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Case Presentation

Case #1: A 45-year-old man presents, via rural EMS, with a chief complaint of "snakebite." EMS reports that the patient ran over a 6 to 8ft snake with his pickup truck, cutting it in half. The patient doubled back to pick up the dead snake (foreseeing a nice new pair of snakeskin boots) and when he grabbed it, the snake "came around" and bit his hand. He has two puncture wounds almost 7cm apart on his right hand surrounded by dark purple ecchymosis and the start of bullae formation. He has edema and erythema of his hand and arm to the elbow and is having fasciculations of most of his large skeletal muscle groups. He is in pain and EMS reports that he seemed to be getting progressively confused and lethargic during their 70 minute transport. He is hypotensive, tachycardic, and is oozing blood from his IV sites. You realize that his life depends on your actions...

Case #2: A 30-year-old man presents with a chief complaint of "snakebite." About 30 minutes prior to arrival he was wading in murky water cleaning debris out of a stream and felt a bite on his hand. As he pulled his hand out of the water, he briefly caught a glimpse of a snake as it swam away; he gives a fairly good description of a small copperhead. He has two small punctures on his right index finger about 1 cm apart. He is currently pain free, without erythema, swelling, or ecchymosis. His vitals and remaining physical exam are normal. He wants to know if he can go home...

Case #3: A 39-year-old man presents to your Florida ED about four hours after being bitten on the forearm by a small red, yellow, and black snake while clearing brush. The snake escaped and was thought to be a king snake. There was minimal pain at the site of the bite and no swelling or bleeding, so he continued working. The patient started to get worried when he developed twitching in his arms and face about one hour before arrival at the ED. Soon after the twitching started, he began having difficulty talking and swallowing and had an episode of double vision, prompting him to call 911. On arrival, the patient is awake, alert, and anxious. His heart rate is 92, blood pressure 140/85, temperature 98.2°F orally, respiratory rate 22, and oxygen saturation 95% on room air. You note right eye ptosis; the pupils are equal, round, and reactive to light, but the right eye does not move past the midline on lateral gaze. Mild dysarthria is present. There are two tiny puncture marks on the right forearm with 1-2cm of surrounding ecchymosis, but no swelling. During your exam, respirations became shallower and labored, with some snoring upper airway sounds. You realize that this might be more than just the bite of a king snake...


There are approximately 8000 venomous snakebites in the US each year. The vast majoity of these bites are from rattlesnakes, copperheads and water mocosins. Management is based on early recognition, envenomation assessment, and administration of the appropriate antivenom. Current concepts in care have relenquished incision and suction techniques to history books and have promoted antivenom that is immunotherapy based. The three cases presented at the beginning of this article illustrate scenarios that may confront any emergency medicine physician. The case outcomes show the benefit of proper clinical management.

Case #1: This case represents a very severe envenomation (Grade III/IV). This patient needed 12 vials of CroFab™ to achieve initial control and resolve the coagulopathy. He was admitted to the medical ICU and monitored for several days. His pain was controlled with narcotics and benzodiazepines; he ultimately did well and was discharged home. He did not get a new pair of boots.

Case #2: This patient required eight hours of observation. The bite was a "Grade 0" at presentation and he remained asymptomatic for the eight hour stay. The patient was discharged home after wound cleansing and administration of tetanus prophylaxis.

Case 3: In this case, the patient was experiencing neurotoxic effects of a coral snake envenomation and was at a high risk for respiratory failure. Three vials of North American coral snake antivenom were given, with additional doses made available at the bedside. Aggressive supportive care, including endotracheal intubation and mechanical ventilation were required. The patient made an uneventful recovery. He decided to hire someone the next time the brush needed clearing.

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Last Modified: 08/17/2017
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