The evolution of coagulation abnormalities was studied in Russell's viper bite victims who, on admission to hospital, showed no clinical signs of systemic envenoming. Based on the laboratory results and subsequent clinical course, three groups were distinguished. The first group, consisting of five cases, showed no activation of coagulation at any stage. The second group, consisting of six cases, developed mild to moderate abnormalities in some tests, particularly in the aPTT and factor V assay, which corrected to normal without treatment. The third group, consisting of nine patients, developed haemostatic abnormalities as early as 1-2 h after the bite, which progressed to severe defibrination 4-8 h later at which time antivenom was given. Comparison of the haemostatic abnormalities in the three groups suggested that serial monitoring of the serum FDP concentration may be of value in predicting the likelihood of systemic envenoming and progression to complete defibrination.
Amongst its many actions, Russell's viper (RV) venom activates factors X and V and enhances fibrinolysis, leading to defibrination which contributes to the clinical sequelae of RV bite. Early administration of antivenom may be life-saving, but not all of those bitten become sufficiently envenomed to require treatment. In an attempt to predict at an early stage those subjects who will progress to defibrination, we have serially monitored the haemostatic changes in 20 bite victims using the PT, APTT, thrombin time, platelet count, assays for factors X and V and fibrinogen and fibrin(ogen) degradation products (FDP).In five patients, no evidence of defibrination was seen at any time and none of these developed obvious clinical symptoms. In a further six subjects, slight prolongation of the PT (16-21/14s), APTT (39-51/38s) and thrombin time (16-25/14s) occurred concomitantly with a moderate fall in factor X (20-80%), factor V (30-66%) and fibrinogen (0.6-2.Og/1), but FDP never exceeded 40ug/ml. In the remaining nine subjects who all eventually defibrinated completely, moderate coagulation factor deficiency and thrombocytopenia developed as early as 1-2h after bite. The most pronounced and consistent changes were a rise in FDP to above 80ug/ml (80-640ug/ml) and a fall in factor V (2-50%), these results being obtained on admission, 1-12h after bite. We conclude that an FDP level of 80ug/ml or more is highly suggestive of impending defibrination and could be regarded as a criterion for commencing antivenom therapy.
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