Sometimes victims arrive late after the bite, often after several days, usually with acute kidney injury. Determine current venom activity such as bleeding in case of viperine envenomation. Perform 20WBCT and determine if any coagulopathy is present then administer ASV. If no coagulopathy is evident, treat kidney injury, if any.

In patients with neuroparalytic envenomation (ptosis, respiratory failure etc.)

• Continue respiratory support until recovery

• Give 10 vials of ASV on arrival and if no improvement within one hour repeat

10 vials of ASV (No more than 20 vials of ASV).

• No further ASV and Atropine Neostigmine (AN) infusion is required ONLY to reverse the Ptosis. Ptosis in Common Krait bite is due to presynaptic blockage, further ASV and Neostigmine dose beyond 3 doses cannot reverse it, since regeneration is a natural process and may take 4-5 days. Both ASV and AN injection should be stopped when the initial syndrome of pharyngeal muscle palsy is over.

Monitoring of Patients on ASV therapy

– All patients should be watched carefully every 5 min for first 30 min, then at

15 min for 2 hours for manifestation of a reaction. At the earliest sign of an adverse reaction suspend temporarily.

– Maintain a strict intake output chart and note colour of urine to detect acute kidney injury early.