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Clinical challenges, controversies, and regional strategies in snakebite care in India

PMCID: PMC12145746

PMID: 40487912

Abstract

Summary Snakebite envenomation remains a significant public health issue, particularly in southeast Asia, where diverse venomous snake species and resource-limited healthcare settings complicate effective management. This Health Policy employed thematic analysis of a panel discussion involving multidisciplinary experts with over 300 years of combined experience. Four key themes were identified: (i) the evolution of snakebite treatment paradigms, (ii) clinical and procedural challenges, (iii) debates over controversial practices, and (iv) the role of policy and research in improving outcomes. The findings emphasise the need for region-specific antivenoms, enhanced peripheral healthcare capabilities, and evidence-based treatment protocols. This work provides actionable insights to inform health policy, guide targeted training initiatives, and prioritise research on neglected areas in the management of snakebite.

Full Text

Snakebite envenomation remains a significant public health challenge in India, particularly in rural areas where access to timely and appropriate medical care is limited. The complexities of snakebite management are compounded by the diverse species of venomous snakes present in the region, each with varying effects on the human body. Despite advancements in antivenom production and snakebite care protocols, there remains considerable debate and variability in treatment approaches, particularly for species like Hump-nosed pit viper (Hypnale hypnale) that are not covered by the Indian polyvalent antivenom (IPAV).
The Snake Bite Life Support (SBLS) workshop, held as part of ongoing efforts to enhance snakebite management within a One Health framework, to improve snakebite management, brought together a panel of experts with over 300 years of collective experience in treating snakebite cases. This panel discussion, titled “Core Principles and Controversies in Snake Bite Management”, aimed to explore the evolving treatment paradigms, the challenges faced by clinicians, and the need for region-specific antivenom strategies. The discussion also focused on the current consensus guidelines and the controversies that still exist in the field, providing valuable insights into the complexities of managing snakebite envenomation in the region.
The research team consisted of experts with diverse backgrounds in snakebite management. The panellists, who are also the authors, are recognised leaders in relevant fields, including general physicians (KBM, UBV, JT), a paediatrician (PKK), emergency medicine physicians (RPC, MA, FMS), a wilderness medicine expert (FMS), national policymakers (FMS, MA), a toxicologist (IM), a haematologist (AMR), and a zoologist (SD). Each has at least 15 years of experience in treating snakebites, bringing over 300 years of combined clinical experience to the discussion (see Supplementary Information S1: Panellist profile).
Data collection involved video recordings of the 90-min panel discussion using a Canon EOS 60D camera, with a Canon EOS 1500D as backup. Audio and video were stored as MP4 files and securely backed up. Field notes were taken during the session using Microsoft OneNote on a Surface Pro. Audio recordings were transcribed verbatim by AG, verified by DM, and cross-checked for accuracy by VC. The transcripts were shared with panellists for revision to ensure accuracy. Initial coding of the transcripts was done using Microsoft Excel, with additional codes generated using OpenAI's GPT-4 and manually assigned by AG and SVA, then verified by AS. Supporting quotes were organised under relevant themes and subthemes, with overlapping statements assigned multiple codes. In instances where a sentence or segment was relevant to multiple themes, we duplicated the quote under each applicable code to ensure comprehensive representation of the data (Supplementary Information S2: Coded quotes). Frequency summaries were used descriptively to illustrate recurring themes, but thematic prioritisation was based on the depth and relevance of insights, rather than frequency alone. Thematic analysis followed Braun and Clarke's six-phase framework. Data were securely stored in password-protected cloud storage (Google Drive).
ES-AV (Historical changes in antivenom use): The approach to antivenom has evolved from limited and low-dose use in the 1970s to a standardised 10-vial treatment across snake species. “The serious nature of pit viper bites was fully acknowledged in 2006, marking a major shift in management” (KBM). Recognising the ineffectiveness of antivenom for pit viper bites helped reduce wastage and unnecessary administration.
Challenges in snakebite management span the entire continuum of care, from prehospital treatment to hospital care. In rural areas, “patients often visit traditional healers”, leading to delays in presentation (RPC). Once at the hospital, variations in case presentation and inconsistent management complicate treatment, particularly when referral systems fail., Peripheral centres frequently lack resuscitation support and clarity on antivenom dosage, leading to confusion and sometimes non-administration of anti-snake venom (ASV). Early ‘referral to better-equipped centres’ is often seen as the ‘safest option’ (Audience). Additionally, managing allergic reactions, coagulopathy, capillary leak syndrome, and other complications remains a significant challenge in these settings.
“Venom-induced consumption coagulopathy can lead to systemic manifestations such as stroke, myocardial infarction, and acute kidney injury” (FMS). In certain regions H. hypnale bites are associated with “more severe complications and higher mortality rates” due to coagulopathy (FMS). The complexity of coagulopathy in snakebites is heightened by the fact that “snake venom contains both procoagulants and anticoagulants, and the dominant factors determine the presentation of symptoms” (UB). This raises critical questions in treatment, such as whether “anticoagulation is an appropriate treatment option for hemispheric stroke” (UB) or if blood component therapy, while considered the next best option after antivenom, can “lead to more complications than benefits if used without a clear indication” (JT).
There was a debate over how different antivenom brands influence outcomes, especially regarding complications like capillary leak syndrome (JK) suggesting a need for implementation of standardisation of manufacturing and better quality control. The potential of “plasmaphaeresis to remove toxins such as phospholipase A2, zinc metalloprotease, and vascular apoptosis-inducing proteins 1 & 2” (JK) and “role of steroids … often administered for capillary leak syndrome” (JK) remains areas needing further investigation.
There are no considerable changes in management of paediatric bite in case of antivenom however “smaller volumes of treatment, generally 5–10 ml/kg” for paediatric patients was suggested (PKK). It was also noted that “The response of paediatric patients to treatments or interventions can vary somewhat, and even experienced faculty have limited experience with cases involving newborns and very young” (PKK). Additionally a comment on, “many snakebites happen in school settings” was made noting recent events across India including one death in Wayanad, Kerala.11, 12, 13, 14, 15
Experts noted significant ‘differences in antivenom potency in clinical practice’, emphasising the need for region-specific antivenom production in India. Strategic plans, such as expanding venom centres and implementing policy changes at state and district levels, were discussed as critical for improving antivenom quality.
