Snake bite with a healer's tourniquet and 35 km to anti-snake venom

Priorities

1. Airway, breathing, circulation - oxygen, monitor respiratory rate and effort, keep him lying flat with the bitten limb immobilised at about heart level.
2. IV access in the other arm, Ringer lactate running slowly; keep him nil by mouth.
3. Reassure and keep him warm; sweating and vomiting may be fear as well as envenomation.

The tourniquet

• It must come off, but gradually. After 90 minutes of tight pressure the limb is dusky and cold, which is already ischaemic. Remove the leaf paste, then loosen the band slowly over 1–2 minutes while watching pulse and BP, because sudden release can flush a bolus of venom and venom-induced vasodilators into the circulation and drop the BP further.
• Never re-tie it. Do not use a tight bandage in place of a tourniquet for this bite.

The cuts

• Do not squeeze, suck or cauterise them. Wash gently with saline or clean water, apply a sterile dressing, and control oozing with direct pressure. Do not apply the leaf paste.

Then

• Remove rings and anklets; mark the swelling edge with a pen and time it.
• Chart ptosis, swallowing, limb power, bleeding from gums or wound, and urine colour.
• Call the district hospital to keep anti-snake venom ready, and transfer with a referral note giving bite time, tourniquet time and removal time.

Reasoning: the only specific treatment is anti-snake venom, which this centre does not have - so the tourniquet and the clock are the two things you can still influence.

The tourniquet "The cloth is so tight that no blood reaches the leg. In a few more hours the flesh will die and may have to be cut off. The poison is not sitting in one place waiting - it has already gone into the tissues and the lymph channels, and a bandage above the knee cannot stop it. If we keep it, we trade a snake bite for a dead leg. We will loosen it slowly, watching his pulse, because letting it go all at once can make his blood pressure fall suddenly."

The cuts "The cuts do not remove poison - the fangs put it deep, far below the skin, and squeezing only damages muscle and lets him bleed. They also let dirt in and cause infection, and bleeding makes it harder for us to judge whether the poison is affecting his clotting. The hospital has the antidote; that is what neutralises the venom, and it must be given there."

Explaining the signs "His heavy eyelids are a warning that the poison may be affecting his breathing muscles. That is why we cannot wait at home or argue about the bandage - we need to reach the hospital quickly so the antidote can be started and his breathing watched."

Reasoning: the attendant is acting on a belief, not on obstinacy. Naming the harm - dead limb, bleeding, infection - and offering a clear alternative is more likely to gain cooperation than ordering him to stop.

Chart every 10–15 minutes

• Respiratory rate and effort, ability to speak, cough and swallow - the earliest sign of neurotoxic envenomation (cobra, krait) is ptosis, then bulbar weakness, then respiratory paralysis. Rising respiratory rate with shallow breathing is the warning that ventilation is failing.
• Eyelid lift and limb power - simple bedside tests that show progression.
• Pulse, BP, capillary refill, consciousness - shock from vasodilatation, bleeding or anaphylaxis to venom.
• Bleeding from the wound, gums, nose or IV site, and urine colour and output - viper bites cause coagulopathy and haemoglobinuria, which can lead to acute kidney injury.
• Swelling edge, limb colour, temperature and pain - progression of local damage after tourniquet release.
• Times: bite, tourniquet applied, tourniquet released, arrival, and any deterioration.

Why these Deaths from snake bite come from respiratory paralysis and shock, both of which develop over minutes to hours and are detectable at the bedside without any laboratory. Charting them converts a vague 'he looks worse' into a trend the receiving doctor can act on immediately.

Reasoning: the transfer is the most dangerous part of the journey because there is no antidote on board. Observation is the only monitoring available, so it has to be systematic and time-stamped, and the record must travel with the patient.