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  5. Clinical entry: Echis sp. – Indian Subcontinent

Clinic: Echis sp. – Indian Subcontinent

Examine for 

Local Effects

  • Pain
  • Tender local (spreading) swelling
  • Blistering
  • Lymphangiopathy and lymphadenopathy
  • Necrotic skin

Haematological effects 

  • Clotting disturbances:
    • Bleeding from the fang marks and from injuries, in particular ones that are not located in the region in which venom application occurred.
    • Bleeding into the skin (ecchymosis, petechiae)
    • Gingival bleeding, bleeding from the nose, conjunctiva, haematemeis, bleeding per rectum, including melaena, haematuria, haemoptysis.
    • Oliguria, anuria (VICC / AKI)
  • Bleeding and/or haemolytic anaemia:
    • Arterial hypotension (haemorrhagic shock)
    • Acute abdomen (intra-abdominal bleeding!)
    • Loin pain/renal bed sensitive to percussion (ischaemia, renal haemorrhage!)
    • Local neurological signs, meningism, coma (intracranial bleeding!)
    • Pale sclera
    • Oliguria, anuria (arterial hypotension / AKI)
    • Neurological features of hypoglycaemia, or refractory shock (acute pituitary-adrenal insufficiency!)  

Renal effects

  • Acute kidney injury:
    • Loin pain (lower back pain)
    • Renal bed sensitive to percussion
    • Haematuria, haemoglobinuria, myoglobinuria
    • Oliguria (< 400 ml of urine / 24 h), anuria
    • Uraemia (nausea, acidotic breathing, hiccups, pleuritic chest pain, encephalopathy) 

Species-specific envenoming pattern

The assessment of the envenoming pattern is based on the data from publication in which the identification of the snakes is clearly specified and in accordance with accepted criteria.

   Local
effects
 		 Haematological effects Renal
effects2
 Bleeding  Coagulopathy  Thrombotic
microangiopathy (TMA)1
Echis carinatus carinatus       ?  
Echis carinatus sinhaleyus          
Echis carinatus sochureki          

Main venom effects see ‘Species-specific evidence’ below.

1Features of TMA include “disseminated intravascular coagulation, microangiopathic haemolytic anaemia diagnosed by finding schistocytes in peripheral blood films, thrombocytopenia, and acute kidney injury associated with arteriolar and capillary microthrombi” (Noutsos et al. 2020, 2022; Warrell and Willimas 2023)1

2Secondary to renal ischaemia due to shock, disseminated intravascular coagulation with thrombotic microangiopathy (TMA), and haemoglobinuria contributing to acute tubular necrosis.

Clinical management

See also Clinical Management: Indian Subcontinent and Southeast Asia

for advice on post-First Aid measures, diagnosis (clinical, laboratory) and treatment (supportive, antivenom).

First Aid

Release of any type of tourniquet follow link above.

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care
Necroses: debridement; split-thickness skin grafting
Systemic antibiotics: standard indications
WHO (2010, 2016) 

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

Follow SAMPLE & ABCDE ApproAch

Obey echis sp. - specific features

see 

  • 'Species-specific envenoming pattern' above

and

Key issues:

Acute kidney injury (AKI), chronic kidney disease
“Envenoming by many snake species occasionally results in acute kidney injury, but Russell’s vipers are the most dangerous. Acute kidney injury is the major cause of mortality and morbidity among people who have been bitten by these species. Direct venom nephrotoxicity, renal ischaemia secondary to shock, disseminated intravascular coagulation with thrombotic microangiopathy (TMA), haemoglobinuria, myoglobinuria, and hyperkalaemia contribute to acute tubular necrosis.” (Warrell and Williams 2023).

Thrombotic microangiopathy (TMA)

“TMA include disseminated intravascular coagulation, microangiopathic haemolytic anaemia diagnosed by finding schistocytes in peripheral blood films, thrombocytopenia, and acute kidney injury associated with arteriolar and capillary microthrombi. TMA with acute kidney injury is increasingly recognised in patients envenomed by Russell’s vipers and a variety of other species.” (Warrell and Williams 2023).
See also Noutsos et al (2020, 2022).

Venom-induced consumptive coagulopathy (VICC)

Gingival bleeding, epistaxis, haematemesis, haematuria, etc., haemorrhagic schock. 

