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Dr. Chris Leptak: Today’s case is that of a 46-year-old man who was brought to the Emergency Department (ED) after a motor vehicle crash (MVC). The patient reported that he was driving at a high rate of speed on the way to the hospital after being bitten by a snake. Paramedics reported that the car struck a pole on the side of the road. There was moderate damage to the car and the airbag was deployed. The windshield was intact and there was no damage to the inside of the vehicle. The patient was found sitting in the front seat awake and alert; he was unsure whether he lost consciousness. He only complained of left hand pain. The patient was placed in a cervical collar, moved on to a long board, and transported to the hospital. Dr. Eric Nadel: It is unclear whether this MVC was related to a snakebite, a high rate of speed, or some other reason. As he was the single driver involved in a MVC, it is important to think of other etiologies that may have caused the crash. Did the patient have any chest pain or headache? Did he have a history of diabetes, seizure, or other medical problems that may have predisposed the patient to syncope? Dr. Leptak: The paramedics reported no history of diabetes or seizure, and the patient denied headache, chest pain, or lightheadedness prior to the accident. Dr. David Peak: In the metropolitan area near Boston, it is unusual to see snake envenomations. Was there any further history from the patient regarding how the snakebite occurred? Also, please describe his appearance and physical examination upon presentation to the Emergency Department (ED). Dr. Leptak: The patient reported being bitten by a snake while hiking alone in the Blue Hills area of Massachusetts, approximately 15 miles southwest of Boston. He said that the snake made a “rattling noise.” Upon presentation to the ED the patient appeared anxious and agitated. His only complaint was pain in the left hand where he said the snake bit him. He denied headache, vision changes, neck pain, chest pain, abdominal or back pain, or extremity pain other than in the left hand. His past medical history was noted for a cavernous hemangioma resection in the remote past. He denied medications or allergies to medications. He drank alcohol infrequently, did not smoke, and denied use of recreational, i.v., or street drugs. On physical examination vital signs were: temperature 36.9°C (98.4°F), pulse 126 beats/min, systolic blood pressure 80 mm Hg, respirations 28 breaths per minute, and oxygen saturation 97% on room air. There was no evidence of head trauma. Extraocular motions were intact and the pupils were midsize and reactive bilaterally. The oropharynx was clear and without secretions. The trachea was midline, and there was no evidence of chest wall tenderness or crepitance. Breath sounds were clear |
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