The use of tourniquets in snakebite management remains highly controversial. “The use of a tourniquet can provide false reassurance to patients and bystanders” (RPC). Training is essential because “when prompt medical care is available, using a tourniquet can often do more harm than good” (FMS). The use of tourniquets, though generally not recommended, was suggested as a tool that can still be considered “in remote areas where delays in receiving medical attention” are expected, “by experts” to “prioritise life over limb” (FMS). The argument that “tourniquet has some role in delaying envenomation” (UB, FMS) was contested by members of the panel (KBM, PKK) and the overarching consensus in national and international guidelines, that the use of tourniquets is not recommended, and the overarching consensus in national and international guidelines, that the use of tourniquets is not recommended, was emphasised by the panellists (MA, PKK). However to date, none of the panellists reported having seen pressure immobilisation applied to patients they have received.
The role of plasmaphaeresis in treating snakebite complications like capillary leak syndrome remains a topic of debate. “Although the role of plasmaphaeresis in capillary leak syndrome is controversial in studies, we consider it when a patient develops bilateral parotid swelling, periorbital oedema, haemoconcentration, and refractory shock” (JK). In some centres it was pointed out that, “plasmaphaeresis has been used when antivenom was ineffective or not indicated, and has shown potential mortality benefits” (AMR). However it was pointed out that in regions like “Southern Maharashtra, Karnataka, and Goa, Hump-Nosed Pit Vipers are causing more severe complications and higher mortality rates, with plasmaphaeresis often proving ineffective for these patients” (FMS). The statement was supported by noting that “there are no methodological studies supporting the use of plasmaphaeresis for snakebite cases” (IM). Comprehensive studies at the molecular level are needed to assess the factors involved and the effects of plasmaphaeresis before it can be widely adopted (IM).
Accurate snake identification is essential for effective management but remains challenging. Misidentification, particularly with hump-nosed pit vipers, can lead to inappropriate treatment, such as unnecessary use of ASV, which is ineffective for any of the pit viper species (JK, SD). Remote identification tools like “WhatsApp and Facebook groups, along with apps like Snakepedia and SARPA (Snake Awareness Rescue and Protection) can aid in this process” (SD). However, “even for experts, identifying a snake from ambiguous photographs, from bite marks or sometimes without knowing its location and other details can be challenging” (SD).
The WHO's goal to reduce snakebite deaths by 50% by 2030 drives efforts to expand venom centres and allocate funding. “State and district-level action plans are crucial” (MA), for instance taking the Karnataka model-making snakebite cases notifiable. Concerns about “antivenom quality, regulations, and issues with distribution to African countries” were also raised (MA).,
The cross-cutting themes identified in the panel discussion on snakebite management are interconnected and interdependent. Accurate snake species identification, (DC-SI) for instance, is crucial for effective treatment, which in turn relies on high-quality antivenom. Regional differences and variations further complicate treatment strategies, emphasising the need for standardised protocols and guidelines. Data analysis and research are essential for addressing knowledge gaps and developing targeted treatment strategies, which can inform policy changes and improve patient outcomes. Effective collaboration and communication among healthcare providers, researchers, and policymakers are vital for addressing challenges in remote or resource-constrained areas and ensuring that best practices are shared and implemented (Fig. 1).
The thematic analysis from the Snakebite Life Support workshop underscores the complex interplay of evolving treatment paradigms, clinical challenges, and region-specific needs in snakebite management. Key themes that evolved in the panel included the importance of strengthening peripheral care through structured training, the development of region-specific protocols, and the use of digital solutions for registry establishment, snake identification, safe transportation, and telesupport. Although scientific advancements are progressing rapidly, existing textbooks struggle to keep pace, and physicians rely on outdated material for clinical practice., Repeated conditioning has led to acceptance of myths as realities. This growing recognition of the unique challenges in snakebite management has led to its classification as a neglected tropical disease.
The evolution of snakebite treatment in the region reflects a transition from unspecialised care to a more structured approach, characterised by the introduction of antivenom protocols, establishment of specialised care units, and improved diagnostic capabilities. Historical accounts reveal that Indian physicians recognised the need for antivenom as early as the late 18th century.24, 25, 26 Pivotal developments in the 1970s, including haemodialysis, neostigmine, and ventilatory support, significantly reduced mortality from renal failure and neurotoxicity.27, 28, 29, 30 Physicians from high volume centres, trialled different doses of antivenom and studied role of heparin in snakebite. They later started noticing inefficiency of the polyvalent antivenom and lack of understanding for pit viper envenomation and even reported seasonal differences in envenomation.,31, 32, 33 Despite progress, challenges persist, especially in rural settings where antivenom administration is often delayed due to fears of anaphylaxis and improper referrals. Prophylactic use of subcutaneous adrenaline may mitigate such risks, but its efficacy and safety require robust real-world evaluation.34, 35, 36, 37, 38, 39 The complexity of venom effects, combining procoagulant and anticoagulant properties, complicates treatment, particularly regarding anticoagulants and blood component therapy.
Complications such as CLS remain poorly understood yet contribute to up to 80% of deaths from snakebite in the region., The complexity of venom-induced coagulopathy, involving both procoagulant and anticoagulant effects, poses challenges for managing thrombotic complications, including stroke and myocardial infarction, Thrombotic microangiopathy (TMA) as well as bleeding disorders further complicate clinical management including transfusion requirements.,,42, 43, 44, 45, 46 Addressing these gaps requires a dual approach: improving peripheral care through training and resource allocation while continuing advancements in tertiary care settings to refine snakebite management protocols.
Enhancing peripheral care is vital for effective snakebite management. Key priorities include training healthcare workers, providing necessary resources, and empowering peripheral doctors to administer antivenom. In low- and middle-income countries (LMICs), common obstacles such as knowledge gaps, resource shortages (medications, equipment, staffing), and clinician fears hinder effective care.,,
Many authors have pointed out that doctors and nurses globally often lack the knowledge and confidence to manage snakebites, largely attributed to insufficient and outdated information in medical textbooks, highlighting a critical need for updated education and training.,49, 50, 51, 52, 53 Successful implementation of improved care, requires bridging the gap between theory and practice. Structured clinical training programs, such as the SBLS course, may prove essential for addressing this gap.,,53, 54, 55 (Supplementary Information S2: Course outline).
