1) The document provides guidelines for assessing and treating patients presenting with snake bites or hypothermia. For snake bites, it outlines collecting subjective and objective data including the snake description, bite location, signs and symptoms, and diagnostic testing. Interventions include wound care, antivenom as needed, IV fluids, tetanus prophylaxis, and patient education.
2) For hypothermia patients, it describes assessing level of consciousness, vital signs, temperature, and performing diagnostic tests. Interventions include airway management, removing wet clothes, warming the patient through methods appropriate to their temperature, IV fluids, monitoring, and preventing further heat loss.
3) Ongoing monitoring is important for both conditions and
4. Subjective data collection
1) History of present injury/chief complaint
a) Description of incident.
b) Description and identification of the snake.
c) Location of bite.
d) Size and weight of victim.
e) Prehospital care provided.
f) Signs and symptoms before arrival.
g) Shortness of breath.
h) Weakness, paresthesia, diplopia, muscular pain.
i) Nausea and vomiting, diarrhea).
j) Time of incident.
5. 2) Past medical history:
a) Current or preexisting diseases/illness
(1) Cardiovascular disease.
(2) Diabetes.
(3) Immunocompromised.
b) Previous bite injury
c) Previous administration of antivenom
d) Medications
e) Allergies
f) Immunization status
6. Objective data collection
1) Physical examination
a) General appearance
(1) Level of consciousness, behavior, affect, anxiety, euphoria, confusion, seizures
(2) Flaccid paralysis
(3) Moderate to severe distress/discomfort
b) Inspection
(1) Appearance of wound.
(a) Pit viper: fang marks, semicircular, teeth marks.
(b) Coral snake: scratch marks or tiny puncture marks
(c) Nonvenomous: scratch marks, teeth marks
(2) Ecchymosis, edema of area (3) Vesicles, bullae at or around bite site.
(4) Diaphoresis. (5) Bleeding.
7. 2) Diagnostic procedures.
a) CBC with differential.
b) Serum chemistries, CK.
c) Type and crossmatch.
d) Coagulation profile including platelets, fibrin split products.
e) ABGs: if systemic symptoms present.
f) Urinalysis: myoglobin.
g) Wound culture and sensitivity.
i) Chest radiograph: if history of pulmonary edema.
j) EKG: if patient complains of chest pain, dyspnea.
3) Analysis: differential nursing diagnoses/collaborative problems.
a. Risk for ineffective airway clearance.
b. Deficient fluid volume.
c. Impaired skin integrity.
d. Risk for infection.
e. Acute pain.
f. Anxiety/fear.
g. Deficient knowledge.
8. 3. Planning and implementation/interventions
a. Maintain airway, breathing, circulation.
b. Provide supplemental oxygen
c. Establish IV/IO access for administration of crystalloid fluids/blood products/medications
1) With potential coagulopathy, venipuncture attempts should be minimized and noncompressible entry sites (e.g.,
subclavian vein) should be avoided.
2) As IV lines are placed, obtain blood draw for initial laboratory.
d. Prepare for/assist with medical interventions
1) Immobilize affected part: do not apply tourniquets
2) Institute cardiac and pulse oximetry monitoring
3) Perform wound care, mark site of bite and perform serial measurements of increasing edema and redness;
may need compartment measures
4) Determine the severity of envenomation and need for antivenom.
5) Assist with hospital admission and possible fasciotomy for severe issue injury.
9. 3. Planning and implementation/interventions Cont.
c. Administer pharmacologic therapy
1) Antivenom:
2) Nonnarcotic analgesics.
3) Narcotics.
4) Antibiotics.
5) Tetanus immunization.
f. Educate patient:
1) Wound care.
2) Signs and symptoms of infection.
3) Medication administration.
4) Follow-up care.
5) Prevention.
a) Wear boots or high-top shoes when hiking.
b) Do not attempt to pick up or provoke a snake.
10. 3. Evaluation and ongoing monitoring:
a) Airway patency.
b) Level of consciousness.
c) Hemodynamic status.
d) Breath sounds and pulse oximetry.
e) Cardiac rate and rhythm.
f) Extremity edema progression.
g) Neurovascular status distal to bite.
h) Pain relief.
11.
