Therefore, the treating physician should examine the patient and repeat indicated laboratory studies soon after antivenom is administered to evaluate for treatment response. Because fibrinogen and platelet

levels change rapidly after antivenom administration, coagulation studies and platelet counts should be rechecked within one hour of antivenom dosing. If initial control of the envenomation syndrome is achieved, the patient can be observed, either as an inpatient or in a clinical observation unit, to make certain that #ABT-199 manufacturer keyword# this clinical response is maintained. If the first dose of antivenom does not succeed in producing initial control, the initial dose should be repeated. Failure to achieve initial control after two doses of antivenom is uncommon. In a large retrospective

study, only 17% of rattlesnake victims and 2% of Agkistrodon (copperhead and water moccasin) victims required more than 12 vials of antivenom to achieve initial control, Inhibitors,research,lifescience,medical and the presence of thrombocytopenia and neurologic venom effects prior to antivenom therapy were independently associated with the difficulty achieving initial control [41,49]. Consultation with a physician, clinical toxicologist, or other expert who has specific training and expertise in the management of venomous snakebite is recommended in this and other high-risk clinical situations. Information Inhibitors,research,lifescience,medical about how to reach such an expert can be found on the algorithm (box 12), or below. Post-stabilization monitoring and administration of maintenance therapy (boxes 6 and 13) Snake envenomation is a dynamic clinical process. Although Inhibitors,research,lifescience,medical clinical improvement virtually always follows administration of adequate antivenom doses, recurrence or delayed-onset of one or more venom effects occurs in approximately half of patients treated with Fab antivenom [11]. Serial physician examinations and laboratory studies are necessary to detect recurrent or delayed-onset venom effects. When it occurs, local tissue recurrence typically develops within 6 to 36 hours of initial control. Recurrent local tissue effects are clinically evident Inhibitors,research,lifescience,medical to the patient and generally

respond well to re-treatment with antivenom. The onset of recurrent or delayed-onset hematologic venom effects is much more variable, with most cases occurring 2 – 7 days after initial control and some cases up to 10 days after initial control [25,36]. When antivenom is Bumetanide administered to treat recurrent coagulopathy or thrombocytopenia, the treatment response is generally attenuated compared with the response to initial antivenom therapy [26,28,30,31,50-52]. Hematologic venom effects are most often clinically occult; few patients experience medically significant bleeding even in the setting of profound defibrination or thrombocytopenia [26]. The ideal duration of hospitalization and frequency of follow-up observations and laboratory studies is unknown.