Peripheral healthcare systems that have access to antivenom often do not administer it due to fears of complications in most resource limited settings. The most common complication arising from antivenom administration is an allergic response, which can be effectively managed with proper training, particularly in airway management—an essential skill for both treating allergic reactions and transporting patients with neurotoxic snakebites. Inconsistent clinical practices, such as varying approaches to antivenom or blood product use for H. hypnale bites, lead to communication breakdowns and erode trust between healthcare providers and patients. Poor referral systems and inadequate communication between facilities are significant challenges in LMICs lacking structured prehospital care systems.56, 57, 58
Majority of snakebites are non-venomous and require observation rather than immediate intervention, while early antivenom administration for venomous bites can prevent complications. Proper triage, timely antivenom use, managing initial complications (like allergies), and ensuring safe referral are crucial. The Snakepedia® app, for instance, connecting 500 regional physicians via WhatsApp, aids in quick snake identification through photographs. Accurate snake identification, combined with a reliable history and training to recognise snakebite syndromes, can reduce healthcare costs., However, reliance on smartphone-based photography may not be feasible in rural areas due to limited access, and while community education on snake identification is valuable, it should be carefully framed to avoid inadvertently encouraging practices like snake hunting or killing, which can have broader ecological and ethical implications.
Optimal observation policies and referral for venomous bites are often not feasible in peripheral centres due to limited infrastructure and gaps in snakebite care. Adapting a spoke-and-hub model, used in other medical emergencies, could improve snakebite management. Central hubs would provide advanced care, while peripheral spokes would handle triage, initial treatment, and transport. In unsafe transport scenarios, empowering peripheral healthcare workers to administer antivenom and manage complications is essential. Structured training can alleviate fears of complications and enhance their capacity to act decisively. Clear communication and coordination during transport and arrival at care centres are key to the success of this model, ensuring efficient resource allocation and improved care for snakebite victims.
The use of pressure bandage with immobilisation (PBI) is often advocated as first aid for snakebite. The real-world effectiveness of PBI has been questioned, as studies show it is often applied incorrectly, leading to inadequate venom containment.46, 47, 48 The evidence supporting PBI largely comes from experimental studies with tagged proteins, which may not fully capture the complexities of real-life envenomation, as venom consists of diverse proteins with varying sizes and kinetics.61, 62, 63, 64 Tun Pe et al. observed that non-immobilised, pad-treated systemic cases had venom levels comparable to those without PBI, suggesting that the pad alone is ineffective., Reports indicate that the complete PBI method, including pressure pad, bandage, and immobilisation, is rarely used as first aid, despite being the standard recommendation.,67, 68, 69, 70
In contrast, tourniquets, though controversial due to potentially devastating complications like tissue ischaemia and limb loss, is still commonly practiced.,71, 72, 73 Most of the science on which snakebite relies on are archaic and scientific re-examination of existing evidence in snakebite first aid is required. Expert opinions in this paper suggest that while tourniquets carry risks, they may be a more practical alternative in regions with limited resources and training, especially when antivenom access is remote (UB, FMS). In Brazil, post Bothrops jararaca envenomation, those admitted with a tourniquet in place had significantly higher plasma fibrinogen concentrations than those without a tourniquet cases with envenomation, aligning with the opinion of some panellists (UB, FMS) that it has some role in delaying envenomation. However, the debate over tourniquets during the panel was heated, with significant opposition due to their inherent risks. The panel's final consensus was not to recommend tourniquets under current evidence, but rather to advocate for rigorous research to evaluate their real-world utility and safety. Efforts should prioritise education and training in proper PBI techniques while exploring practical alternatives for remote and resource-limited settings. The discourse, on the other hand, reflects the broader need for scientific re-evaluation of snakebite first-aid practices to develop evidence-based interventions that are both safe and effective in real-world scenarios.
The effectiveness of antivenoms, particularly polyvalent formulations like the Indian polyvalent antivenom (IPAV), has been a focal point of debate in snakebite management due to its variable efficacy across different snake species and geographic regions., Standardised treatment protocols for snakebites often fail to account for the regional differences in snake species, venom composition, and healthcare infrastructure. There is a need for region-specific antivenoms, and updated treatment guidelines tailored to the local snake fauna.
Rajasthan, with its desert-adapted snakes, and the North East, where haemotoxic Big Four species are rare, require different management approaches compared to other parts of India.76, 77, 78, 79 Physicians' experience and clinical observations both suggest that, the Indian polyvalent antivenom (IPAV) is ineffective against H. hypnale venom.,,,,79, 80, 81 However, in a recent survey, 43% of respondents indicated they would administer the currently available polyvalent antivenom for snakebites positively identified as H. hypnale. They based their decision on “relying on a syndromic approach rather than species identification”, “lacking confidence in accurately identifying the snake”, and “concern about medicolegal implications of withholding antivenom from patients showing signs of envenomation”. The panel emphasised that administering Indian polyvalent antivenom (IPAV) for H. hypnale envenomation could cause more harm than benefit, particularly when the risks of adverse reactions outweigh any potential, albeit unsupported, benefits of IPAV in non-Big Four species (Table 1). Standardised treatment protocols for snakebites often fail to account for the regional differences in snake species, venom composition, and healthcare infrastructure. There is a need for region-specific antivenoms, and updated treatment guidelines tailored to the local snake fauna.
The Australian experience highlights a shift from using monovalent antivenoms guided by unreliable snake venom detection kits to focussing on diagnosing envenomation and administering polyvalent antivenom or two key monovalent antivenoms (brown and tiger snake) based on geography and clinical presentation. This approach has simplified antivenom use, reduced errors, and minimise risks associated with incorrect antivenom administration, highlighting the importance of diagnostic clarity and pragmatic treatment strategies. Syndromic management, supported by region-specific clinical guidelines, remains the most pragmatic approach until more effective diagnostic and treatment options become available in the region. The inconsistent adherence to snakebite management protocols across India highlights the need for standardised yet adaptable guidelines that cater to regional specificities, ensuring effective, contextually appropriate care that enhances patient outcomes and optimises resource use.