Specific treatment (antivenoms)

References

  • Noutsos T, Currie BJ, Lek RA, Isbister GK. Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis. PLoS Negl Trop Dis. 2020 Dec 8;14(12):e0008936. PMID: 33290400; PMCID: PMC7748274. https://doi.org/10.1371/journal.pntd.0008936
  • Noutsos T, Currie BJ, Wijewickrama ES, Isbister GK. Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice. Toxins (Basel). 2022 Jan 14;14(1):57. PMID: 35051033; PMCID: PMC8778654. https://doi.org/10.3390/toxins14010057 
  • Warrell DA, Williams DJ. Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet. 2023 Apr 22;401(10385):1382-1398. PMID: 36931290. https://doi.org/10.1016/s0140-6736(23)00002-8  
  • WHO-ICRC Basic Emergency Care: approach tothe acutely ill and injured (2018) https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured
  • WHO ABCDE Approach https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
  • WHO (2010) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139
  • WHO (2016) Guidelines for the management of snakebites. 2nd edition. https://www.who.int/publications/i/item/9789290225300
  • WHO Snakebite Information and Data Platform https://www.who.int/teams/control-of-neglected-tropical-diseases/snakebite-envenoming/snakebite-information-and-data-platform

Species-specific evidence

Echis carinatus carinatus

India (Karnataka)

  • Lath et al. (2024)
    5 cases; identification:  morphological or photograph produced by the attendants and identified by the authors based on morphological features and corroborated by an expert.

    Signs & symptoms     (selected problems)
    Local effects
    Swelling 5/5 (Lath et al. 2024).
    Haematological effects
    Bleeding from the oral cavity 2/5; hematemesis 1/5; haematuria 1/5 (Lath et al. 2024).
    Renal effects
    Mild AKI 2/5 (Lath et al. 2024).

    Laboratory investigations
    Haemostasis
    Type of haemostatic defect
    Venom-Induced Consumptive Coagulopathy (VICC) (Lath et al. 2024).

Echis carinatus sinhaleyus

Sri Lanka

  • Fonseka et al. (2013)
    1 case; identification: morphological.
  • Kularatne et al. (2011)
    26 cases; identification: morphological.  
  • Pirasath et al. (2021)
    1 case; identification: morphological.

    Signs & symptoms (selected problems)
    Local effects
    Swelling 19/26; haemorrhagic blisters 1/26 (Kularatne et al. 2011).
    Pain and swelling of right hand (Pirasath et al. 2021).
    Haematological effects
    Bleeding 3/26 (haematemesis or haematuria or bleeding gums) (Kularatne et al. 2011).
    No bleeding. Anaemia (MAHA) (see also section ‘Haemostasis’,Laboratory and physical investigations below)(Pirasath et al. 2021).
    Mild local bleeding at the bite site. 3 hrs after the bite: progressive headache (and incoagulable blood (20WBCT)). The following day: right sided complete ptosis with fixed dilated pupil. Non-contrast CT: massive left temporo-parietal region intra-cerebral haemorrhage with intra-ventricular extension (Fonseka et al. 2013).
    Renal effects
    Mild AKI 1/26 (Kularatne et al. 2011).
    Mild AKI managed with fluids and furosemide (see also section ‘Kidney function’,Laboratory and physical investigations below)(Pirasath et al. 2021).

    Laboratory investigations
    Haemostasis
    Type of haemostatic defect
    Venom-Induced Consumptive Coagulopathy (VICC) (Pirasath et al. 2021).
    Haemostatic parameters
    Incoagulable blood 24/26 (20WBCT) (Kularatne et al. 2011).
    Incoagulable blood (20WBCT) 3 hrs after the bite (Fonseka et al. 2013).
    Incoagulable blood (20WBCT). PT/INR (<1.4) > 12: APTT (<35 sec) >128 (on admission); normalized within 12 hrs. (Pirasath et al. 2021).
    Thrombotic microangiopathy (TMA)
    24 hours after admission: Drop in haemoglobin (10 g/dL) and platelets (131 × 103/μL); elevated total bilirubin (1.9 mg/dL); serum lactate dehydrogenase 850 U/L (240–480 U/L); reticulocyte count 4%.
    Normochromic normocytic anaemia, marked thrombocytopenia, fragmented red blood cells (schistocytes) suggestive of microangiopathic haemolytic anaemia (MAHA).
    With the presence of acute renal failure, thrombocytopenia and intravascular haemolysis with normal clotting profile, the diagnosis of TMA was made(Pirasath et al. 2021).
    Kidney function
    Serum creatinine (0.7–1.5 mg/dL) max after 24 hrs: 3.1 mg/dL (Pirasath et al. 2021).

