Cao Dazhe, Domanski Kristina, Hodgman Erica, Cardenas Carlos, Weinreich Mark, Hutto Jake, AbdelFattah Kareem R, Chen Catherine
Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
Emergency Medicine, University of Nevada, Reno School of Medicine, Reno, NV, USA.
Toxicon. 2018 Sep 1;151:29-33. doi: 10.1016/j.toxicon.2018.06.079. Epub 2018 Jun 21.
A 51-year-old man presented with rapid onset encephalopathy and respiratory failure after a suspected intravascular envenomation from a North American pit viper. The patient received antivenom and was transferred to a tertiary care facility where he had cardiovascular collapse and persistent coagulopathy requiring 28 vials of Crotalidae polyvalent immune Fab antivenom for initial control and six vials for maintenance. The patient's coagulopathy was monitored using "traditional" measures (platelets, fibrinogen, and prothrombin time/international normalized ratio) and rotational thromboelastometry (ROTEM). The patient also subsequently developed intestinal necrosis requiring exploratory laparotomy with ileum and colonic resections, and anuric renal failure requiring continuous renal replacement therapy. After coordinated multidisciplinary management, he was discharged to an acute inpatient rehabilitation on hospital day 25 and has since made a full recovery.
In the setting of a severe intravascular pit viper envenomation, thromboelastometry correlated well with "traditional" measures. During recovery, ROTEM demonstrated measurable improvements in the extrinsic coagulation pathway while the INR remained between 1.5 and 1.6. Patient's intestinal necrosis may have resulted from microvascular thrombosis due to Crotalinae venom. The patient's ultimate recovery necessitated a coordinated multidisciplinary effort. ROTEM abnormalities after North American pit viper envenomation may be more sensitive than "traditional" measures and may have prognostic value to determine the severity of envenomation, but further research to define its utility is required.
一名51岁男性在疑似被北美蝰蛇血管内注入毒液后，迅速出现脑病和呼吸衰竭。患者接受了抗蛇毒血清治疗，并被转至三级医疗机构，在那里他发生了心血管衰竭和持续性凝血病，最初控制需要28瓶多价抗蝰蛇毒免疫Fab片段抗血清，维持治疗需要6瓶。使用“传统”指标（血小板、纤维蛋白原和凝血酶原时间/国际标准化比值）和旋转血栓弹力图（ROTEM）对患者的凝血病进行监测。患者随后还出现了肠坏死，需要进行剖腹探查并切除回肠和结肠，以及无尿性肾衰竭，需要持续肾脏替代治疗。经过多学科协调管理，患者于住院第25天出院，接受急性住院康复治疗，此后已完全康复。
在严重的血管内蝰蛇毒中毒情况下，血栓弹力图与“传统”指标相关性良好。在恢复过程中，ROTEM显示外源性凝血途径有可测量的改善，而国际标准化比值保持在1.5至1.6之间。患者的肠坏死可能是由于蝰蛇毒液导致的微血管血栓形成。患者最终康复需要多学科协调努力。北美蝰蛇毒中毒后的ROTEM异常可能比“传统”指标更敏感，可能对确定中毒严重程度具有预后价值，但需要进一步研究以明确其效用。
