Snakebite first aid in Bangladesh

Call for help

Call 999 for an ambulance⁴. Bangladesh’s guideline says to get the bitten person to a hospital quickly by motorbike or ambulance, and not to delay reaching a health facility¹. Do not waste time with a traditional healer (ozha)¹. DGHS reports that 42% of people with envenoming still go to an ozha first, spend about an hour there and reach hospital late³.

While you wait

These are the first-aid steps in Bangladesh’s national guideline¹:

• Reassure the person. Tell them that most snakes are not venomous, and that venomous snakes sometimes fail to inject enough venom¹.
• Keep the person and the bitten limb still. If the bite is on the leg: “Sit down, do not walk.” If it is on the arm: “Do not move the limb.” Splint or sling the limb as you would a broken long bone¹.
• Gently wash the bite with soap and water, or wipe it with a wet cloth, and cover it with a bandage¹.
• As early as possible, remove rings, bangles, anklets, cords, tight clothing, tabij and taga, which may squeeze the limb if it swells¹.
• Lay the person on their side¹.
• If the person is not breathing, give rescue breathing¹.
• If the snake has already been killed, bring it to hospital, but do not touch it with bare hands, as it may only seem dead. Do not waste time trying to catch or kill it¹.

The pressure pad

The guideline says pressure immobilisation is the ideal first aid, and recommends a pressure pad over the bite¹. It is based on WHO’s South-East Asia guideline¹, which advises a pressure pad whenever a bite by an elapid snake, such as a cobra or krait, cannot be ruled out, and prefers it to a full pressure bandage because it is simpler and more practical². WHO describes the pad as a folded piece of cloth or rubber about 5 cm square and 2–3 cm thick, placed directly over the bite and bound in place with a bandage that does not stretch, at a pressure of at least 70 mmHg². In practice, pressure immobilisation is hardly used in Bangladeshi communities, and DGHS notes that doubts have been raised about applying it at the correct pressure in rural settings³.

What not to do

The guideline’s list of don’ts¹:

• Do not tie a tourniquet or ligature on the bitten limb. There is no proof that it helps¹, and ligatures can cause or worsen tissue death around the bite³. If one is already tied, do not release it until the person is in hospital, with staff and resuscitation facilities ready and antivenom started if needed¹.
• Do not cut the bite, prick it with needles or put any cream on it, and do not burn it with chemicals¹.
• Do not apply herbal medicines, stones, seeds, saliva, potassium permanganate, cow dung or mud¹.
• Do not give oil, ghee or pepper to make the person vomit, and do not apply alcohol¹.
• Do not give aspirin for pain¹.
• Give nothing by mouth if the person has trouble swallowing or talking, is vomiting, has a nasal voice or is drooling¹.
• Do not panic, and do not delay reaching a health facility¹.

How this differs from the general advice

Bangladesh’s guideline goes further than the general first-aid page in two ways. It recommends a pressure pad over the bite¹, which the general page does not include; WHO’s own first-aid advice says only that a pressure pad may be suitable in some cases, and that a tight arterial tourniquet must never be used⁵. It also says to wash the bite gently with soap and water¹, a step the general page does not cover.

In hospital

Antivenom is the only definitive treatment, and it is given as a drip into a vein as soon as doctors find signs of envenoming¹. Bangladesh uses Indian polyvalent antivenom: the first dose is 10 ampoules over one hour, the same for adults and children¹. It is given for cobra, krait and Russell’s viper bites, but the antivenom available is not recommended for green pit viper or sea snake bites¹. Antivenom is not made in Bangladesh; the imported Indian product is not made from local snakes’ venoms, and its effect is variable³. People with paralysis are also given atropine and neostigmine, and breathing support if their breathing muscles are affected¹.

Snakes that matter here

Kraits and cobras cause most snakebite deaths in Bangladesh, through venom that paralyses¹. These are the species the guideline names¹:

• Kraits: at least five species cause deaths: Wall’s krait, the greater black krait, the common krait, the banded krait and the lesser black krait¹. Wall’s, greater black and common kraits cause most krait bites; banded and lesser black kraits cause very few².
• Monocled cobra, found throughout the country, causes most cobra bites^1,2.
• Indian cobra, around Dhaka and to the west and north of the capital¹.
• Russell’s viper, patchy in the north-west and south, where it has caused serious illness and deaths since 2013¹.
• Green pit vipers, found throughout the country, cause the largest share of venomous bites in records from Chittagong Medical College Hospital, mostly with local pain and swelling only¹.
• King cobra, in the remaining forests and bamboo stands, has not caused a documented bite in recent years¹.

There is no evidence that saw-scaled vipers live anywhere in Bangladesh¹.