Echis carinatus sochureki

India (Kashmir)

  • Bath (1974)
    117 E. carinatus bites; identification: a total of 310 viper bites are discussed in this study. The snake that caused the bite was identified morphologically in 121 cases: E. carinatus 117/310, V. russelli 4/310. Thus 96.7% of the snakes brought in by patients were E. carinatus and 3.3% were V. russelli. In this region, clinical criteria do not aid in the differentiation of the type of viper that caused the bite. However, with certain qualifications, the snakes brought in by patients in this study can be considered a representative sample that gives an idea of the prevalence of these snakes as the cause of snakebites.
    Classification of the severity of envenoming caused by verified E. carinatus bites:
    Systemic envenoming
    mild envenoming (impaired haemostasis) 16/117,
    moderately severe envenoming (incoagulable blood) 22/117,
    severe envenoming (haemorrhaging) 79/117.
    All other data discussed in this study refer to the total number of observed cases (310). Assuming that the sample of herpetologically identified snakes (121/310), of which 96.7% were E. carinatus bites, is representative, the data from this study concerning the total number of bites provide a good approximation of the clinical picture and course of E. carinatus envenoming in Kashmir.

India (Rajasthan)

  • Gopalakrishnan et al. (2021)
    1 case; identification: morphological from photo.
  • Gopalakrishnan et al. (2025)
    105 cases; identification: 53 patients ‘confirmed’ (the dead snake was brought to the hospital, or a photograph of the snake was available with the patient or the family, 52 patients ‘syndromic diagnosis’ (syndrome 1 in WHO syndromic diagnosis for South-East Asia with a positive WBCT20 at presentation or the presence of coagulopathy (elevated PT/INR>1.3 or elevated aPTT) or elevated D-Dimer (>10 times the upper limit) or low fibrinogen (<180 mg/dl). Russell’s viper envenoming was not considered because it is extremely rare in the desert regions of western Rajasthan, unless the patient presented with Syndrome 2/Syndrome 5 features specific to Russell’s viper envenoming.

Captive snakes

  • Valenta et al (2016)
    1 case; identification: morphological
  • Weis et al(1991)
    1 case; identification: morphological.

    Signs & symptoms (selected problems)
    Local effects
    Slight pain in the region of the bite, duration <24 h (65/310) (Bhat 1974).
    Swelling 248/310. The swelling was particularly marked in those patients who had had tourniquets applied or whose wound had been incised (162/310); in the remaining 148/310 only 86/310 had noticeable swelling, 62/310 merely had local oedema. Onset of swelling shortly after the bite, at the latest after 24 h. Regional lymph node swelling 84/310. Blistering, diameter <1 cm to several cm (130/310). Necroses 0/130.
    42% of the patients with systemic envenoming who had had no local intervention did not develop local swelling (Bhat 1974).
    Haematological effects
    Systemic bleeding 202/310, interval between the bite and onset of bleeding: 1–6 h: 6/202; 7–48 h: 168/202; 25–48 h: 44/202; >48 h: 28/202.
    Hypovolaemic shock because of haemorrhaging 6/310; all 6 were not hospitalised until >2 days after the bite.
    Bleeding from bite wounds 108/310, severe and persistent if an incision had been made. Many of these patients required blood transfusions. Ecchymosis 133/310, gingival bleeding 40/310, haematemesis 37/310, bleeding per rectum 6/310, haemorrhoidal bleeding 6/310, epistaxis 22/310, haemoptysis 87/310, haematuria, microscopic 242/310, macroscopic 102/310, subarachnoid haemorrhage 6/310, of whom 2 died (Bhat 1974).
    Local bleeding 36/105; systemic bleeding 55/105 (Gopalakrishnan et al. 2025).
    Gross haematuria 35/105; intramuscular/retroperitoneal/paraspinal/pelvic haematomas 19/105; intracranial haemorrhage 6? (4?)/105 (1 decompressive craniotomy, 4 died); gingival bleeding, haematemesis and haemoptysis 3/105; melena 2/105; sublingual haematoma 1/105. Hypovolemic shock due to bleeding 3/105. Thrombosis 4/103 (Gopalakrishnan et al. 2025).
    103/105 venom-induced consumption coagulopathy (VICC). 2/53 ‘confirmed’ bites had no VICC (Gopalakrishnan et al. 2025).
    Renal effects
    AKI 19/105; haemodialysis 17/19. Evidence of TMA 11/105 (Gopalakrishnan et al. 2025).

    Laboratory investigations
    Haemostasis
    Bhat 1974 (see above for a description of the study).
    All patients (310) included in the study had a haemostatic defect (clotting time according to Lee and White).
    Incoagulable blood 242/310, of these patients 188 had systemic bleeding. 14/310 with systemic bleeding had severe haemostatic defects, but not completely incoagulable blood.
    103/105 venom-induced consumption coagulopathy (VICC). 2/53 ‘confirmed’ bites had no VICC.
    Mild coagulopathy (INR 1.3–3) 18/103; severe coagulopathy 66/103; thrombocytopenia 55/103.
    Deep vein thrombosis 4/103.
    Hypofibrinogenaemia 80/90 with fibrinogen values available on admission.

    Positive WBCT20 on admission 87/105; negative WBCT20 on admission 18/105 (Gopalakrishnan et al. 2025).

