Venomous snakebites pose a significant risk of morbidity and mortality in rural and austere environments, so it is not surprising that the World Health Organization recently set a goal of reducing snakebite deaths by half by 2030. Many of these envenomations are due to pit vipers, leading to severe hematologic derangements, such as venom-induced consumptive coagulopathy (VICC). Immediacy in detection of envenomations is crucial for ameliorating morbidity and mortality, but diagnosis of envenomization can be challenging, requiring access to clinical laboratory facilities. Further, the laboratory-based evaluations of coagulation function take more than an hour to conduct. In contrast, thromboelastography (TEG) is promising as a rapid, portable, bedside test of coagulation that produces meaningful results in less than 15 minutes. Therefore, the primary objective of this study was to assess the efficacy of TEG compared to standard lab tests in detecting pit viper venom at increasing concentrations. Blood samples drawn from 19 healthy adult volunteers were mixed with varying concentrations of western diamond back rattlesnake (Crotalus atrox) venom (none, 0.5%, 1%, 2%, 33%, 66%, and 100% of LD50), then assessed with standard laboratory-based tests of coagulation function (labs), including prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), D-dimer, and Fibrinogen, as well as with TEG measures of reaction time (R), amplification (K), rate of clot formation (Angle), and clot strength (MA). Data were analyzed as changes from baseline and categorized as percent of samples out of normal physiologic range, then analyzed using ANOVA and binomial statistics at the p<.05 threshold for statistical significance. TEG and standard labs were both excellent (100%) at detecting higher concentrations of venom (33%, 66%, 100%), save D-dimer. Importantly, at low venom concentration levels (0.5%, 1%, 2%), the TEG measures of R, K, alpha, and MA were similar to laboratory-based evaluations of PT and INR at detecting venom, and were significantly superior to PTT, D-dimer, and Fibrinogen. TEG provides a sensitive, real-time quantitative evaluation of coagulation derangements during simulated pit viper envenomation that is faster than standard laboratory tests. TEG was sensitive at low venom concentrations, outperforming multiple traditional laboratory evaluations of VICC. While the present study was limited to in vitro analyses, our findings suggest that TEG is a fast, effective, and portable point-of-care testing modality to assist the emergency physician community to rapidly and accurately diagnose patients stricken with venomous snake bites.
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