A 28-year-old emergency physician is bitten by a diamondback rattlesnake on the right middle finger. He applies a tourniquet and arrives to the hospital approximately four hours after envenomation. On physical examination, the patient is in mild distress because of hand pain. His vital signs were as follows: temperature, 99° F; pulse, 118 and regular; blood pressure 130/75 mm Hg. Pulse oximetry on room air showed 100% saturation but not detected on the injured digit. Respiratory, cardiopulmonary, abdominal and neurological examinations were normal. No lymph node tenderness was present. Extremity exam is normal except for mild swelling of the hand that the finger is noted to be necrotic. (left).

The patient had a white blood count, hemoglobin, fibrinogen and platelet counts were normal.

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