A Tight Rope, a Blade Cut and Fifty Minutes of Darkness
At 6:30 p.m. in a village in Goalpara district, a 14-year-old boy is carried into the sub-centre about 90 minutes after being bitten on the right ankle while walking through a paddy field. The villagers have tied a plastic rope tightly around his calf, cut the wound with a blade, and applied a green herbal paste. The foot is swollen to the ankle, tender, and oozing blood from the cut; two small puncture marks are visible. He is frightened but alert, with a blood pressure of 96/60 mmHg and a pulse of 112/min. There is no bleeding from the gums yet. The nearest facility with antivenom is the district hospital, 38 km away on a road that will take 50 minutes after dark, and an ambulance has been called. The health worker must act while waiting.
1. List, in order, what the health worker should do in the first ten minutes, including what must be undone and how.
Read the worked answer
Airway, breathing, circulation first. He is alert with a pulse of 112 and systolic 96, so he is compensating. Keep him lying flat, keep him warm, give oxygen if available, and establish one large-bore IV line. Run normal saline cautiously, starting with 10 to 20 mL/kg and reassessing, because a rapid bolus can worsen hypotension when venom is releasing vasoactive compounds.
Undo the harmful first aid, carefully.
- The plastic rope: a tight tourniquet causes ischaemic damage and, when released suddenly, can flush a bolus of venom into the circulation and drop the blood pressure. Get IV access first, then loosen it progressively over a minute or two while watching pulse and blood pressure. Do not pull it off in one movement.
- The herbal paste: wipe it away gently with water. It irritates tissue, hides the wound and invites infection. Do not scrub.
- The blade cut: do not cut further, do not suck, do not apply ice, kerosene or lime.
Then: splint the leg and keep it at about heart level rather than elevated. Mark the upper edge of the swelling with a pen and note the time so progress can be measured. Keep him nil by mouth, give tetanus toxoid, and give paracetamol for pain while avoiding aspirin and other NSAIDs because of bleeding risk. Reassure him, keep a responsible adult with him, and record vital signs every 15 minutes.
2. What findings would make you suspect systemic envenomation, and what exactly would you tell the district hospital by phone?
Read the worked answer
Local versus systemic. This looks like a viper-type bite: an ankle wound with swelling spreading up the leg and blood oozing from the cut. Systemic envenomation is suggested by swelling that crosses a joint within hours, bleeding from the gum or wound that does not stop, blood in the urine, a 20-minute whole blood clotting test that fails to clot, a falling blood pressure, vomiting, or new drooping eyelids and difficulty swallowing, which point more to a neurotoxic elapid. Do the bedside clotting test if a plain glass tube is available, and repeat it before transfer and on arrival.
Telephone handover, in this order:
- A 14-year-old boy, about 40 kg, bitten at 17:00 on the right ankle.
- First aid already given, including the tourniquet and the blade cut, and what was done about them.
- Current vital signs and the trend, urine output, and level of consciousness.
- Extent of swelling and the time it was marked; any bleeding; clotting test result.
- Working diagnosis of suspected viper envenomation.
- What is needed: antivenom, blood products and a bed; estimated arrival time.
Ask them to confirm the ambulance and to have adrenaline ready at the destination, because antivenom reactions are common. Do not give antivenom at the sub-centre unless trained and equipped to manage anaphylaxis.
3. What must be monitored during the 50-minute journey, and what must not happen?
Read the worked answer
Monitor every 15 minutes: pulse, blood pressure, respiratory rate, consciousness using AVPU, urine output, the pen mark on the leg, and any new bleeding from the wound, gums or nose. Watch for vomiting, drooping eyelids, a change in voice or difficulty breathing. Keep the limb splinted and still, keep him warm, and keep the IV running at a modest rate with reassessment.
What must not happen:
- Relatives must not reapply the tourniquet or a tight bandage; explain why in their own language, and check the leg yourself during the journey.
- No food or drink by mouth.
- No herbal paste, kerosene, ice or incision.
- No NSAIDs, aspirin or sedatives.
- Do not delay transport to finish paperwork, and do not let the boy walk.
Carry the referral note, the time of the bite, the times of the clotting tests and the name of the receiving doctor. Keep the used blade and rope out of the boy's reach and record what was removed and when, because the receiving team will need to know how long the tourniquet was in place.