Environmental Exposures; September 2022 Question – In Collaboration with EMCoach

Topic: Environmental Exposures
Section: Animal Bites, Envenomation, and Exposure
Acuity: Critical
Age group: Adult

A museum snake handler was bitten on the hand while transferring snakes to a display container. He is unsure which snake bit him. Upon arrival to the emergency department, his vital signs are HR 97, BP 126/87, RR 35, SpO2 97% on room air, T 37.0°C. His exam is significant for rapid shallow breathing and the HEENT exam below. Lung sounds are normal. Extremity strength is normal throughout.

Correct answer:
A. Administer antivenom and admit for monitoring
The patient was most likely bitten by a coral snake since he is experiencing signs of neuromuscular dysfunction. The picture shows bilateral ptosis, and the rapid shallow breathing is concerning for diaphragmatic weakness. Coral snake venom is a neurotoxin that can produce systemic neurological dysfunctions such as diplopia, ptosis, dysphagia, and possibly seizures. In this case, the patient is showing clear signs of envenomation and should be treated with antivenom and admitted for monitoring. Of note, the coral snake head is actually quite small, so the bites tend to be on small parts of extremities like fingers because the snakes cannot open their mouths wide enough to bite a large diameter extremity.

See the video below for a video explanation of this month’s question:

Here is a table on Arachnid and Snake Envenomations

References:

Sheikh, S, Leffers, P. Emergency Department Management of North American Snake Envenomations. EB Medicine. September 1, 2018. Accessed June 15, 2022. https://www.ebmedicine.net/topics/toxicology-environmental/snake-bite-antivenom (full free access for residents)

Dart, RC, White, J. Chapter 212. Snakebite. In: Tintinalli JE, Stapczynski JS, Ma OJ, et al. <em>Tintinalli’s Emergency Medicine: A Comprehensive Study Guide</em>. 8th ed. New York: McGraw Hill Professional; 2016.

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