A snake bite presenting to general practitioners could be an emergency requiring immediate attention and ambulance conveyance to the nearest emergency department. Through a clinical case study, Changi General Hospital shares helpful resources and tips on how to manage such cases in the primary care setting – including checking for envenomation, wound care and immobilisation.
A 34-year-old male presented to the Changi General Hospital (CGH) emergency department (ED) with a snake bite in the anterior leg acquired while on a boat (Figure 1). He came to the hospital by his own transport within two hours.
Clinically, the patient had normal vital signs with no systemic and local signs to suggest envenomation. A picture taken of the snake using a mobile device was shared by the patient (Figure 2).
This was sent by instant messaging to ACRES (Animal Concerns Research and Education Society), which identified the snake as a non-venomous red-tailed racer (gonyosoma oxycephalum). The patient was discharged uneventfully from the ED after 13 hours of observation.
Figure 1 Snake bite
Figure 2 Red-tailed racer (gonyosoma oxycephalum)
In Singapore, we have found the following resources useful at helping to identify snakes:
Call 1800 476 1600 and ask to have an expert sent to deal with the snake (operates 24/7)
In this case, the immediate assistance from ACRES via WhatsApp helped to reassure the patient and develop the management plan early. The availability of such resources should not delay the management of emergencies, or immediate transfer of patients by ambulance to the hospital.
Digital pictures should be taken from a safe distance and show the whole snake.
The following areas are important while attending to a snakebite victim:
1. General Points and Transportation
Ambulance conveyance to the nearest ED
2. Check for Envenomation
Note: Anti-snake venom (ASV) should be given only at the ED or where resources to manage anaphylaxis are immediately available.3
3. Wound Care
Mark the leading edge of the skin swelling4
Cover the wound with a dressing
Note: Do not attempt to cut the wound or suck the venom, because there is no proven benefit3 and it increases the possibility of infection.
Immobilise the bitten limb
Pressure immobilisation bandage
5. Snake Identification
Do not handle the snake (if it is brought to the clinic)
Digital picture of snake
In conclusion, there are useful resources in Singapore to help identify and remove snakes. When in doubt, it is safer to assume envenomation after a snake bite and convey the victim to the ED without delay.
Marking the leading edge of skin swelling will help subsequent providers monitor progress of the condition, and good prehospital management will aid to improve outcomes.
Animal Concerns Research and Education Society. ACRES Advisory Notice: Snakes [online]. Available at: https://acres.org.sg/core/wp-content/uploads/2017/01/ACRES-Advisory-on-Snakes.pdf. Accessed 27 Sep 2021.
National Parks. Snakes [online]. 5 Feb 2021. Available at: https://www.nparks.gov.sg/gardens-parks-and-nature/dos-and-donts/animal-advisories/snakes. Accessed 27 Sep 2021.
Weinstein S, Dart R, Staples A, White J. Envenomations: an overview of clinical toxinology for the primary care physician. American family physician 2009; 80:793-802.
Ashurst J, Cannon R. Approach and management of venomous snake bites: a guide for the primary care physician. Osteopathic Family Physician 2012; 4:155-159.
Zarisfi F, Pek JH, Oh JHH, Loke JH, Lim SH. Singapore First Aid Guidelines 2021. Singapore Med J. 2021; 62(8):427-432.
Parker-Cote J, Meggs WJ. First aid and pre-hospital management of venomous snakebites. Tropical medicine and infectious disease 2018; 3(2): 45.