How to manage a sickle cell positive 36-year-old lady bitten by a snake?

Management of Snake Bite in a Sickle Cell Positive 36-Year-Old Woman

For a 36-year-old woman with sickle cell disease who has been bitten by a snake, immediate medical attention should be sought as the definitive treatment is antivenom which is only available in hospital settings. 1

Immediate First Aid Measures

1. Call emergency services immediately

   • This is the most critical first step as definitive treatment requires hospital care 1

2. Immobilize the affected limb

   • Rest and immobilize the bitten extremity to reduce venom spread 1
   • Keep the bitten area at or below heart level

3. Remove constricting items

   • Take off rings, watches, and tight clothing from the affected limb to prevent complications from swelling 1

4. Apply pressure immobilization bandage (for appropriate snake species)

   • Apply a pressure immobilization bandage with pressure between 40-70 mmHg for upper extremity and 55-70 mmHg for lower extremity 2
   • For practical purposes, the bandage should be comfortably tight and snug but allow a finger to be slipped under it 2
   • Note: This recommendation applies to most snake species but may not be appropriate for North American pit vipers 1

What NOT to Do

• Do not apply suction to the bite area - this has no clinical benefit and may worsen injury 2, 1
• Do not apply ice to the bite site - unproven benefits and may cause tissue injury 1
• Do not apply tourniquets - can worsen local tissue injury 1
• Do not make incisions at the bite site
• Do not apply electric shock - ineffective and potentially harmful 1

Hospital Management

1. Antivenom administration

   • The mainstay of treatment for venomous snakebites 3
   • Should be administered in a hospital setting with monitoring for adverse reactions
   • Equine-derived antivenin is considered standard of care, though sheep-derived antigen binding fragment ovine (CroFab) is less allergenic 4

2. Special considerations for sickle cell disease

   • Monitor closely for signs of vaso-occlusive crisis which may be triggered by the stress of envenomation
   • Ensure adequate hydration with appropriate fluids (5% dextrose or 5% dextrose in 25% normal saline rather than normal saline) to prevent sickling 5
   • Monitor oxygen saturation and provide supplemental oxygen if hypoxic 5

3. Laboratory monitoring

   • Complete blood count to assess for hemolysis and anemia (already a concern with sickle cell disease)
   • Coagulation studies to detect venom-induced coagulopathy
   • Renal function tests to monitor for acute kidney injury
   • Electrolytes and cardiac monitoring

4. Supportive care

   • Pain management for both snake bite and potential sickle cell crisis
   • Prophylactic antibiotics if indicated for wound infection
   • Tetanus prophylaxis if needed

Potential Complications to Monitor

• Vaso-occlusive crisis - snake venom and the stress response may trigger sickle cell crisis
• Acute chest syndrome - a life-threatening complication of sickle cell disease that may be triggered by the stress of envenomation 5
• Allergic reactions to antivenom - can range from mild to severe anaphylaxis 3, 6
• Delayed serum sickness - may occur 5-14 days after antivenom administration 3
• Coagulopathy - from certain snake venoms
• Renal failure - can be caused by both snake venom and sickle cell complications

Follow-up Care

• Monitor for delayed reactions to antivenom (serum sickness)
• Wound care and monitoring for infection
• Continue management of underlying sickle cell disease
• Physical therapy may be needed depending on extent of tissue damage

The combination of snake envenomation and sickle cell disease presents a complex clinical scenario requiring prompt attention to both conditions simultaneously, with particular attention to hydration, oxygenation, and prevention of vaso-occlusive complications.