A young lady is brought by friends on a makeshift stretcher. They have leaves in their hair and look frantic. They report that the patient went behind a tree to urinate, while on a hiking trip, and screamed after being bit on her L-forearm by a snake. They don’t know what the snake looked like. She’s been awake for the 5hours it took them to get her here. On exam, she has mild erythema and swelling about the bite marks. She is wearing two rings on her pinky and index finger; she has signs of good distal perfusion. Next steps?

1. Remain calm.

2. ABCs.

3. Remove her ring (hand/fingers may swell). Here are some options (the dental floss one makes you look particularly savvy): http://www.wikihow.com/Remove-a-Stuck-Ring

4. The patient probably doesn’t need broad spec antibiotics unless it’s a severe case, but it’s still standard of care.

5. Get the antivenim (use caution as anaphylaxis or serum sickness can result); you may need to contact/transfer to a bite center (Jacobi Hospital in NYC).

6. Consider diphtheria (not in pregnant persons)-tetanus toxoid administration.

7. Consult surgery, as a fasciotomy may be warranted to relieve compartment syndrome.

8. Call the local poison center (212.447.8224).


1. http://emedicine.medscape.com/article/168828-medication#3

2. Ling Zhang, MD