Toxicology

Snakebite at outdoor community festival

Intermediate

Adult · 35yr · female

Patient Information

Dispatch	You are called to a patient (Sarah Nguyen, 35YO female) who is sitting near the bushline at the Mundaring Community Festival. Bystanders report she was walking near the tree line and felt a sharp pain on her right ankle. She is conscious and anxious.
Patient	Sarah Nguyen — 35yr (65kg)
Incident History	Pt was walking along the grassed bushline area of the festival grounds approximately 10 minutes ago when she felt a sudden sharp pain to her right lower leg/ankle. A bystander saw what appeared to be a snake moving away into the brush. Pt has not walked since and is sitting on the ground where she was found.
Emergency Contact	David Nguyen (Husband) — 0412 338 774

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil airway obstruction. Nil swelling or stridor.
Breathing	Adequate. Self-ventilating. RR slightly elevated due to anxiety. Nil audible wheeze or crackles.
Circulation	Radial pulse present, regular, normal rate. Skin warm and dry. Small puncture marks noted to right lateral ankle — nil significant bleeding. Mild localised redness at bite site.
Disability	GCS 15 (E4V5M6). Orientated to time, place and person. Anxious but co-operative.
Exposure	Two small puncture marks visible to right lateral ankle. Mild localised redness. No visible swelling or bruising at this stage. No rash. Rest of limb appears normal.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	98% (RA)	Nil	18	96	122/78	<2s	15	4 4 ++	36.7	–	3
10 mins	98% (RA)	Nil	16	88	118/76	<2s	15	4 4 ++	36.7	–	2

History Taking

Treatment Response

Diagnosis

This patient is suffering from a suspected snakebite with potential envenomation to the right lower limb. No overt signs of systemic envenomation are present at this time, however all Australian snakebites must be treated as potentially life-threatening until proven otherwise at a medical facility.

Facilitator Triggers — if trainees miss a critical step

! (If trainees allow the patient to walk or stand to reach the stretcher — patient begins to feel lightheaded and nauseous, HR increases to 110. Remind trainees: do NOT walk the patient.)
! (If Pressure Immobilisation Technique is not applied within 5 minutes of assessment — patient begins to develop mild tingling in the right calf and reports feeling slightly weak in the leg. Prompt trainee: 'The patient asks if she should have something wrapped around her leg.')
! (If trainees attempt to cut, suck, or wash the bite site — facilitator stops them and asks: 'Is that recommended for snakebite management?')
! (If trainees attempt to apply a tourniquet — facilitator intervenes: 'What is the difference between a tourniquet and the Pressure Immobilisation Technique for snakebite?')
! (If trainees do not immobilise the limb with a splint after PIT — patient moves her foot to 'get comfortable'. Prompt: 'Can you keep the limb as still as possible?')
! (If trainees do not mark the bite site on the bandage — facilitator prompts: 'Is there anything else you should document on the bandage itself?')
! (If patient is not continuously reassured and kept calm — her RR increases to 22 and she becomes more distressed. Remind trainees that anxiety increases lymphatic flow and venom spread.)

Treatment Objectives

1. Ensure scene safety — confirm snake is no longer present and maintain safe perimeter around bushline area.
2. Perform Primary Survey — confirm airway patent, breathing adequate, circulation present, GCS 15.
3. Keep patient completely at rest — do NOT allow patient to walk or stand. Bring equipment and stretcher to patient.
4. Continuously reassure patient to reduce anxiety and minimise lymphatic flow.
5. Apply Pressure Immobilisation Technique (PIT) to right lower limb — commence bandaging from toes/foot distally and extend as far up the limb as possible using snakebite bandage with continuous indicator. Bandage should be firm: unable to easily slide finger beneath, similar tension to bandaging a sprained joint.
6. Mark the bite site location on the outside of the PIT bandage with a pen/marker.
7. Apply splint to right lower limb to further minimise movement.
8. Assess distal neurovascular observations to right foot post-PIT application: capillary refill, colour, warmth, movement and sensation to toes.
9. Conduct full Vital Signs Survey: GCS, SpO2, RR, BP, HR, CRT — monitor closely for respiratory depression.
10. Perform thorough IMISTAMBO history: signs/symptoms, allergies (nil known), medications (OCP), pertinent history (nil), last oral intake, events leading.
11. Do NOT remove PIT bandage or splint prior to hospital arrival.
12. Do NOT attempt to trap, identify, or kill the snake.
13. Do NOT cut, incise, suck, or wash the bite site.
14. Do NOT apply an artery tourniquet (CAT) — PIT is the correct technique for snakebite.
15. Monitor patient persistently — record full observations every 10 minutes, with close attention to any new neurological symptoms (drooping eyelids, difficulty speaking/swallowing, limb weakness, visual disturbance), worsening respiratory effort, or deteriorating GCS.
16. Arrange Priority 1 transport to nearest Emergency Department — pre-notify receiving facility of suspected snakebite with PIT in situ.
17. Facilitate gentle transfer to stretcher without patient weight-bearing — use carry device to bring patient to stretcher.
18. Scenario ends on arrival of ambulance and IMISTAMBO handover.
19. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Snakebite · Pressure Immobilisation Technique (P.I.T) · Primary Survey

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Signs/Symptoms	Sharp localised pain at right ankle bite site, mild anxiety, nausea. Denies headache, visual disturbance, weakness in limbs, difficulty breathing or swallowing at this stage.
Allergies	Nil known drug or environmental allergies.
Medications	Oral contraceptive pill only.
Pertinent History	No significant medical history. No previous snakebite. Nil recent illness or injury.
Last Oral Intake	Ate lunch approximately 1 hour ago. Water since then.
Events Leading	Pt was attending the Mundaring Community Festival with her husband and walked to the bushline to take a photo. Felt sudden sharp pain and saw a dark-coloured snake retreat into the scrub. She sat down immediately and called for help.
Treatment Prior	Bystander told patient not to move. No bandage or tourniquet applied prior to EHS arrival.

Onset	Approximately 10–12 minutes ago while walking near the tree line.
Pain	Sharp pain at right ankle bite site.
Quality	Localised sharp pain at wound. Nil radiation of pain into limb at this time.
Radiates	Nil at this stage.
Severity	3/10