Theoretically, therapeutic plasma exchange (TPE) should facilitate the removal of venom toxins from the intravascular compartment, potentially redistributing them from extravascular spaces for subsequent elimination. While early case reports and studies indicate its utility in managing haematologic complications, robust evidence remains sparse.., A retrospective study of 37 snakebite patients treated with TPE showed significant laboratory improvements and limb salvage without complications, supporting its use in complex cases. However, a systematic review by Noutsos and colleagues found no definitive evidence for TPE's benefit in TMA-associated acute kidney injury (AKI), despite a TMA prevalence of 5.4% in H. hypnale bites and 10–15% in Australian elapid envenomations. The American Society for Apheresis (ASFA) classifies TPE for snakebite envenomation as a Category III intervention, indicating that its optimal role in therapy remains unestablished and decisions should be made on a case-by-case basis. Plasmaphaeresis, while promising for complications like VICC and thrombotic microangiopathy (TMA), lacks robust evidence from randomised controlled trials.,85, 86, 87, 88 The panel identified this as a priority for future research to determine its optimal timing, efficacy before integration into treatment protocols, as outlined in Table 1, and emphasised the need for interim observational studies to guide current practice.
To bridge the gaps in snakebite management and build on existing evidence, targeted research, and policy development are essential in several key areas. Establishing structured training platforms is critical to enhancing the skills of healthcare providers, particularly in peripheral care centres. Strengthening these centres, improving the prehospital care system, optimising referral processes, including notifications and patient reception, and ensuring mandatory reporting of this neglected tropical disease are recognised as necessary steps to improve patient outcomes. On November 27, 2024, India's Ministry of Health and Family Welfare (MoHFW) has urged all states to make snakebite cases “notifiable disease”.
The standard treatment guidelines (STGs) for snakebite management was published in 2017, following the 2nd edition of WHO treatment guidelines in 2016. The National Action Plan for Prevention and Control of Snakebite Envenoming in India was launched on March 12, 2024. However there is a clear gap in the dissemination of national action policies and guidelines within the healthcare community, as evidenced by expert commentary. This highlights a pressing need for implementation research to facilitate the integration of evidence-based guidelines and policies, particularly in the areas of first aid practices and the development of optimal referral policies to ensure timely and effective treatment in snakebite management. Recently, India's Department of Health Research has identified snakebite management and research as a national health research priority, developing a district-level integrated patient-centric emergency care model in which time-sensitive emergencies, including snake bite is being envisaged.
There is a pressing need for newer, more effective antivenoms, along with better diagnostic tests, particularly for managing envenomations by species like the H. hypnale. This highlights the importance of regional specificity in antivenom development, given that venom composition can vary significantly due to factors such as geographical location, seasonal changes, and even the snake's hibernation patterns. Table 1 summarises consensus statements, controversies, and research questions outlining the research priorities, offering a roadmap to translate expert opinions into actionable strategies for guidelines and policy.
Further research should also focus on addressing complications and developing treatment guidelines for special conditions especially capillary leak syndrome and VICC.,
The integration of digital platforms for snake identification, the establishment of state-maintained registries, and the creation of common platforms for interaction and audit are crucial for ensuring standardised care and improving patient outcomes. Accurate snake species identification and the production of region-specific antivenoms are critical steps in reducing the impact of snakebites in high-incidence areas.
This Health Policy highlights the complex and multifaceted nature of snakebite management in India, emphasising the need for region-specific protocols, enhanced peripheral care, and ongoing research. The discussion reveals the perceived limitations of current antivenoms, the variability in clinical practices, and the importance of accurate snake identification (Table 1). To address these challenges, there is a pressing need for tailored training programs, improved dissemination and implementation of guidelines, and the development of region-specific antivenoms and protocols, in non-Big Four snakes including H. hypnale to strengthen snakebite care in diverse geographic settings. The integration of digital platforms and the establishment of comprehensive data registries will further support standardised care and improve patient outcomes. The insights gained from the panel discussion serves as a foundational framework for further enquiry and policy initiatives that can be better aligned to bridge existing gaps and advance snakebite management in India.

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"[{\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib1\", \"bib2\"], \"section\": \"Introduction\", \"text\": \"Snakebite envenomation remains a significant public health challenge in India, particularly in rural areas where access to timely and appropriate medical care is limited. The complexities of snakebite management are compounded by the diverse species of venomous snakes present in the region, each with varying effects on the human body. Despite advancements in antivenom production and snakebite care protocols, there remains considerable debate and variability in treatment approaches, particularly for species like Hump-nosed pit viper (Hypnale hypnale) that are not covered by the Indian polyvalent antivenom (IPAV).\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib3\"], \"section\": \"Introduction\", \"text\": \"The Snake Bite Life Support (SBLS) workshop, held as part of ongoing efforts to enhance snakebite management within a One Health framework, to improve snakebite management, brought together a panel of experts with over 300 years of collective experience in treating snakebite cases. This panel discussion, titled \\u201cCore Principles and Controversies in Snake Bite Management\\u201d, aimed to explore the evolving treatment paradigms, the challenges faced by clinicians, and the need for region-specific antivenom strategies. The discussion also focused on the current consensus guidelines and the controversies that still exist in the field, providing valuable insights into the complexities of managing snakebite envenomation in the region.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"appsec1\"], \"section\": \"Researcher characteristics and reflexivity\", \"text\": \"The research team consisted of experts with diverse backgrounds in snakebite management. The panellists, who are also the authors, are recognised leaders in relevant fields, including general physicians (KBM, UBV, JT), a paediatrician (PKK), emergency medicine physicians (RPC, MA, FMS), a wilderness medicine expert (FMS), national policymakers (FMS, MA), a toxicologist (IM), a haematologist (AMR), and a zoologist (SD). Each has at least 15 years of experience in treating snakebites, bringing over 300 years of combined clinical experience to the discussion (see Supplementary Information S1: Panellist profile).