1. Case Presentation Bianca Brif MD

2. Background  10 year old, previously healthy male  No PMH of hospitalizations/illness  NKDA  Vaccinations up to date  Lives in rural area.

3. Chief complaint  40 min previously to arrival to the ER was bitten by a snake, that was described as “brown colored.”

4. ER  brought to the pediatric ER by a military helicopter.  300 ml IV fluids during transportation  On arrival: decreased level of consciousness, vomiting.  Mean BP during administration of IV fluids 45.  Saturation 100% with oxygen mask.

5. Status localis:  Two puncture wounds, without bleeding, with moderate edema of surrounding skin on the right ankle, anterior surface  Faint, irregular pulse palpated on popliteal, dorsalis pedis and tibialis posterior of right lower limb

6. ER Course  Multiple IV 0.9% NaCl boluses  promethazine  Dopamine drip 10cc/kg/min.

7. Toxicology consult  According to geographic area, description of the snake (assumption viper) and clinical presentation, an antivenom was administered.

8. Admitted to ICU  CNS- decreased level of consciousness, answering to questions, oriented to time and space. Moving four limbs in a symmetrical manner. Opposing resistance.  CV-jugular venous line was placed. After dopamine drip and saline at maximum rate, Mean blood pressure 65. pulse 142 b/min. Saturation held above 96, without need for supplemental oxygen. Heart sounds are clear, without murmurs.  Respiratory - 36 breaths/min, clear breath sounds bilaterally, saturation 96, no need for supplemental oxygen. Chest x-ray was ordered.

9. Admitted to ICU  Musculoskeletal - right limb moderate edema up to the knee, slight change in color. Peripheral pulse was weak. Right leg circumference was measured at the level of the wound, the calf and the knee.Orthopedic consult was invited. Diameters: ankle 23 cm, calf 31 cm, knee 35.5 cm  GI - several episodes of vomiting at arrival. At present NPO with IV fluids administration. Abdomen- soft, not painful, no organ enlargement was noted. Liver and pancreas enzymes were within normal limits.  GU - catheter was placed. Urinary output at 3ml/Kg/hour. Urea, creatinine and electrolytes within normal limits  HEM- normal CBC. INR 1.4

10. Laboratory work-up  Blood gases: Ph 7.26, PaO2 50.3, PaCO2 48, HCO3 21.2, K 3.01, Na 144.1, Ca 1.17, HCT 39.5, Glucose 212, Lactate 18, BE -6  Chemistry: creatinine 0.8 mg/dl, K 3.3meq/l, Na 140 meq/l, albumin 3.4g/dl, Alk Phos 251 IU/l  Bood count: Hb 13.37 g/dl, WBC 25 070/ μ L, RBC 4 690/microl, PLT 218 000/ μ L, HCT %-41.22, Neutro% 87.4, Lympho% 11.3

11. ICU Course  3 days in the ICU, with favorable evolution.  Dopamine - administered for 24 hours,  IV fluids @ 1M  The diameter of the right leg progressively decreased, with no signs of compartment syndrome.  The patient is still not ambulating and requires pain control  In light of his favorable evolution - transferred on the pediatric floor.

12. Hospital Course  Started to ambulate within 24h from transfer  Swelling of the leg progressively reduced and no signs of secondary infection were noted.  The range of motion remained reduced, as did the sensory function of the skin in the bite area.

13. Discharge Instructions  1 continuation of normal physical activity,  2 return for orthopedic consult in three weeks, or at appearance of local or systemic deterioration  3 at any signs of rash, edema, respiratory distress, immediately report to the hospital