A 55-year-old male presented to the emergency room with swelling and numbness in his left leg after being bitten by a snake while gardening that morning. Tests revealed decreased hemoglobin and platelets, elevated coagulation markers, and electrolyte abnormalities indicating disseminated intravascular coagulation (DIC) from the snake bite. He was given oxygen, fluids, steroids, tetanus shot, anti-venom, and blood products to treat the DIC but his condition deteriorated and he died after being transferred to another hospital. The take-home message is that abnormal or prolonged bleeding after a snake bite could indicate DIC.

2. Cleopatra VII

3. 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 Vipera
palaestinae.
 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.

5. Case
A 55 year old male, came to the ER on 1772013 at 1
pm
Presenting complaints:
 Snake bite in the morning at 9 am.
 Bleeding from the site of bite till now

6.  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.

8.  Past medical/surgical:
Angiography & angioplasty: 5yrs ago.
 Personal hx: appetite-N, micturation-N
bowels-N, sleep-disturbed.
 Drug hx: none.
 Family hx: not significant.

9. 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.

11. 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

12. Chest X- ray
 It was normal

13. Investigations
 Hb-9.1
 Plt-110,000
 WBCs : 9.5
 MCV : 86
 RDW : 11.6

14. Investigations
Coagulation 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
 Calcium : 8.17
 Magnesium: 1.92
 Sodium: 141
 Chloride: 100
(2.7-4.5)
(8.1-10.4)
(1.58-2.55)
(136-140)
(98-104)

15. Investigations
LFTs:
 Bilirubin Total: 2.08 (<1.3)
 Bilirubin direct: 0.47 (<0.3)
 ALT: 21
(upto 40)
 Alk Phosphate: 62 (39-117)

16. Diagnosis
 Most likely snake bite complicated by DIC .

17. 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.

18. Treatment
 Then transferred to Nablus to Rafidia hospital , there
he was admitted to ICU and the after 3 hours he died .

19. Take home massage
 Any prolonged bleeding or any abnormal
bleeding following a snake bite it is DIC .

20. Thanks to
 Darwish Nazal Governmental hospital.
 Qulqilia UNRWA hospital .