    Type of haemostatic defect
    Venom-induced consumption coagulopathy (VICC)
    Induced by prothrombin activation and reactive (secondary) hyperfibrinolysis. Little intravascular fibrin deposition (this is reflected in the low incidence of renal function defects and microangiopathic haemolysis). Fibrin clearance appears to be very efficient. Haemorrhagic activity is present, which together with the coagulation defect is responsible for the systemic bleeding (see clinical entry for Echis ocellatus, Nigeria) (Warrell et al. 1977, Edgar et al. 1980)).

    Haemoglobin
    116/202 patients with systemic bleeding had an average decrease in haemoglobin of 3.8 g/100 ml (Bhat 1974).

References

  • Bhat RN. Viperine snake bite poisoning in Jammu. J Indian Med Assoc. 1974 Dec 16;63(12):383-92.PMID: 4452795.Fonseka CL, Jeevagan V, Gnanathasan CA. Life threatening intracerebral haemorrhage following saw-scaled viper (Echis carinatus) envenoming--authenticated case report from Sri Lanka. BMC Emerg Med. 2013 Apr 8;13:5. PMID: 23565979; PMCID: PMC3636000. https://doi.org/10.1186/1471-227x-13-5
  • Edgar W, Warrell MJ, Warrell DA, Prentice CR. The structure of soluble fibrin complexes and fibrin degradation products afterEchis carinatusbite. Br J Haematol. 1980 Mar;44(3):471-81. PMID: 7378311. https://doi.org/10.1111/j.1365-2141.1980.tb05917.x
  • Gopalakrishnan M, Yadav P, Mathur R, Midha N, Garg MK. Venom-Induced Consumption Coagulopathy Unresponsive to Antivenom After Echis carinatus sochureki Envenoming. Wilderness Environ Med. 2021 Jun;32(2):221-225. Epub 2021 Mar 26. PMID: 33781663. https://doi.org/10.1016/j.wem.2021.01.004
  • Gopalakrishnan M, Kumar Ph A, Tanwar D, Bhat Ks S, Choudhary B, Garg MK. Antivenom ineffectiveness in Echis carinatus sochureki envenoming: a five-year, single-centre experience from India. Trans R Soc Trop Med Hyg. 2025 Jan 3. Epub ahead of print. PMID: 39749523. https://doi.org/10.1093/trstmh/trae111
  • Kularatne SA, Sivansuthan S, Medagedara SC, Maduwage K, de Silva A. Revisiting saw-scaled viper (Echis carinatus) bites in the Jaffna Peninsula of Sri Lanka: distribution, epidemiology and clinical manifestations. Trans R Soc Trop Med Hyg. 2011 Oct;105(10):591-7. Epub 2011 Aug 25. PMID: 21868049. https://doi.org/10.1016/j.trstmh.2011.07.010
  • Lath V, Shekhawat D, Sirur FM. Strikes and stripes of the Saw-scaled Viper in the Western Ghats-A case series. Toxicol Rep. 2024 Aug 31;13:101721. PMID: 39295951; PMCID: PMC11408150. https://doi.org/10.1016/j.toxrep.2024.101721 
  • Noutsos T, Currie BJ, Lek RA, Isbister GK. Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis.PLoS Negl Trop Dis. 2020 Dec 8;14(12):e0008936. PMID: 33290400; PMCID: PMC7748274. https://doi.org/10.1371/journal.pntd.0008936
  • Noutsos T, Currie BJ, Wijewickrama ES, Isbister GK.Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice. Toxins (Basel). 2022 Jan 14;14(1):57. PMID: 35051033; PMCID: PMC8778654. https://doi.org/10.3390/toxins14010057
  • Pirasath S, Athirayan C, Gajan D. Thrombotic microangiopathy following saw-scaled viper (Echis carinatus) envenoming in Sri Lanka. SAGE Open Med Case Rep. 2021 Jul 13;9:2050313X211032399. PMID: 34345431; PMCID: PMC8283212. https://doi.org/10.1177/2050313x211032399
  • Valenta J, Stach Z, Michálek P. Snakebite Envenoming by Sochurek's Saw-scaled Viper Echis Carinatus Sochureki. Prague Med Rep. 2016;117(1):61-7. PMID: 26995204. https://doi.org/10.14712/23362936.2016.6
  • Warrell DA, Williams DJ.Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet. 2023 Apr 22;401(10385):1382-1398. PMID: 36931290. https://doi.org/10.1016/s0140-6736(23)00002-8
  • Weis JR, Whatley RE, Glenn JL, Rodgers GM. Prolonged hypofibrinogenemia and protein C activation after envenoming by Echis carinatus sochureki. Am J Trop Med Hyg. 1991 Apr;44(4):452-60. PMID: 1904199. https://doi.org/10.4269/ajtmh.1991.44.452