Cover Image

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


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.

Full Text:



Gold BS, Dart FC, Barish RA.Bites of venomous snakes. N Engl J Med. 2002, 347:347-356

White J. Snake venoms and coagulopathy. Toxicon. 2005, 45:951-967

Kitchens CS, Van Mierop LHS. Mechanisms of defibrination in humans after envenomation by the Eastern diamondback rattlesnake. Am J Hematol. 1983, 14:345-353

Van Mierop LHS, Kitchens CS.Defibrination syndrome following bites by the Eastern diamondback rattlesnake. J Fla Med Assoc. 1980, 67:21-27

Boyer IV, Seifert SA, Clark RF et al. Recurrent and persistent coagulopathy following pit viper envenomation. Arch Intern Med. 1999, 159:706-710

Lavonas EJ, RuhaAM, Banner W, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med. 2011, 11:2

Bogdan GM, Dart RC, Falbo SC, et al. Recurrent coagulopathy after antivenom treatment of crotalid snakebite. South Med J. 2000, 93:562-566.

Lavonas EJ. Coagulopathy: the most important thing we still don’t know about snakebite. West J Emerg Med. 2012, 13:75-76

Kitchens CS, Eskin TA. Fatality in a case of envenomation by Crotalus adamanteus initially successfully treated with polyvalent ovine antivenom followed by recurrence of defibrinogenation syndrome. J Med Toxicol. 2008, 4:180-183

Bush SP, Seifert SA, Oakes J, et al. Continuous IV crotilidae polyvalent immune Fab (ovine) (FabAV) for selected North American rattlesnake bite patients. Toxicon. 2013, 69:29-37

Bush SP, Ruha AM, Seifert SA, et al. Comparison of F(ab’)2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial. ClinToxicol (Phila). 2015, 53:37-45

Seifert SA, Kirschner R, Martin N. Recurrent, persistent, or late, new-onset hematologic abnormalities in crotaline snakebite. ClinToxicol (Phila). 2011, 49:324-329


  • There are currently no refbacks.

AJT (ISSN 2689-1875)© 2012-2021. All rights reserved. Published by Ivy Union Publishing, 3204 Valley Rush Dr, Apex, North Carolina 27502, United States