\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"appsec1\", \"bib4\"], \"section\": \"Data management and analysis\", \"text\": \"Data collection involved video recordings of the 90-min panel discussion using a Canon EOS 60D camera, with a Canon EOS 1500D as backup. Audio and video were stored as MP4 files and securely backed up. Field notes were taken during the session using Microsoft OneNote on a Surface Pro. Audio recordings were transcribed verbatim by AG, verified by DM, and cross-checked for accuracy by VC. The transcripts were shared with panellists for revision to ensure accuracy. Initial coding of the transcripts was done using Microsoft Excel, with additional codes generated using OpenAI's GPT-4 and manually assigned by AG and SVA, then verified by AS. Supporting quotes were organised under relevant themes and subthemes, with overlapping statements assigned multiple codes. In instances where a sentence or segment was relevant to multiple themes, we duplicated the quote under each applicable code to ensure comprehensive representation of the data (Supplementary Information S2: Coded quotes). Frequency summaries were used descriptively to illustrate recurring themes, but thematic prioritisation was based on the depth and relevance of insights, rather than frequency alone. Thematic analysis followed Braun and Clarke's six-phase framework. Data were securely stored in password-protected cloud storage (Google Drive).\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib5\"], \"section\": \"\", \"text\": \"ES-AV (Historical changes in antivenom use): The approach to antivenom has evolved from limited and low-dose use in the 1970s to a standardised 10-vial treatment across snake species. \\u201cThe serious nature of pit viper bites was fully acknowledged in 2006, marking a major shift in management\\u201d (KBM). Recognising the ineffectiveness of antivenom for pit viper bites helped reduce wastage and unnecessary administration.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib6\", \"bib7\"], \"section\": \"CP-C (challenges in snakebite management)\", \"text\": \"Challenges in snakebite management span the entire continuum of care, from prehospital treatment to hospital care. In rural areas, \\u201cpatients often visit traditional healers\\u201d, leading to delays in presentation (RPC). Once at the hospital, variations in case presentation and inconsistent management complicate treatment, particularly when referral systems fail., Peripheral centres frequently lack resuscitation support and clarity on antivenom dosage, leading to confusion and sometimes non-administration of anti-snake venom (ASV). Early \\u2018referral to better-equipped centres\\u2019 is often seen as the \\u2018safest option\\u2019 (Audience). Additionally, managing allergic reactions, coagulopathy, capillary leak syndrome, and other complications remains a significant challenge in these settings.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib8\", \"bib9\", \"bib8\"], \"section\": \"CP-VIC (venom-induced coagulopathy)\", \"text\": \"\\u201cVenom-induced consumption coagulopathy can lead to systemic manifestations such as stroke, myocardial infarction, and acute kidney injury\\u201d (FMS). In certain regions H. hypnale bites are associated with \\u201cmore severe complications and higher mortality rates\\u201d due to coagulopathy (FMS). The complexity of coagulopathy in snakebites is heightened by the fact that \\u201csnake venom contains both procoagulants and anticoagulants, and the dominant factors determine the presentation of symptoms\\u201d (UB). This raises critical questions in treatment, such as whether \\u201canticoagulation is an appropriate treatment option for hemispheric stroke\\u201d (UB) or if blood component therapy, while considered the next best option after antivenom, can \\u201clead to more complications than benefits if used without a clear indication\\u201d (JT).\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib10\"], \"section\": \"CP-CLS (capillary leak syndrome)\", \"text\": \"There was a debate over how different antivenom brands influence outcomes, especially regarding complications like capillary leak syndrome (JK) suggesting a need for implementation of standardisation of manufacturing and better quality control. The potential of \\u201cplasmaphaeresis to remove toxins such as phospholipase A2, zinc metalloprotease, and vascular apoptosis-inducing proteins 1 & 2\\u201d (JK) and \\u201crole of steroids \\u2026 often administered for capillary leak syndrome\\u201d (JK) remains areas needing further investigation.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib11\", \"bib12\", \"bib13\", \"bib14\", \"bib15\"], \"section\": \"CP-PED (paediatric snakebite management)\", \"text\": \"There are no considerable changes in management of paediatric bite in case of antivenom however \\u201csmaller volumes of treatment, generally 5\\u201310 ml/kg\\u201d for paediatric patients was suggested (PKK). It was also noted that \\u201cThe response of paediatric patients to treatments or interventions can vary somewhat, and even experienced faculty have limited experience with cases involving newborns and very young\\u201d (PKK). Additionally a comment on, \\u201cmany snakebites happen in school settings\\u201d was made noting recent events across India including one death in Wayanad, Kerala.11, 12, 13, 14, 15\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib6\"], \"section\": \"CP-RD (regional differences in venom and antivenom potency)\", \"text\": \"Experts noted significant \\u2018differences in antivenom potency in clinical practice\\u2019, emphasising the need for region-specific antivenom production in India. Strategic plans, such as expanding venom centres and implementing policy changes at state and district levels, were discussed as critical for improving antivenom quality.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib16\"], \"section\": \"DC-TQ (controversies over tourniquet use)\", \"text\": \"The use of tourniquets in snakebite management remains highly controversial. \\u201cThe use of a tourniquet can provide false reassurance to patients and bystanders\\u201d (RPC). Training is essential because \\u201cwhen prompt medical care is available, using a tourniquet can often do more harm than good\\u201d (FMS). The use of tourniquets, though generally not recommended, was suggested as a tool that can still be considered \\u201cin remote areas where delays in receiving medical attention\\u201d are expected, \\u201cby experts\\u201d to \\u201cprioritise life over limb\\u201d (FMS). The argument that \\u201ctourniquet has some role in delaying envenomation\\u201d (UB, FMS) was contested by members of the panel (KBM, PKK) and the overarching consensus in national and international guidelines, that the use of tourniquets is not recommended, and the overarching consensus in national and international guidelines, that the use of tourniquets is not recommended, was emphasised by the panellists (MA, PKK). However to date, none of the panellists reported having seen pressure immobilisation applied to patients they have received.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib17\", \"bib9\"], \"section\": \"DC-PLAS (controversies in plasmaphaeresis)\", \"text\": \"The role of plasmaphaeresis in treating snakebite complications like capillary leak syndrome remains a topic of debate. \\u201cAlthough the role of plasmaphaeresis in capillary leak syndrome is controversial in studies, we consider it when a patient develops bilateral parotid swelling, periorbital oedema, haemoconcentration, and refractory shock\\u201d (JK). In some centres it was pointed out that, \\u201cplasmaphaeresis has been used when antivenom was ineffective or not indicated, and has shown potential mortality benefits\\u201d (AMR). However it was pointed out that in regions like \\u201cSouthern Maharashtra, Karnataka, and Goa, Hump-Nosed Pit Vipers are causing more severe complications and higher mortality rates, with plasmaphaeresis often proving ineffective for these patients\\u201d (FMS). The statement was supported by noting that \\u201cthere are no methodological studies supporting the use of plasmaphaeresis for snakebite cases\\u201d (IM). Comprehensive studies at the molecular level are needed to assess the factors involved and the effects of plasmaphaeresis before it can be widely adopted (IM).