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Initial management

  • analgesia e.g. paracetamol
  • urgent referral to casualty department
  • immobilise the whole patient (particularly the bitten limb with a splint or sling) during transport to hospital
  • if anaphylaxis/allergic reaction oral or parenteral antihistamines or adrenaline (epinephrine) (Epi-Pen), depending on severity
  • it is advised that tourniquets, ligatures, and compression bandages should not be used

Hospital based management:

  • seek expert advice
  • clinical assessment
  • careful monitoring of the blood pressure and evolution of envenoming over at least 24 hours
  • antivenom (e.g. Zagreb antivenom) may be indicated although early anaphylactoid reactions may complicate about 10% of treatments with Zagreb antivenom. The use of antivenom prevents mortality and reduces hospital stay and morbidity. Indications for the use of antivenom (1):
    • hypotension (with or without signs of shock)
    • signs of systemic envenoming, electrocardiographic abnormalities, peripheral neutrophil leucocytosis, elevated serum creatine kinase, or metabolic acidosis
    • if there is local swelling that is either extensive (involving more than half the bitten limb within 48 hours of the bite) or rapidly spreading (beyond the wrist after bites on the hand or beyond the ankle after bites on the foot within about four hours of the bite)
  • intravenous fluids or blood transfusion may be required
    • to correct hypovolaemia and anaemia from massive extravasation into the tissues
  • bitten limb
    • should be nursed in the most comfortable position - however excessive elevation must be avoided
    • splinting of the limb to prevent contractures
  • rehabilitation physiotherapy


  • frequency of anaphylactoid reactions to antivenom may be reduced by giving prophylactic subcutaneous adrenaline (adult dose 0.25 mg of 0.1%) but is not affected by antihistamines


  1. Warrell DA. Treatment of bites by adders and exotic venomous snakes. BMJ 2005; 331:1244-47

Last reviewed 11/2020