Local envenomation by green pit viper complicated with airway obstruction

Snake-related injury (SRI) is one of the most common medical emergencies encountered in tropical countries such as Malaysia. The majority of snake bites are nonvenomous, while the less common venomous snakebite can cause major disability or even death. There are 16 pit viper species documented in Malaysia which can be categorized based on their habitat. We report a case of a 41-year-old male who presented to a district hospital 1 h after being bitten twice by a pit viper snake (Trimeresurus sabahi fucatus) on the left side of his face. He was given green pit viper anti-venom (GPAV). He later underwent an emergency tracheostomy due to progressive local swelling causing upper airway obstruction and required a second regime of antivenom. In our opinion, early recognition of snake species, clinical syndrome, and life-threatening conditions in patients with SRI is important. While careful clinical, laboratory, and patient observation is important in determining the need for anti-venom, a life-saving procedure such as intubation, in this case, should not be delayed. From our experience, SRI at the head with progressive swelling to zone 2 of the neck may signal a red flag to the attending clinician for the possibility of impending upper airway obstruction.