\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib5\"], \"section\": \"DC-SI (issues in snake identification)\", \"text\": \"Accurate snake identification is essential for effective management but remains challenging. Misidentification, particularly with hump-nosed pit vipers, can lead to inappropriate treatment, such as unnecessary use of ASV, which is ineffective for any of the pit viper species (JK, SD). Remote identification tools like \\u201cWhatsApp and Facebook groups, along with apps like Snakepedia and SARPA (Snake Awareness Rescue and Protection) can aid in this process\\u201d (SD). However, \\u201ceven for experts, identifying a snake from ambiguous photographs, from bite marks or sometimes without knowing its location and other details can be challenging\\u201d (SD).\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib16\", \"bib18\", \"bib19\", \"bib20\"], \"section\": \"PR-PC (policy changes)\", \"text\": \"The WHO's goal to reduce snakebite deaths by 50% by 2030 drives efforts to expand venom centres and allocate funding. \\u201cState and district-level action plans are crucial\\u201d (MA), for instance taking the Karnataka model-making snakebite cases notifiable. Concerns about \\u201cantivenom quality, regulations, and issues with distribution to African countries\\u201d were also raised (MA).,\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"fig1\"], \"section\": \"Cross-cutting themes and theme relationships\", \"text\": \"The cross-cutting themes identified in the panel discussion on snakebite management are interconnected and interdependent. Accurate snake species identification, (DC-SI) for instance, is crucial for effective treatment, which in turn relies on high-quality antivenom. Regional differences and variations further complicate treatment strategies, emphasising the need for standardised protocols and guidelines. Data analysis and research are essential for addressing knowledge gaps and developing targeted treatment strategies, which can inform policy changes and improve patient outcomes. Effective collaboration and communication among healthcare providers, researchers, and policymakers are vital for addressing challenges in remote or resource-constrained areas and ensuring that best practices are shared and implemented (Fig. 1).\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib21\", \"bib22\", \"bib23\"], \"section\": \"Discussion\", \"text\": \"The thematic analysis from the Snakebite Life Support workshop underscores the complex interplay of evolving treatment paradigms, clinical challenges, and region-specific needs in snakebite management. Key themes that evolved in the panel included the importance of strengthening peripheral care through structured training, the development of region-specific protocols, and the use of digital solutions for registry establishment, snake identification, safe transportation, and telesupport. Although scientific advancements are progressing rapidly, existing textbooks struggle to keep pace, and physicians rely on outdated material for clinical practice., Repeated conditioning has led to acceptance of myths as realities. This growing recognition of the unique challenges in snakebite management has led to its classification as a neglected tropical disease.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib24\", \"bib25\", \"bib26\", \"bib27\", \"bib28\", \"bib29\", \"bib30\", \"bib5\", \"bib31\", \"bib32\", \"bib33\", \"bib34\", \"bib35\", \"bib36\", \"bib37\", \"bib38\", \"bib39\"], \"section\": \"Evolution of snakebite treatment in the region and clinical challenges\", \"text\": \"The evolution of snakebite treatment in the region reflects a transition from unspecialised care to a more structured approach, characterised by the introduction of antivenom protocols, establishment of specialised care units, and improved diagnostic capabilities. Historical accounts reveal that Indian physicians recognised the need for antivenom as early as the late 18th century.24, 25, 26 Pivotal developments in the 1970s, including haemodialysis, neostigmine, and ventilatory support, significantly reduced mortality from renal failure and neurotoxicity.27, 28, 29, 30 Physicians from high volume centres, trialled different doses of antivenom and studied role of heparin in snakebite. They later started noticing inefficiency of the polyvalent antivenom and lack of understanding for pit viper envenomation and even reported seasonal differences in envenomation.,31, 32, 33 Despite progress, challenges persist, especially in rural settings where antivenom administration is often delayed due to fears of anaphylaxis and improper referrals. Prophylactic use of subcutaneous adrenaline may mitigate such risks, but its efficacy and safety require robust real-world evaluation.34, 35, 36, 37, 38, 39 The complexity of venom effects, combining procoagulant and anticoagulant properties, complicates treatment, particularly regarding anticoagulants and blood component therapy.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib40\", \"bib41\", \"bib8\", \"bib17\", \"bib42\", \"bib43\", \"bib44\", \"bib45\", \"bib46\"], \"section\": \"Evolution of snakebite treatment in the region and clinical challenges\", \"text\": \"Complications such as CLS remain poorly understood yet contribute to up to 80% of deaths from snakebite in the region., The complexity of venom-induced coagulopathy, involving both procoagulant and anticoagulant effects, poses challenges for managing thrombotic complications, including stroke and myocardial infarction, Thrombotic microangiopathy (TMA) as well as bleeding disorders further complicate clinical management including transfusion requirements.,,42, 43, 44, 45, 46 Addressing these gaps requires a dual approach: improving peripheral care through training and resource allocation while continuing advancements in tertiary care settings to refine snakebite management protocols.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib6\", \"bib47\", \"bib48\"], \"section\": \"Need for strengthening the peripheral care settings\", \"text\": \"Enhancing peripheral care is vital for effective snakebite management. Key priorities include training healthcare workers, providing necessary resources, and empowering peripheral doctors to administer antivenom. In low- and middle-income countries (LMICs), common obstacles such as knowledge gaps, resource shortages (medications, equipment, staffing), and clinician fears hinder effective care.,,\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib21\", \"bib49\", \"bib50\", \"bib51\", \"bib52\", \"bib53\", \"bib50\", \"bib51\", \"bib53\", \"bib54\", \"bib55\", \"appsec1\"], \"section\": \"Need for strengthening the peripheral care settings\", \"text\": \"Many authors have pointed out that doctors and nurses globally often lack the knowledge and confidence to manage snakebites, largely attributed to insufficient and outdated information in medical textbooks, highlighting a critical need for updated education and training.,49, 50, 51, 52, 53 Successful implementation of improved care, requires bridging the gap between theory and practice. Structured clinical training programs, such as the SBLS course, may prove essential for addressing this gap.,,53, 54, 55 (Supplementary Information S2: Course outline).