Follow-up visits with laboratory testing are therefore recommended

2 – 3 days and 5 – 7 days after discharge, with additional visits as needed based on signs, symptoms, and laboratory trends. High risk situations requiring expert consultation (box 12) Of the crotaline victims treated with antivenom, approximately 13% develop severe Selleck AZD6244 envenomation [37]. Clinicians who practice outside of referral centers that see a large volume of snakebite patients rarely have the opportunity to develop a large base of experience treating critically envenomated patients. For this reason, the panel identified certain high-risk clinical situations in which consultation Inhibitors,research,lifescience,medical with a physician who has specific training and expertise in the management of crotaline snakebite is strongly encouraged. In institutions where bedside consultation Inhibitors,research,lifescience,medical is available, bedside consultation should be sought. In the remainder of institutions, telephone

consultation, facilitated by a regional poison center, is recommended. Even if local practice calls for transfer of patients from the presenting facility to a tertiary care center, early consultation with a physician-expert (or, alternatively, a pharmacologist or clinical toxicologist with specific training and expertise in snakebite management) Inhibitors,research,lifescience,medical is recommended to ensure that early interventions are ideal and all appropriate preparations are made at the receiving facility. Patients with life-threatening envenomation Inhibitors,research,lifescience,medical Frank hypotension, active hemorrhage,

and airway edema are uncommon but life-threatening manifestations of crotaline snakebite [37]. Evidence supports a benefit from antivenom therapy in the former two situations, while the use of antivenom Inhibitors,research,lifescience,medical combined with active airway management is recommended for the latter situation based on case reports [26,36,37,56]. For the reasons previously described, the panel recommended a larger initial dose of antivenom for patients with shock or active hemorrhage due to snakebite. Only 1% of snake envenomations involve the head or neck, but the experience of panel members suggests a high risk of subsequent loss of airway. This situation is considered analogous first to thermal airway burns, in which early endotracheal intubation may prevent the need for surgical airway placement and its attendant complications. Difficult to control envenomations Even in a severely envenomated cohort, initial control of the envenomation syndrome can be achieved with one or two doses of antivenom in most patients [37]. Case reports of refractory neurotoxicity and hematologic toxicity exist, but the available evidence do not define a point at which further administration of antivenom is likely to be futile [26,33,37,50]. In addition to assisting with cost-benefit estimation, a physician-expert may be able to identify secondary complications (e.g.