A total of ten patients were admitted with snakebite. Male to female ratio was 1:1. Mean age of presentation was 8.9 years. Mean arrival time at hospital after bite was 3.8 hours (range 2-6 hrs). Mean dose of antivenom given was 20.7. Mean hospitalization period was 3.6 days (range 1–5 d). Snakebite was vasculotoxic in seven and mixed (neurotoxic and vasculotoxic) in two. Levantine viper or "Gunas" (local name) was identified as a source of envenomation in five.

Children with Levantine viper injuries came from areas around Sindh valley. This is consistent with observation that they are numerous in Lar area and seldom seen on the southern side of the Kashmir [2]. Envenomation was reported between months of May and August (summer), an active season for vipers. Envenomation occurred during daytime. Levantine viper is usually inactive during daytime, but quite alert and apt to attack swiftly if disturbed. Further, few children would venture during night to be exposed to snakes. Site of Levantine viper bite was hand (in three) and foot (in two). Envenomation resulted due to unintentional encounters. Hand bites occurred while working in agricultural fields during harvest time. Foot bites occurred while climbing a rock (in one) and playing in field (in one). Patients with Levantine viper injuries had Grade 3 bites. They were brought to hospital early because of severe local envenomation. They also had severe coagulopathy (PT>20 s, INR >1.8, aPTT >1 min or non clotting blood) and hypotension. Hemolysis occurred in one.

All children were treated with polyvalent antisnakevenom (ASV). Local management consisted of minor surgical procedures in the form of bleb removal and surgical dressings. Symptomatic treatment was given for hypotension and hemolysis. All patients completely improved with no permanent physical or physiological abnormality.

We propose that current ASV should continue to be used for Levantine viper bites, an observation in contrast to that reported earlier [3]. Education of local populace is needed regarding habits of Levantine vipers. They should wear gloves and shoes when working in fields during seasons when snakes are active. They should be asked to be cautious when reaching under logs or climbing rocks.

1. Holve S. Envenomations. In: Kliegman RM, Behrman RE, Jenson HB, editors. Nelson Textbook of Pediatrics, 18th ed. Philadelphia: Elsevier. 2007.p.2932-5.

2. Lawrence WR. The Valley of Kashmir. 2nd ed. Srinagar: Nice Printing Press. 2005.p. 155-6.