\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib54\", \"bib56\", \"bib57\", \"bib58\"], \"section\": \"Primary care and referral challenges\", \"text\": \"Peripheral healthcare systems that have access to antivenom often do not administer it due to fears of complications in most resource limited settings. The most common complication arising from antivenom administration is an allergic response, which can be effectively managed with proper training, particularly in airway management\\u2014an essential skill for both treating allergic reactions and transporting patients with neurotoxic snakebites. Inconsistent clinical practices, such as varying approaches to antivenom or blood product use for H. hypnale bites, lead to communication breakdowns and erode trust between healthcare providers and patients. Poor referral systems and inadequate communication between facilities are significant challenges in LMICs lacking structured prehospital care systems.56, 57, 58\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib59\", \"bib60\"], \"section\": \"Proposed solutions for improving snakebite outcomes\", \"text\": \"Majority of snakebites are non-venomous and require observation rather than immediate intervention, while early antivenom administration for venomous bites can prevent complications. Proper triage, timely antivenom use, managing initial complications (like allergies), and ensuring safe referral are crucial. The Snakepedia\\u00ae app, for instance, connecting 500 regional physicians via WhatsApp, aids in quick snake identification through photographs. Accurate snake identification, combined with a reliable history and training to recognise snakebite syndromes, can reduce healthcare costs., However, reliance on smartphone-based photography may not be feasible in rural areas due to limited access, and while community education on snake identification is valuable, it should be carefully framed to avoid inadvertently encouraging practices like snake hunting or killing, which can have broader ecological and ethical implications.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib48\"], \"section\": \"Proposed solutions for improving snakebite outcomes\", \"text\": \"Optimal observation policies and referral for venomous bites are often not feasible in peripheral centres due to limited infrastructure and gaps in snakebite care. Adapting a spoke-and-hub model, used in other medical emergencies, could improve snakebite management. Central hubs would provide advanced care, while peripheral spokes would handle triage, initial treatment, and transport. In unsafe transport scenarios, empowering peripheral healthcare workers to administer antivenom and manage complications is essential. Structured training can alleviate fears of complications and enhance their capacity to act decisively. Clear communication and coordination during transport and arrival at care centres are key to the success of this model, ensuring efficient resource allocation and improved care for snakebite victims.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib46\", \"bib47\", \"bib48\", \"bib61\", \"bib62\", \"bib63\", \"bib64\", \"bib65\", \"bib66\", \"bib52\", \"bib67\", \"bib68\", \"bib69\", \"bib70\"], \"section\": \"Pressure immobilisation vs. tourniquet use\", \"text\": \"The use of pressure bandage with immobilisation (PBI) is often advocated as first aid for snakebite. The real-world effectiveness of PBI has been questioned, as studies show it is often applied incorrectly, leading to inadequate venom containment.46, 47, 48 The evidence supporting PBI largely comes from experimental studies with tagged proteins, which may not fully capture the complexities of real-life envenomation, as venom consists of diverse proteins with varying sizes and kinetics.61, 62, 63, 64 Tun Pe et al. observed that non-immobilised, pad-treated systemic cases had venom levels comparable to those without PBI, suggesting that the pad alone is ineffective., Reports indicate that the complete PBI method, including pressure pad, bandage, and immobilisation, is rarely used as first aid, despite being the standard recommendation.,67, 68, 69, 70\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib67\", \"bib71\", \"bib72\", \"bib73\", \"bib72\"], \"section\": \"Pressure immobilisation vs. tourniquet use\", \"text\": \"In contrast, tourniquets, though controversial due to potentially devastating complications like tissue ischaemia and limb loss, is still commonly practiced.,71, 72, 73 Most of the science on which snakebite relies on are archaic and scientific re-examination of existing evidence in snakebite first aid is required. Expert opinions in this paper suggest that while tourniquets carry risks, they may be a more practical alternative in regions with limited resources and training, especially when antivenom access is remote (UB, FMS). In Brazil, post Bothrops jararaca envenomation, those admitted with a tourniquet in place had significantly higher plasma fibrinogen concentrations than those without a tourniquet cases with envenomation, aligning with the opinion of some panellists (UB, FMS) that it has some role in delaying envenomation. However, the debate over tourniquets during the panel was heated, with significant opposition due to their inherent risks. The panel's final consensus was not to recommend tourniquets under current evidence, but rather to advocate for rigorous research to evaluate their real-world utility and safety. Efforts should prioritise education and training in proper PBI techniques while exploring practical alternatives for remote and resource-limited settings. The discourse, on the other hand, reflects the broader need for scientific re-evaluation of snakebite first-aid practices to develop evidence-based interventions that are both safe and effective in real-world scenarios.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib74\", \"bib75\"], \"section\": \"Antivenom efficacy and development of region-specific protocols for effective snakebite management\", \"text\": \"The effectiveness of antivenoms, particularly polyvalent formulations like the Indian polyvalent antivenom (IPAV), has been a focal point of debate in snakebite management due to its variable efficacy across different snake species and geographic regions., Standardised treatment protocols for snakebites often fail to account for the regional differences in snake species, venom composition, and healthcare infrastructure. There is a need for region-specific antivenoms, and updated treatment guidelines tailored to the local snake fauna.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib76\", \"bib77\", \"bib78\", \"bib79\", \"bib2\", \"bib5\", \"bib9\", \"bib74\", \"bib79\", \"bib80\", \"bib81\", \"bib82\", \"tbl1\"], \"section\": \"Antivenom efficacy and development of region-specific protocols for effective snakebite management\", \"text\": \"Rajasthan, with its desert-adapted snakes, and the North East, where haemotoxic Big Four species are rare, require different management approaches compared to other parts of India.76, 77, 78, 79 Physicians' experience and clinical observations both suggest that, the Indian polyvalent antivenom (IPAV) is ineffective against H. hypnale venom.,,,,79, 80, 81 However, in a recent survey, 43% of respondents indicated they would administer the currently available polyvalent antivenom for snakebites positively identified as H. hypnale. They based their decision on \\u201crelying on a syndromic approach rather than species identification\\u201d, \\u201clacking confidence in accurately identifying the snake\\u201d, and \\u201cconcern about medicolegal implications of withholding antivenom from patients showing signs of envenomation\\u201d. The panel emphasised that administering Indian polyvalent antivenom (IPAV) for H. hypnale envenomation could cause more harm than benefit, particularly when the risks of adverse reactions outweigh any potential, albeit unsupported, benefits of IPAV in non-Big Four species (Table 1). Standardised treatment protocols for snakebites often fail to account for the regional differences in snake species, venom composition, and healthcare infrastructure. There is a need for region-specific antivenoms, and updated treatment guidelines tailored to the local snake fauna.