Snakebite with a Tight Tourniquet and Incision
At 06:00 a 30-year-old farmer was bitten on the right ankle while harvesting. He reaches the PHC at 07:10. His family has tied a cloth tourniquet tightly above his knee and made a 2 cm cut over the fang marks; the wound is bleeding. The right foot is swollen to mid-calf and there are two puncture marks. Blood pressure is 100/70 mmHg, pulse 88/min, respiratory rate 18/min. He has no bleeding gums, no ptosis, and no difficulty breathing. The 20-minute whole blood clotting test has not been done. The PHC has no antivenom. The district hospital is 50 minutes away and the ambulance is available. His brother insists that the tourniquet must stay on until they reach the hospital, and that cutting and sucking the wound is traditional.
1. Describe your immediate first aid for this patient, including what you would not do and why.
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I would remove the tourniquet, loosening it gradually while watching for any deterioration, because a tight tourniquet causes ischaemia, nerve damage, and tissue necrosis and does not prevent venom spread. I would not cut or suck the wound; the cut has already caused tissue damage, and suction increases local injury and infection risk without removing meaningful venom. I would clean the wound with saline and cover it with a dry dressing, remove rings or bands from the limb, and immobilise the leg with a splint at about heart level. I would keep him calm and nil by mouth, secure IV access, and monitor pulse, blood pressure, respiration, and oxygen saturation. I would not apply ice, and I would avoid aspirin and NSAIDs because they can worsen bleeding. Immobilisation reduces lymphatic spread of venom, while tourniquets and incisions are harmful. I would document the time of bite, first aid given, and tourniquet removal.
2. Explain the 20-minute whole blood clotting test and its role here. If the blood is still liquid at 20 minutes, what does it mean and where should antivenom be given?
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I would draw about 2 mL of venous blood into a clean, dry glass tube, leave it upright for 20 minutes, and then tilt it. If the blood has not clotted and is still liquid, the test is positive for coagulopathy, suggesting venom-induced consumption coagulopathy, especially with a viper bite. That is a bedside clue to systemic envenoming and makes urgent referral essential. Antivenom should be given at the district hospital, because this PHC has none and cannot monitor for anaphylaxis; the 50-minute journey should not be delayed to repeat the test if he has systemic signs such as bleeding. If antivenom were available at the PHC, it could be started with adrenaline and airway support ready, but here the priority is safe transfer. I would monitor for bleeding, drowsiness, ptosis, breathing difficulty, and measure urine output.
3. How would you address the brother's insistence on keeping the tourniquet and cutting the wound, and what would you document?
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I would not argue or shame him. I would say: 'I know you are trying to stop the poison. The tight cloth is actually cutting off blood to his leg and can damage it permanently. The cut can push poison in and cause infection. The hospital has the antivenom, and the best thing we can do now is keep the leg still, clean, and get him there quickly.' I would show him that the limb is swollen and explain that the tourniquet will be removed gradually while we watch. If he physically resists, I would call the doctor and continue explaining; I would not remove it forcibly without support. I would document the time, who was present, the tourniquet removal, wound care, advice given, his concerns, referral time, and the signs I asked him to report, such as bleeding, drowsiness, or difficulty breathing.