The Setting
You and a friend have been rock climbing at the local limestone climbing area outside of Lander, Wyoming. While walking along the base of the cliff, your partner drops a piece of climbing gear and reaches to retrieve it. You hear a buzzing noise, a cry of surprise, and then your partner falls backward and tumbles down the sloped hill.
Photo by Mark Bratton.
A snake with a triangular head and diamond pattern quickly slides around the corner. Your partner is sitting on the ground where they came to a stop. You rush down to them and, as you approach, they say, “It bit me!”
SOAP Report
Subjective
The patient is a 25 year old whose chief complaint is a possible snakebite to the right forearm. They also tumbled head over heels down the hillside. They were wearing a helmet. There is no mechanism for a spine injury.
Objective
Patient Exam
The patient is sitting and supporting their right forearm. The head-to-toe exam revealed two puncture wounds approximately ¾ inches apart on the right forearm. One puncture is weeping clear fluid tinged with blood. The patient complains of persistent ache in right elbow, and states this was present prior to this event. There is no bruising or swelling at the bite site, no tingling or numbness in the arm, and good CSM (circulation, sensation, and motion) in the right hand. In addition, the patient denies head, neck, and back pain, and did not lose responsiveness. No other injuries were found. CSMs are also normal in the feet and left hand.
Vital Signs
|
Time |
3:40pm |
4:00pm |
|
Level of Responsiveness (LOR) |
A&Ox4, anxious |
A&Ox4, anxious |
|
Heart Rate (HR) |
100, strong and regular |
80, strong and regular |
|
Respiratory Rate (RR) |
22, shallow and regular |
16, shallow and regular |
|
Skin Color, Temperature, Moisture (SCTM) |
pale, cool, clammy |
pink, warm, dry |
|
Blood Pressure (BP) |
strong radial pulse |
strong radial pulse |
|
Pupils |
PERRL (equal, round, responsive to light) |
PERRL |
|
Temperature (T°) |
not taken |
not taken |
History
|
Symptoms: |
Nausea, anxiety |
|
Allergies: |
Penicillin (not taken today). Seasonal allergies, not presently a problem. |
|
Medications: |
Ibuprofen 400mg for elbow pain, taken w/ breakfast |
|
Pertinent Hx: |
Ache in right elbow for last two weeks. Believed to be climbing overuse injury. |
|
Last in/out: |
Energy bar at 1:00 p.m., 2 liters of water today, bowel movement normal, urine pale yellow |
|
Events: |
None relevant |
STOP READING!
What is your assessment and plan? Take a few minutes to figure out your own assessment and make a plan. Don’t cheat—no reading on without answering this first!
Practicing giving patient care. Photo by Jared Steinman
Assessment
Patient has a probable snakebite on right forearm.
Plan
- Calm the patient.
- Clean the wound.
- Splint and immobilize right arm at the level of the heart.
- Monitor for signs of envenomation.
- Evacuate.
Anticipated problems
- If the patient was envenomated there may be increased pain, bruising and swelling, CSM deficit, or other signs of poisoning by the venom.
Notes on SnakeBites
There is a lot of misinformation and lore surrounding snakebite first aid. Having the right information about this kind of injury will go far in keeping the patient from harm.
Data suggests that envenomation is not automatic every time a snake strikes. Although exact numbers are hard to find, an estimated 30-50% of reported snake bites are “dry” bites and do not result in envenomation.
Signs and symptoms of envenomation also may not present early. Some snakes, such as the coral snake, are known to make you sick 12 or more hours after the bite. Waiting for signs and symptoms of envenomation may delay access to antivenom, so it is recommended that all snake bite patients be evacuated, and those with signs and symptoms of envenomation be rapidly evacuated.
The Tale Continues…
You rinse off the wound and cover it with gauze. Then, you place the patient’s arm in a sling and swathe and walk five minutes on the trail, back towards the trailhead.
On the way, you meet a fellow climber who offers to pull the venom out by applying mechanical suction through a commercially-made unit. Since this isn’t a proven treatment technique, you politely decline his offer to help and continue on your way. You also decline his offer to cut your patient and draw the venom from the wound with suction applied orally—you know that this only works in the movies.
When you arrive at a dirt access road, you bring your truck to the patient, knowing that physical activity could cause the venom to spread more quickly.
When you reach your vehicle, you find another well-intentioned bystander who offers jumper cables and a car battery to render the venom impotent. This final obstacle between you and your patient’s best interest is calmly avoided and you drive towards town.
Notes on Envenomation Treatments
When envenomation does occur there are a number of techniques erroneously believed to be effective. Don't perform any unproven or discredited treatments that may cause your patient harm. Some of these incorrect treatments are supposed to keep the venom in an extremity (tourniquet, ice), deactivate the venom (ice, electricity, meat tenderizer), or remove the venom (incision and suction, suction). These techniques have been shown to lack effectiveness when studied in a clinical setting.
What is known to be effective is calming the patient, immobilizing of the limb at the level of the heart, and once definitive care is reached, antivenom therapy as necessary.
End of the Tale
On the way to the hospital you observe a noticeable increase in swelling in the patient's arm. Your patient also reports an increase in pain locally where they were bitten, but their vital signs remain stable. By the time you reach the hospital, your patient has a tingling sensation throughout the arm, and bruise-like tissue surrounds the punctures. The patient is evaluated in the emergency room and given antivenom treatment.
Learn more about treating snakebites on a wilderness medicine course.