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib83\", \"bib84\"], \"section\": \"Antivenom efficacy and development of region-specific protocols for effective snakebite management\", \"text\": \"The Australian experience highlights a shift from using monovalent antivenoms guided by unreliable snake venom detection kits to focussing on diagnosing envenomation and administering polyvalent antivenom or two key monovalent antivenoms (brown and tiger snake) based on geography and clinical presentation. This approach has simplified antivenom use, reduced errors, and minimise risks associated with incorrect antivenom administration, highlighting the importance of diagnostic clarity and pragmatic treatment strategies. Syndromic management, supported by region-specific clinical guidelines, remains the most pragmatic approach until more effective diagnostic and treatment options become available in the region. The inconsistent adherence to snakebite management protocols across India highlights the need for standardised yet adaptable guidelines that cater to regional specificities, ensuring effective, contextually appropriate care that enhances patient outcomes and optimises resource use.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib85\", \"bib86\", \"bib87\", \"bib88\", \"bib89\", \"bib17\", \"bib85\", \"bib86\", \"bib87\", \"bib88\", \"tbl1\"], \"section\": \"Plasmaphaeresis\", \"text\": \"Theoretically, therapeutic plasma exchange (TPE) should facilitate the removal of venom toxins from the intravascular compartment, potentially redistributing them from extravascular spaces for subsequent elimination. While early case reports and studies indicate its utility in managing haematologic complications, robust evidence remains sparse.., A retrospective study of 37 snakebite patients treated with TPE showed significant laboratory improvements and limb salvage without complications, supporting its use in complex cases. However, a systematic review by Noutsos and colleagues found no definitive evidence for TPE's benefit in TMA-associated acute kidney injury (AKI), despite a TMA prevalence of 5.4% in H. hypnale bites and 10\\u201315% in Australian elapid envenomations. The American Society for Apheresis (ASFA) classifies TPE for snakebite envenomation as a Category III intervention, indicating that its optimal role in therapy remains unestablished and decisions should be made on a case-by-case basis. Plasmaphaeresis, while promising for complications like VICC and thrombotic microangiopathy (TMA), lacks robust evidence from randomised controlled trials.,85, 86, 87, 88 The panel identified this as a priority for future research to determine its optimal timing, efficacy before integration into treatment protocols, as outlined in Table 1, and emphasised the need for interim observational studies to guide current practice.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib90\", \"bib91\"], \"section\": \"Bridging knowledge gaps: future research and policy directions in snakebite care\", \"text\": \"To bridge the gaps in snakebite management and build on existing evidence, targeted research, and policy development are essential in several key areas. Establishing structured training platforms is critical to enhancing the skills of healthcare providers, particularly in peripheral care centres. Strengthening these centres, improving the prehospital care system, optimising referral processes, including notifications and patient reception, and ensuring mandatory reporting of this neglected tropical disease are recognised as necessary steps to improve patient outcomes. On November 27, 2024, India's Ministry of Health and Family Welfare (MoHFW) has urged all states to make snakebite cases \\u201cnotifiable disease\\u201d.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib89\", \"bib92\"], \"section\": \"Bridging knowledge gaps: future research and policy directions in snakebite care\", \"text\": \"The standard treatment guidelines (STGs) for snakebite management was published in 2017, following the 2nd edition of WHO treatment guidelines in 2016. The National Action Plan for Prevention and Control of Snakebite Envenoming in India was launched on March 12, 2024. However there is a clear gap in the dissemination of national action policies and guidelines within the healthcare community, as evidenced by expert commentary. This highlights a pressing need for implementation research to facilitate the integration of evidence-based guidelines and policies, particularly in the areas of first aid practices and the development of optimal referral policies to ensure timely and effective treatment in snakebite management. Recently, India's Department of Health Research has identified snakebite management and research as a national health research priority, developing a district-level integrated patient-centric emergency care model in which time-sensitive emergencies, including snake bite is being envisaged.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib75\", \"tbl1\"], \"section\": \"Bridging knowledge gaps: future research and policy directions in snakebite care\", \"text\": \"There is a pressing need for newer, more effective antivenoms, along with better diagnostic tests, particularly for managing envenomations by species like the H. hypnale. This highlights the importance of regional specificity in antivenom development, given that venom composition can vary significantly due to factors such as geographical location, seasonal changes, and even the snake's hibernation patterns. Table 1 summarises consensus statements, controversies, and research questions outlining the research priorities, offering a roadmap to translate expert opinions into actionable strategies for guidelines and policy.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib40\", \"bib93\"], \"section\": \"Bridging knowledge gaps: future research and policy directions in snakebite care\", \"text\": \"Further research should also focus on addressing complications and developing treatment guidelines for special conditions especially capillary leak syndrome and VICC.,\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"bib94\"], \"section\": \"Bridging knowledge gaps: future research and policy directions in snakebite care\", \"text\": \"The integration of digital platforms for snake identification, the establishment of state-maintained registries, and the creation of common platforms for interaction and audit are crucial for ensuring standardised care and improving patient outcomes. Accurate snake species identification and the production of region-specific antivenoms are critical steps in reducing the impact of snakebites in high-incidence areas.\"}, {\"pmc\": \"PMC12145746\", \"pmid\": \"40487912\", \"reference_ids\": [\"tbl1\", \"bib95\"], \"section\": \"Conclusion\", \"text\": \"This Health Policy highlights the complex and multifaceted nature of snakebite management in India, emphasising the need for region-specific protocols, enhanced peripheral care, and ongoing research. The discussion reveals the perceived limitations of current antivenoms, the variability in clinical practices, and the importance of accurate snake identification (Table 1). To address these challenges, there is a pressing need for tailored training programs, improved dissemination and implementation of guidelines, and the development of region-specific antivenoms and protocols, in non-Big Four snakes including H. hypnale to strengthen snakebite care in diverse geographic settings. The integration of digital platforms and the establishment of comprehensive data registries will further support standardised care and improve patient outcomes. The insights gained from the panel discussion serves as a foundational framework for further enquiry and policy initiatives that can be better aligned to bridge existing gaps and advance snakebite management in India.\"}]"

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