Snakebite on a Night Shift in a Sugarcane Field
At 8:40 pm in a sugarcane field near Mandya, a 42-year-old male labourer is bitten on the right ankle by a snake he did not see. Two puncture marks are visible with swelling and pain but little bleeding. He walks 400 m to the road. Bystanders tie a cloth tourniquet above his knee and make a small cut over the bite, then suck the wound. The PHC ambulance is 12 km away; the district hospital with antivenom is 55 km away. When the ambulance reaches him at 9:15 pm he is alert, BP 110/70 mmHg, pulse 96/min, respiratory rate 22/min, pupils equal. He complains of numbness around the mouth and says his eyelids feel heavy. The ambulance has oxygen but no antivenom. His brother insists on taking him by motorcycle to a private clinic 30 km away, saying the ambulance is too slow.
1. Set out your first-aid priorities for the next 15 minutes, in order, and justify the position of each. Include what you would do about the tourniquet and the cut.
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Order of priorities
- Scene and ambulance safety; call ahead. Confirm the snake is gone, keep bystanders back, and alert the receiving hospital. This costs seconds and prevents a second victim.
- ABC and oxygen. Check airway, breathing and circulation; give oxygen if saturation is low. Respiratory muscle paralysis is the main killer in neurotoxic bites.
- Release the tourniquet cautiously. Loosen it gradually over 1-2 minutes while watching for brisk bleeding and for sudden worsening of systemic symptoms. A tight tourniquet causes limb ischaemia and nerve damage, and releasing it abruptly can flush a bolus of venom into the circulation. Do not leave it on.
- Remove rings, anklets and tight clothing; immobilise the limb. Use a splint and keep the limb still at about heart level. Movement and elevation above the heart increase lymphatic spread of venom.
- Do not cut, suck, cauterise or apply ice. These do not remove meaningful venom and add infection, bleeding and tissue damage.
- Keep him warm, lying down and calm; no food, alcohol or sedatives. Sedatives can mask or worsen respiratory depression.
- Rapid transport to an antivenom-capable hospital. The motorcycle is unsafe: he needs oxygen, monitoring, IV access and airway support, and a 30 km ride to a private clinic may delay definitive treatment. The ambulance should bypass the PHC and go to the district hospital.
2. At 9:35 pm he develops drooping eyelids and difficulty swallowing saliva. Explain what this means, where he should be taken, and what you will communicate and monitor during transfer.
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Interpretation. New ptosis and difficulty swallowing after a snakebite indicate neurotoxic envenomation with bulbar weakness. The species cannot be confirmed from the wound, and the swelling does not exclude a neurotoxic bite. The timing, about 55 minutes after the bite, fits early neurotoxicity.
Disposition. He must go to the district hospital, which has antivenom, not to the PHC or a private clinic without antivenom. Antivenom is the definitive treatment and is most effective before respiratory failure. Bypassing the PHC avoids a second delay.
During transfer
- Pre-alert the district hospital about a suspected neurotoxic snakebite with bulbar signs, and give the estimated arrival time.
- Protect the airway, keep suction ready, and give oxygen.
- Monitor respiratory rate, oxygen saturation, ability to swallow saliva, power and level of consciousness every 10-15 minutes.
- Give nothing by mouth, including water, because of aspiration risk.
- Have a plan for assisted ventilation if breathing deteriorates; the crew should know the nearest facility with a bag-mask and oxygen.
- Record the exact time each symptom began; this helps the receiving team.
3. The brother asks why the tourniquet and cut were wrong. Give a short explanation you would use, and note what you would record about the pre-hospital care.
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What to tell the brother, briefly and without blame: 'The cloth band was meant to stop the poison, but it also stops blood and can damage the leg. When it is finally released, the poison can move suddenly into the body. Cutting and sucking do not remove the poison; they add infection and bleeding. The best first aid is to keep him still, keep the leg supported, and get him to the hospital quickly.'
Record in the pre-hospital notes
- Time of bite and time of arrival.
- Tourniquet: material, site, how long applied, time released, condition of the limb after release.
- Cut and suction: who did it, site, any bleeding.
- Bystander details and the brother's request for motorcycle transfer, with the advice given.
- Vital signs, symptoms and times (numbness, ptosis, dysphagia).
- Consent and refusal discussions, if any.
This record guides antivenom decisions, flags limb ischaemia, and supports later community education.