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Clinic

 

Crotalus molossus molossus

Case reports

Hardy et al. 1982: 2 Crotalus molossus molossus bites; identification: morphological.

Signs & symptoms

Local effects

Pain, extensive swelling, in one patient involving the thorax (haematothorax) and abdomen over a period of 72 h after the bite, with extensive ecchymosis, blistering (Hardy et al. 1982).

Haemostatic effects

See below, Laboratory and physical investigations.

Morbidity

After 22 months reduced fist grasp and dorsiflexion of the wrist (1/2). After 12 months mild swelling and stiffness of the finger in the morning (1/2).

Case fatality rate

0/2 (Hardy et al. 1982).

Laboratory and physical investigations

1. Haemostasis
Type of haemostatic defect

Primary, direct, i.e. not plasminogen-dependent, fibrin(ogen)olysis and platelet aggregation, weak coagulative activity (Hardy et al. 1982).


Haemostatic parameters


Overview haemostasis
         
A
 
 
A
 
 
C
 
                     
 
H CT (FSP) Tc PT aPTT TT I FSP D II V VIII X XIII PC ATIII PI tPA α2AP
       
 
D
     
 
B
                       
 

Essential

bed-side

tests

Tests for full clinical assessment Tests for research purposes
H haemorhagic effects
+ definite evidence in
human envenoming
CT full blood clotting test
(FSP)  FSP rapid test
Tc platlets
PT prothrombin time
aPTT partial thromboplastin time
TT thrombin time
I fibrinogen
FSP  fibrinogen split products
D D-dimer
II, V, VII, X, XIII
  clotting factors
PC protein C
ATIII antithrombin III
PI plasminogen
tPA tissue plasmin activator
α2AP α2-antiplasmin
 
In this overview, the deviations from normal
are recorded for those haemostasis para-
meters only, for which good evidence is
documented in the literature.
 
A PT, thrombin time: increased; approx. 1 h after the bite PT >100 s (normal 11–13 s), thrombin time >100 s (normal 11–12 s) (Hardy et al. 1982).
B Fibrinogen: approx. 1 h after the bite 60 mg/dl, minimum 12 mg/dl 12½ h after the bite, returned to normal after 28 h; 30 vials of polyvalent Wyeth (Crotalidae) antivenom were administered (Hardy et al. 1982).
C FSP: 16 h after the bite, 40 μg/ml (normal <10 μg/ml), not determined prior to that (Hardy et al. 1982).
D Platelets: approx. 1 h after the bite, 80,000/mm³, fluctuating for up to 40 h after the bite (1/2); 30 vials of polyvalent Wyeth (Crotalidae) antivenom were administered. Within the first hour after the bite 32,000/mm³, <150,000/mm³ up to and on the 4th day after the bite (fibrinogen was not decreased at any point in time) (1/2); 21 vials of polyvalent Wyeth (Crotalidae) antivenom were administered (Hardy et al. 1982).

Treatment (symptomatic)

Fluid replacement i.v. (Hardy et al. 1982).

Treatment (specific)

 

1. Crotalidae Polyvalent Immune Fab Antivenom, ovine (immunized with Crotalus adamanteus, Crotalus atrox, Crotaus scutulatus ssp. and Agkistrodon piscivorus) / CroFab™, Savage Laboratories, Melville, New York

 

see Crotalus sp.

 

2. Wyeth antivenom (Crotalidae), polyvalent, Philadelphia, USA (no longer in use)

Studies

No controlled clinical studies available. Experience from observations of individual cases. Hardy et al. 1982: antivenom administration commenced 7.5 h after the bite: total dose 300 ml (= 30 vials) within 20 h (1/2); and 1.25 h after the bite: total dose 210 ml (= 21 vials) within 3 h (1/2).


Efficacy

  • Effect on local cytotoxicity: no effect, drastic increase in local symptoms during and after antivenom administration. One patient received antivenom as early as 1.25 h after the bite. Apart from thrombopaenia (30,000/mm³), he did not show any haemostatic defect, but did develop massive swelling involving the right thorax (haematothorax) and abdomen within 72 h (Hardy et al. 1982).
  • Effect on the haemostatic defect: clear effect on platelets, no significant effect on fibrinogen (Hardy et al. 1982).


Adverse reactions

Acute: skin rash, pruritus, rhonchi 1/2 (Hardy et al. 1982).

Delayed: on 6th day (210 ml of antivenom) 1/2 (Hardy et al. 1982).