Utilization of thromboelastograms in management of Crotalus adamanteus envenomation

Abstract

Background Crotalinae (pit viper) envenomations are frequently encountered in North American emergency departments. Cases can be complicated by ambiguity in initial species identification as well as timing and duration of current antivenin treatment. Recently, thromboelastography (TEG) has emerged as an enhanced real-time monitoring parameter for snake envenomations that may aid in management of venom-induced consumptive coagulopathy. Case A 61-year-old snake handler presented with severe coagulopathy and hypofibrinogenemia following envenomation from her pet eastern diamondback rattlesnake (Crotalus adamanteus). Her coagulopathy transiently improved with Crotalidae Polyvalent Immune Fab (Ovine) (FabAV) but would repeatedly rebound following cessation of antivenin over the next 10 days. Serial TEGs were successfully utilized to identify and corroborate fibrinolysis while predicting clot formation prior to routine coagulation studies. Discussion Traditional coagulation parameters have not always been ideal when treating severe coagulopathy from pit viper envenomations and may not identify active fibrinolysis for several hours. In this case of C. adamanteus envenomation, TEG proved to be useful in demonstrating improvements in clotting function prior to standard laboratory measures, which further guided antivenin therapy.