J Curr Surg

Journal of Current Surgery, ISSN 1927-1298 print, 1927-1301 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Curr Surg and Elmer Press Inc

Journal website https://www.currentsurgery.org

Case Report

Volume 11, Number 1, March 2021, pages 15-20

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

Figure 1. Timeline of the presentation of envenomation until normalized coagulation status. Timeline includes significant events in the patient’s care and transfusion management. ICU: intensive care unit; PEA: pulseless electrical activity; MAP: mean arterial pressure; TXA: tranexamic acid; TEG: thromboelastography.

**Table 1.** Notable Lab Values and Transfusion of Various Products Throughout the First Week of Hospitalization
	Reference range	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6
CBC: complete blood count; WBC: white blood cell; CK: creatine kinase; TEG: thromboelastography; PT: prothrombin time; PTT: partial thromboplastin time; INR: international normalized ratio; MA: maximal amplitude; LY30: clot lysis at 30 min after maximum clot strength.
CBC
Hemoglobin	14 - 18 g/dL	17	21.6	17.6	-	13.8	10.6	10.7	9.9	-	-	9.2
Hematocrit	40-54%	51.7	64.5	51.7	-	39.7	31	30.4	28.1	-	-	26.9
Platelets	150 - 400 × 10³/mm³	-	401	318	-	343	173	175	148	-	-	178
WBC	4.5 - 11 × 10³/mm³	7.7	21.6	45.9	-	39.3	17.5	15.1	8.8	-	-	10.4
Creatinine	0.6 - 1.6 mg/dL	-	1.34	-	-	1.23	0.7	0.64	-	-	-	-
Lactic acid	0.5 - 2.2 mmol/L	-	-	-	-	10.3	1.1	1.2	-	-	-	-
CK	32 - 200 U/L	-	-	102	-	133	205	250	-	-	-	-
Coagulation studies
PT	10.1 - 12.9 s	10.7	-	-	-	12.4	13.2	13.8	15.1	-	-	-
PTT	28 - 35.7 s	26.5	-	-	-	27	28.2	-	23.4	-	-	-
INR	0.9 - 1.1	0.9	-	-	-	1.1	1.2	1.2	1.3	-	-	-
D-dimer	0 - 230 ng/mL	-	-	12,331	-	3,107	1,813	-	4,502	-	-	-
Fibrinogen	200 - 400 mg/dL	-	-	-	-	318	368	-	60	-	40	107
TEG studies
R clot time	5 - 10 min	-	-	7.7	6.6	6.2	-	-	-	6.2	3.8	4.8
K clot time	1 - 3 min	-	-	14.6	4.1	1.6	-	-	-	9.2	5.7	3.9
Angle	53 - 72 degrees	-	-	24.9	44.5	67.6	-	-	-	34.7	41.5	52
MA clot strength	50 - 70 mm	-	-	24.7	43.9	69.3	-	-	-	22.4	39.3	45
LY30	0-3%	-	-	36.3	1.8	0	-	-	-	0.2	0.1	0
Transfusion products		Day 1	Day 2	Day 5
Units of cryoprecipitate		-				1 at 00:00 and 2 at 02:00	1 at 13:00 and 1 at 23:00
Units of fresh frozen plasma		1 at 22:00 and 1 at 23:00	1 at 01:00 and 1 at 03:00	-
Units of platelets		-	1 at 02:00	1 at 13:00 and 1 at 23:00
Units of tranexamic acid		1 at 22:00	-				-

Table 1. Notable Lab Values and Transfusion of Various Products Throughout the First Week of Hospitalization

Reference range

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

14:30

17:30

20:00

22:30

1:30

4:00

1:00

8:30

17:30

0:30

CBC: complete blood count; WBC: white blood cell; CK: creatine kinase; TEG: thromboelastography; PT: prothrombin time; PTT: partial thromboplastin time; INR: international normalized ratio; MA: maximal amplitude; LY30: clot lysis at 30 min after maximum clot strength.

CBC

Hemoglobin

14 - 18 g/dL

21.6

17.6

13.8

10.6

10.7

9.9

9.2

Hematocrit

40-54%

51.7

64.5

51.7

39.7

30.4

28.1

26.9

Platelets

150 - 400 × 10³/mm³

401

318

343

173

175

148

178

WBC

4.5 - 11 × 10³/mm³

7.7

21.6

45.9

39.3

17.5

15.1

8.8

10.4

Creatinine

0.6 - 1.6 mg/dL

1.34

1.23

0.7

0.64

Lactic acid

0.5 - 2.2 mmol/L

10.3

1.1

1.2

32 - 200 U/L

102

133

205

250

Coagulation studies

10.1 - 12.9 s

10.7

12.4

13.2

13.8

15.1

PTT

28 - 35.7 s

26.5

28.2

23.4

INR

0.9 - 1.1

0.9

1.1

1.2

1.3

D-dimer

0 - 230 ng/mL

12,331

3,107

1,813

4,502

Fibrinogen

200 - 400 mg/dL

318

368

107

TEG studies

R clot time

5 - 10 min

7.7

6.6

6.2

3.8

4.8

K clot time

1 - 3 min

14.6

4.1

1.6

9.2

5.7

3.9

Angle

53 - 72 degrees

24.9

44.5

67.6

34.7

41.5

MA clot strength

50 - 70 mm

24.7

43.9

69.3

22.4

39.3

LY30

0-3%

36.3

1.8

0.2

0.1

Transfusion products

Day 1

Day 2

Day 5

Units of cryoprecipitate

1 at 00:00 and 2 at 02:00

1 at 13:00 and 1 at 23:00

Units of fresh frozen plasma

1 at 22:00 and 1 at 23:00

1 at 01:00 and 1 at 03:00

Units of platelets

1 at 02:00

1 at 13:00 and 1 at 23:00

Units of tranexamic acid

1 at 22:00