.int/news-room/fact-sheets/detail/snakebite-envenoming

Exploring The Impact of Bite-to-Needle Time on Snakebite Complications: Insights from a Study at Tertiary Care Hospital

More Related Content

Similar to Exploring The Impact of Bite-to-Needle Time on Snakebite Complications: Insights from a Study at Tertiary Care Hospital (20)

Recently uploaded (20)

Exploring The Impact of Bite-to-Needle Time on Snakebite Complications: Insights from a Study at Tertiary Care Hospital