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Apparent Efficacy of Low-Dose Constant-Infusion Crotalidae Antivenom for Control of Defibrinogenation Recurrence Syndrome Following Envenomation by the Eastern Diamondback Rattlesnake (Crotalus adamanteus)

Sarunas Sliesoraitis, Hassan Hassan, Napoleon Santos, Anita Rajasekhar, Craig Kitchens

Abstract


Background: Eastern Diamondback rattlesnake bites produce coagulopathy in the bite victims. The syndrome is treated with antivenom called Crotalidae Polyvalent Immune Fab. However following resolution of coagulopathy with the antidote, and sometimes days later, fibrinogen drops to very low levels. Rare bleeding may occur due to this recurrent defibrinogenation syndrome. No guidelines exist at this time of how these patients should be treated. However, many centers repeat the initial treatment protocol using another 6-18 vials of antidote acquiring significant treatment costs.
Methods: We analyzed all cases treated at the University of Florida between 2013 and 2014 for the rattlesnake bites.  All cases were treated with Crotalidae Polyvalent Immune Fab as recommended per manufacturer recommendations upon initial presentation.  However, upon the recurrence of defibrinogenation, we administered the antivenom 1 vial diluted in 250 ml of normal saline and administered by continuous IV infusion over 2 to 12 hours tapered over 2 to 3 days. The patients and their coagulation labs were monitored at least daily during the recurrence of the defibrinogenation.
Results: We identified 5 cases treated for Eastern Diamondback snake bites. All cases had recurrent defibrinogenation syndrome and treated as described above. All patients had normalization in their fibrinogen levels with the reinstitution of the antidote. Additionally, none of them had any further bleeding. No chills, fevers or cloudiness of solution reported during the continuous antidote administration.

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