Cleopatra VII

introduction 70 % of snakes in Palestine are non venomous .

Males are bitten almost twice as often as females.

Most common snake her in Palestine is Viperapalaestinae.

No available data about number of snake bites her in Palestine.

Test dose of ASV is not essential because even if victim is sensitive to ASV, does not preclude its use.

CaseA 55 year old male, came to the ER on 17\7\2013 at 1

pm

Presenting complaints:

Snake bite in the morning at 9 am.

Bleeding from the site of bite till now

Present history: According to the patient he was alright before he was suddenly bitten while he was walking in the garden . The escaped snake was about 20 cm long & brownish in color. The patient, went home & only bandaged the wound. In a few hours the pain got intense & the bleeding didn’t stop from the wound. There was difficulty in walking associated with the pain & he felt numbness in the left leg.

There are no associated features of hematomesis, melena, epistaxis or vomiting , haemoptisis .

There was no history of bleeding disorders among the family.

Past medical/surgical:

Angiography & angioplasty: 5yrs ago.

Personal hx: appetite-N, micturation-N

bowels-N, sleep-disturbed.

Drug hx: none.

Family hx: not significant.

Physical examination Patient looks ill, but conscious in time/place/person.

Vitals: Bp-110/63, pulse-96 bpm, R/R: 21/min O2 sat : 96 temp : 37.1

General impression: swelling on left leg from the foot to the knee.

Examination

CNS- sensory was bilaterally equal, but slightly decreased at the lateral side of the left foot and leg .

Tone, power & reflexes were bilaterally equal & normal.

Abdomen- firm, non tender, relax, no vissibel venes .

Cvs- s1 + s2, no murmurs

Resp- Normal vesicular breathing, no additional sounds

No skin rash

Chest X- ray It was normal

Investigations Hb-9.1

Plt-110,000

WBCs : 9.5

MCV : 86

RDW : 11.6

InvestigationsCoagulation profile: PT-48 (control 9-13) INR-4.53 APTT-98

Biochemistry: Urea: 22 (10-50) Creatinine: 0.68 Albumin: 4.17 (3.8-4.4)

Electrolytes: Potassium : 2.28 (2.7-4.5) Calcium : 8.17 (8.1-10.4) Magnesium: 1.92 (1.58-2.55) Sodium: 141 (136-140) Chloride: 100 (98-104)

InvestigationsLFTs:

Bilirubin Total: 2.08 (<1.3)

Bilirubin direct: 0.47 (<0.3)

ALT: 21 (upto 40)

Alk Phosphate: 62 (39-117)

Diagnosis Most likely snake bite complicated by DIC .

Treatment O2 by nasal cannulae

500 cc normal saline

100 mg hydrocortison

Anti tetanus serum ( ATS ) 2 cc

given 10U of anti venom

120 ml of FFP.

Treatment Then transferred to Nablus to Rafidia hospital , there

he was admitted to ICU and the after 3 hours he died .

Take home massage Any prolonged bleeding or any abnormal

bleeding following a snake bite it is DIC .

Thanks to

Darwish Nazal Governmental hospital.

Qulqilia UNRWA hospital .