Page 47 - JSOM Summer 2020

i. Advanced laboratory tests Initial Antivenom Treatment –
1. Complete blood count (CBC) Universal Recommendations
a. Hemoglobin (Hb) or hematocrit (HCT) if no Antivenom dosing, preparation, and administration recommenda-
CBC but separate testing for either Hb or HCT tions vary by product and are detailed in Appendix B: Coverage,
is available initial dosing, preparation, and administration of antivenoms in-
2. Prothrombin time (PT), partial thromboplastin time cluded in this CPG. Refer to the specific guidelines for the specific
(PTT), and international normalized ratio (INR) product you have available prior to administering the antivenom.
3. Fibrinogen
4. Comprehensive metabolic panel (CMP) 8. The presence of one or more of the criteria for each category
in Table 1 is generally sufficient to diagnose the syndrome,
5. Creatine kinase (CK)
ii. Simple coagulation test for austere environments determine severity, and initiate treatment. Patients who pres-
ent with “mixed syndromes” (signs and symptoms of > 1 syn-
1. Use the whole blood clotting test (WBCT) as de-
scribed in Appendix A to diagnose and monitor co- drome present) receive the same initial doses of antivenom as
those presenting with a single syndrome.
agulopathy if advanced labs not available
5. If the patient is being medically evacuated from the field or a. To identify the appropriate antivenom and initial dosing
for your patient, refer to the Regionally Specific Snake-
between roles of care, confirm that the receiving facility has an
adequate supply of the appropriate regionally specific antiven- bite Treatment for Each Combatant Command (page 49)
section later in this document. Once you have identified
oms listed in this CPG to ensure treatment coverage against the appropriate product, refer to the detailed informa-
local species of concern. tion sheets in Appendix B (page 63) for comprehensive
a. Evacuation is not an alternative to antivenom adminis- instructions on preparation, dosing, and administration
tration. A patient whose snakebite warrants evacuation of each antivenom in the CPG.
will require antivenom, and the earlier it can be given the
greater the chance of a full recovery without permanent dis- 9. In certain instances, pretreatment with a low dose of SQ
epinephrine prior to antivenom administration may be rec-
ability. DO NOT delay administration of antivenom in the
field to a patient with an envenomation. ommended to reduce the risk of an adverse reaction to an-
6. If clinical evidence of envenomation is present and treatment is tivenom therapy. Refer to Pretreatment with Epinephrine to
occurring in a hospital setting, always admit to a bed with con- Prevent Early Adverse Reactions (page 47) for specific guide-
lines on pretreatment.
tinuous vital sign monitoring if available. If no initial clinical
evidence of envenomation, admit for 24 hours for observation. 10. The majority of severe early reactions to antivenom occur
within the first 5–60 minutes after antivenom administration.
If treating in the field, continuously monitor patient trends for
signs of progression, improvement, or deterioration. Observe and monitor the patient closely at the bedside for a
7. Symptoms should be expected within 24 hours; if the patient minimum of 1 hour after each dose of antivenom has been
is completely asymptomatic after 24 hours then they most given.
a. Refer to Management of Mild, Moderate, and Severe Anti-
likely received a dry bite and can be discharged as detailed in
step 17. venom Reactions (page 48) for specific guidelines on how
to manage mild, moderate, or severe reactions to anti-
venom therapy
TABLE 1: Simplified Universal Diagnosis and Treatment Criteria for Snakebite Worldwide

S/Sx = signs & symptoms; SBC = single breath count test; LOC = level of consciousness; WBCT = whole blood clotting test.

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