Although most patients tolerate hematological venom effects without incident, severe or fatal bleeding events have occurred [27-31]. Transfusion also has associated cost and risks. Consultation prior to transfusion is recommended, when possible, to maximize the utility of transfusion and reduce unnecessary use of blood products. Rhabdomyolysis Although crotaline venom is

directly myotoxic, clinically severe rhabdomyolysis is uncommon in the United States [61]. Although routine creatine kinase measurement is not recommended, specific patients, such as Inhibitors,research,lifescience,medical those with severe local tissue injury and/or prolonged systemic neurotoxicity can develop rhabdomyolysis. Consultation with a physician-expert is recommended in these cases. AMPK activation Suspected compartment syndrome Crotaline snakebite Inhibitors,research,lifescience,medical can produce pain, swelling, induration, paresthesias, color changes (e.g. bluish discoloration from bruising), difficult-to-palpate pulses, and tenderness in the envenomated extremity, mimicking the initial signs of compartment Inhibitors,research,lifescience,medical syndrome. However, true compartment syndrome is much less common, and a prospective observational study

in humans showed that most rattlesnake victims have greater blood flow in the envenomated than in the non-envenomated limb [62]. Animal research and human experience demonstrate that antivenom administration reduces compartment pressures, and surgical groups who used to perform fasciotomy frequently now acknowledge that antivenom administration often precludes the need for fasciotomy [9,40,63,64].

Inhibitors,research,lifescience,medical In one large case series of patients treated in a tertiary referral center, only 8/236 (3.4%) of patients received a fasciotomy or digital dermotomy [10]. Measurement of compartment pressure prior to consideration of fasciotomy is recommended. Compartment pressure measurement may not be feasible in cases of digital envenomation. Consultation with a physician-expert Inhibitors,research,lifescience,medical is recommended whenever compartment syndrome is suspected and prior to any fasciotomy or digit Adenosine dermotomy. Venom-induced hives and angioedema Anaphylactic and anaphylactoid reactions to venom are uncommon manifestations of snakebite which can range in severity from urticarial rash to multisystem organ failure and angioedema causing airway loss [65]. At least 2 deaths have been reported [66,67]. Although standard therapy includes antihistamines, steroids, epinephrine, and antivenom, the ideal management of this condition is unknown. Because these patients are often critically ill and require aggressive, multimodal therapy, panel members recommended expert consultation. Complicated wound issues Crotaline envenomation causes local tissue necrosis by a variety of mechanisms, some of which are not reversible with antivenom therapy [68].