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Snakebite in a 55-year-old female


A 55-year-old female with a medical history significant for asthma and hypertension presented to the ED by ambulance after being bitten by a snake. The patient was walking on a trail in a wooded area wearing sandals when she accidentally stepped on the snake, which bit her right mid-foot. The patient felt sudden, sharp pain to her foot, and was able to shake the snake off. She reported hearing a rattling sound after the bite, and saw the snake slither away. She quickly developed severe pain, redness and swelling of her foot, followed by sensations of numbness and tingling in her hands and tongue. A companion called emergency services, and she was transported to the ED. In the ED, she complained of worsening pain and swelling to her right foot, as well as nausea. She denied chest pain, shortness of breath, abdominal pain or throat swelling. The patient’s tetanus immunization status was unknown.


GENERAL APPEARANCE: The patient was a well-developed, middle-aged female in moderate discomfort.
Temperature 98.6◦F (37◦C)
Pulse 95 beats/minute
Blood pressure 175/74 mmHg
Respirations 18 breaths/minute
Oxygen saturation 100% on room air
HEENT: PERRL, EOMI, oropharynx moist, no uvular swelling.
NECK: Supple.
CARDIOVASCULAR: Regular rate and rhythm without rubs, murmurs or gallops.
LUNGS: Clear to auscultation bilaterally, no rales, rhonchi or wheezes.
ABDOMEN: Soft, nontender, nondistended, active bowel sounds present.
RIGHT FOOT: Edema with erythema of the entire foot, extending to the mid-calf (panel A, Figure 1). Two small puncture wounds present on the medial aspect of the foot (panel B, Figure 1). Diffuse tenderness to palpation and warmth; palpable dorsalis pedis pulse, normal sensation and motor function of the toes and foot. No increased pain on passive extension of the toes.
A peripheral intravenous line was placed, and blood was drawn and sent for laboratory testing. Morphine sulfate and Zofran ® were administered IV for pain and nausea, respectively. The wound was cleaned with normal saline, the foot was elevated and ice packs were applied. Laboratory results, including a complete blood count (CBC), electrolytes, BUN, creatinine, glucose, prothrombin time (PT), activated partial thromboplastin time (aPTT), International Normalized Ratio (INR), fibrin split products, fibrinogen and creatine kinase (CK), were all within normal limits.

What is your diagnosis?

[Image: eme-99-q1.jpg]

Figure 1 Feet from a 55-year-old female following a snakebite to the right foot (panel A); medial view of
the right foot demonstrating two small puncture wounds (panel B, arrows).

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