12. a. Subjective data collection
1) History of present injury/chief complaint
a) Ambient temperature
b) Length of exposure
c) Patient’s clothing
d) Exposure to water/metal
e) Trauma: blunt or penetrating forces
f) Administration of neuromuscular blocking agents
g) Patient age
2) Past medical history.
a) Current or preexisting diseases/illness
(1) Alcoholism
(2) Hypothyroidism
(3) Malnutrition
(4) Diabetes
b) Medications
(1) Phenothiazines
(2) Barbiturates
c) Allergies
d) Immunization status
13. b. Objective data collection
1) Physical examination
a) General appearance
(1) Level of consciousness, behavior, affect: confusion to coma
(2) Subnormal temperature:
(a) Mild hypothermia: (35–36°C)
(b) Moderate hypothermia: (30–34°C)
(c) Severe hypothermia: < (30°C)
(3) Hypoventilation
(4) Hypotension: difficult to detect blood pressure
(5) Moderate to severe distress/discomfort, possibly critically ill
b) Inspection
(1) Fixed, dilated pupils
(2) Pale, cyanotic skin.
(3) Paradoxical undressing: patient removes all clothing even though cold
(4) Shivering diminished or absent at core body temperature of (30°C)
(5) Cardiac dysrhythmias on monitor: bradycardia, atrial fibrillation,
15. 2) Diagnostic procedures
a) CBC with differential:
b) Coagulation profile including platelets.
c) Serum chemistries including glucose, BUN, creatinine: hyperglycemia
d) Liver profiles
e) Serum and urine toxicology screen
f) ABGs
g) Urinalysis;
h) Chest Xray.
i) Head CT scan
j) ECG
16. a. Maintain airway, breathing, circulation
1) Initiate or continue BLS and ALS per
b. Provide supplemental oxygen
1) Repetitive strain injury and ventilatory support in patient with compromised airway
2) High-flow oxygen
c. Establish IV/IO access for administration of crystalloid fluid/medications.
1) Infuse warmed normal saline solutions
3. Analysis: differential nursing diagnoses/collaborative problems
a. Ineffective airway clearance
b. Impaired gas exchange
c. Ineffective thermoregulation
d. Deficient knowledge
4. Planning and implementation/interventions
17. d. Prepare for/assist with medical interventions
1) Advanced airway management
a) Nasal or oral intubation
b) Supraglottic airway (e.g., King, Combi tube, laryngeal mask airway)
c) Surgical airway (e.g., cricothyrotomy).
2) Remove wet clothing and jewelry
3) Maintain normothermic body temperature
a) Treat mild hypothermia 90–95°F (32.2–35°C) with passive rewarming
(1) Warm blankets
(2) Forced warm-air blankets and warmed environment.
(3)Active external: prehospital body-to-body contact
b) Moderate hypothermia [28–32.2°C]) requires active core rewarming with warmed IV solutions, warmed oxygen
c) Severe hypothermia < [28°C]) requires active core rewarming such as warmed solutions, warmed peritoneal lavage.
(1) Consider cardiopulmonary bypass or continuous arteriovenous rewarming
with a rapid fluid warmer if avialbale
18. 4) Institute cardiac and pulse oximetry monitoring
5) Insert gastric tube and attach to suction
6) Insert indwelling urinary catheter
7) Continue resuscitation of a hypothermia victim until patient has been warmed to a minimum 86°F (30°C)
8) Assist with hospital admission.
e. Administer pharmacologic therapy as ordered
1) RSI premedication: sedatives, analgesics, neuromuscular blocking agents
2) ALS medications per protocols.
f. Educate patient and significant others
1) Medical illness, medications, age
2) Early signs and symptoms of hypothermia
3) Prevention of hypothermia (e.g., proper clothing, recognizing when to seek shelter)
19. 5. Evaluation and ongoing monitoring
a. Airway patency
b. Level of consciousness
c. Hemodynamic status
1) Monitor patient for rewarming shock (afterdrop
d. Breath sounds and pulse oximetry
e. Cardiac rate and rhythm
1) Atrial fibrillation is a common dysrhythmia after exposure to cold weather
f. Core temperature measurements continuously during rewarming efforts
g. Intake and output
