Thromboelastometry analysis of severe North American pit viper-induced coagulopathy: A case report

Cao, Dazhe; Domanski, Kristina; Hodgman, Erica I.; Cárdenas, Carlos; Weinreich, Mark; Hutto, Jake; AbdelFattah, Kareem R.; Chen, Catherine

doi:10.1016/j.toxicon.2018.06.079

Cited by 13 publications

(8 citation statements)

References 14 publications

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“…Recently, thromboelastographic analysis of hemostasis has been performed to elucidate the pathophysiology of coagulopathy in patients after a pit viper bite [3][4][5][6][7][8]. In this review, we aim to discuss the advantages of thromboelastography (TEG) by comparing it with traditional coagulation tests to identify the potential treatments for VICC.…”

Section: Introductionmentioning

confidence: 99%

Novel Treatment Strategy for Patients with Venom-Induced Consumptive Coagulopathy from a Pit Viper Bite

Park

Choi

Kim

et al. 2020

Toxins

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Pit viper venom commonly causes venom-induced consumptive coagulopathy (VICC), which can be complicated by life-threatening hemorrhage. VICC has a complex pathophysiology affecting multiple steps of the coagulation pathway. Early detection of VICC is challenging because conventional blood tests such as prothrombin time (PT) and activated partial thromboplastin time (aPTT) are unreliable for early-stage monitoring of VICC progress. As the effects on the coagulation cascade may differ, even in the same species, the traditional coagulation pathways cannot fully explain the mechanisms involved in VICC or may be too slow to have any clinical utility. Antivenom should be promptly administered to neutralize the lethal toxins, although its efficacy remains controversial. Transfusion, including fresh frozen plasma, cryoprecipitate, and specific clotting factors, has also been performed in patients with bleeding. The effectiveness of viscoelastic monitoring in the treatment of VICC remains poorly understood. The development of VICC can be clarified using thromboelastography (TEG), which shows the procoagulant and anticoagulant effects of snake venom. Therefore, we believe that TEG may be able to be used to guide hemostatic resuscitation in victims of VICC. Here, we aim to discuss the advantages of TEG by comparing it with traditional coagulation tests and propose potential treatment options for VICC.

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Section: Introductionmentioning

confidence: 99%

Novel Treatment Strategy for Patients with Venom-Induced Consumptive Coagulopathy from a Pit Viper Bite

Park

Choi

Kim

et al. 2020

Toxins

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show abstract

“…There have been case reports or small case series of thromboelastography in rattlesnake envenomation but many have been from outside of North America [12][13][14][15] and details about methodology were not always included (e.g., citrated versus whole blood, which activator used, etc.). Moreover, all studies, whether from North America [16][17][18] or not, have reported only standard thromboelastography, which do not include platelet activation studies. More recent studies of various rattlesnake venoms added to human plasma have also used TEG [19] but these are not applicable for clinical use because of their in vitro nature, and because the platelet component of coagulation is absent.…”

Section: Introductionmentioning

confidence: 99%

Thromboelastography with Platelet Studies (TEG® with PlateletMapping®) After Rattlesnake Envenomation in the Southwestern United States Demonstrates Inhibition of ADP-Induced Platelet Activation As Well As Clot Lysis

Kang

Fisher

2019

J. Med. Toxicol.

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Introduction Hematologic effects of North American rattlesnake envenomation can include fibrinogenolysis and thrombocytopenia, depending on species, geography, and other variables. During treatment, these effects are routinely monitored through assessment of fibrinogen concentrations and platelet counts. However, these tests provide no information about fibrinolysis or platelet dysfunction, both of which can also occur with venom from some species. Methods This was a retrospective chart review of patients admitted to a quaternary care academic hospital (Banner -University Medical Center Phoenix) in the southwestern United States for treatment of rattlesnake envenomation, over an approximately 1year period from March 2017 through April 2018. Patients who had thromboelastography with platelet studies (TEG® with PlateletMapping®) during their care were included. Results Twelve patients were identified for this study. Four patients exhibited inhibition of ADP-induced platelet activation: one had normal fibrinogen and platelet count, two had concurrent hypofibrinogenemia, and one had concurrent thrombocytopenia. Crotalidae polyvalent immune Fab (ovine) reversed platelet inhibition in the single patient for whom serial thromboelastographs were available. Fibrinolysis was present in seven patients and resolved in the two patients with serial thromboelastographs. Conclusions Inhibition of ADP-induced platelet aggregation and fibrinolysis occurred independent of hypofibrinogenemia and thrombocytopenia, indicating fibrinogen concentration (or protime) and platelet count monitoring alone is insufficient to assess the extent of hematologic toxicity in rattlesnake envenomation. Crotalidae polyvalent immune Fab (ovine) reversed platelet inhibition in one case, suggesting platelet inhibition could also be used in treatment decisions. Fibrinolysis could also be reversed, although the timing to antivenom administration was less clear.

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“…The immediate and delayed venom induced consumptive coagulopathy (VICC) experienced by our patient experienced is a known result of pit-viper envenomation due to the diverse mixture of proteins and metalloproteinases within rattlesnake venom [17][18][19][20][21][22]. The role of TEG in VICC has been previously described and we found it to be a useful adjunct in guiding the management of our patient's coagulopathy, as it obtains a full picture of the coagulation cascade via the utilization of whole blood analysis [23][24][25]. In addition to the various effects on the coagulation system, snake venom metalloproteases (SMVP) also play a role in disrupting the endothelial barrier integrity by widening intercellular junctions [26].…”

Section: Discussionmentioning

confidence: 73%

Rattlesnake Envenomation in a Venom-Naive Man With Significant Coagulopathy and Severe Oropharyngeal Edema Requiring Emergent Surgical Airway

et al. 2021

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The majority of snakebite envenomation events in North America are attributed to rattlesnakes with pit-vipers responsible for nearly all envenomation events. Significant morbidity is associated with rattlesnake envenomation including local tissue destruction and coagulopathy. Severe oropharyngeal edema requiring emergent securing of airway has been reported in victims with no prior exposure to pit-vipers but is exceptionally rare. We present a case report of a venom-naive male in his early twenties who received a pit-viper bite to the right thumb, resulting in an anaphylactoid reaction complicated by severe oropharyngeal edema, coagulopathy, and persistent respiratory failure requiring prolonged ventilator support. This case highlights how anaphylactic and anaphylactoid reactions are nearly identical in presentation and may be associated with significant morbidity. Regardless of whether the underlying etiology is anaphylaxis or anaphylactoid, the management should focus on providing CroFab ® early in the clinical course.

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Thromboelastometry analysis of severe North American pit viper-induced coagulopathy: A case report

Cited by 13 publications

References 14 publications

Novel Treatment Strategy for Patients with Venom-Induced Consumptive Coagulopathy from a Pit Viper Bite

Novel Treatment Strategy for Patients with Venom-Induced Consumptive Coagulopathy from a Pit Viper Bite

Thromboelastography with Platelet Studies (TEG® with PlateletMapping®) After Rattlesnake Envenomation in the Southwestern United States Demonstrates Inhibition of ADP-Induced Platelet Activation As Well As Clot Lysis

Rattlesnake Envenomation in a Venom-Naive Man With Significant Coagulopathy and Severe Oropharyngeal Edema Requiring Emergent Surgical Airway

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