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Thromb Haemost 2017; 117(03): 500-507
DOI: 10.1160/TH16-10-0769
Coagulation and Fibrinolysis
Schattauer GmbH

Performance of the 20-minute whole blood clotting test in detecting venom induced consumption coagulopathy from Russell’s viper (Daboia russelii) bites

Indira Ratnayake
1   South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
,
Fathima Shihana
1   South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
,
Dhammika M. Dissanayake
1   South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
2   Department of Pathology, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
,
Nicholas A. Buckley
1   South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
3   Clinical Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
,
Kalana Maduwage
4   Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
5   Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
,
Geoffrey K. Isbister
1   South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
4   Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
› Author Affiliations
Further Information

Publication History

Received: 11 October 2016

Accepted after major revision: 23 February 2016

Publication Date:
22 November 2017 (online)

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Summary

The 20-minute whole blood clotting test (WBCT20) is used as a bed-side diagnostic test for coagulopathic snake envenoming. We aimed to assess the performance of the WBCT20 in diagnosis of venom induced consumption coagulopathy (VICC) in Russell’s viper envenoming. Adult patients admitted with suspected snake bites were recruited from two hospitals. WBCT20 and prothrombin time (PT) test were performed on admission. WBCT20 was done by trained clinical research assistants using 1 ml whole blood in a 5 ml borosilicate glass tube with a 10 mm internal diameter. The PT was measured by a semi-automated coagulation system and international normalised ratio (INR) calculated. VICC was defined as present if the INR was >1.4. The diagnostic utility of WBCT20 was determined by calculating the sensitivity and specificity of the WBCT20 on admission for detecting VICC. There were 987 snake bites where both WBCT20 and PT were done on admission samples. This included 79 patients (8 %) with VICC. The WBCT20 was positive in 65/79 patients with VICC (sensitivity 82 %; 95 % confidence interval [CI]: 72–90 %) and was falsely positive in 13/908 with no coagulopathy. The WBCT20 was negative in 895/908 snake bites with no coagulopathy (specificity: 98 % 95 % CI: 97–99 %) and was falsely negative in 14/79 with VICC. Using trained clinical staff, the WBCT20 test had a relatively good sensitivity for the detection of VICC, but still missed almost one fifth of cases where antivenom was potentially indicated.

Supplementary Material to this article is available online at www.thrombosis-online.com.

Keywords

Snake venoms - acquired coagulation disorders - diagnosis management

 

  • References

  • 1 Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, Premaratna R, Savioli L, Lalloo DG, de Silva HJ. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoSMed 2008; 05: e218.
    PubMedGoogle Scholar
  • 2 Ediriweera DS, Kasturiratne A, Pathmeswaran A. et al. Mapping the Risk of Snakebite in Sri Lanka - A National Survey with Geospatial Analysis. PLoS Negl Trop Dis 2016; 10: e0004813.
    CrossrefPubMedGoogle Scholar
  • 3 Isbister GK. Procoagulant snake toxins: laboratory studies, diagnosis, and understanding snakebite coagulopathy. Seminars in Thrombosis and Hemostasis 2009; 35: 93-103.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Isbister GK. Snakebite doesn’t cause disseminated intravascular coagulation: coagulopathy and thrombotic microangiopathy in snake envenoming. Semin Thromb Hemost 2010; 36: 444-451.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Suwansrinon K, Khow O, Mitmoonpitak C, Daviratanasilpa S, Chaiyabutr N, Sitprija V. Effects of Russell’s viper venom fractions on systemic and renal hemodynamics. Toxicon 2007; 49: 82-88.
    CrossrefPubMedGoogle Scholar
  • 6 Suntravat M, Yusuksawad M, Sereemaspun A. et al. Effect of purified Russell’s viper venom-factor X activator (RVV-X) on renal hemodynamics, renal functions, and coagulopathy in rats. Toxicon 2011; 58: 230-238.
    CrossrefPubMedGoogle Scholar
  • 7 Isbister GK, Maduwage K, Scorgie FE. et al. Venom Concentrations and Clotting Factor Levels in a Prospective Cohort of Russell’s Viper Bites with Coagulopathy. PLoS Negl Trop Dis 2015; 09: e0003968.
    CrossrefPubMedGoogle Scholar
  • 8 Maduwage K, O’Leary MA, Scorgie FE. et al. Detection of Venom after Antivenom Is Not Associated with Persistent Coagulopathy in a Prospective Cohort of Russell’s Viper (Daboia russelii) Envenomings. PLoS Negl Trop Dis 2014; 08: e3304.
    CrossrefPubMedGoogle Scholar
  • 9 Isbister GK, Shahmy S, Mohamed F. et al. A randomised controlled trial of two infusion rates to decrease reactions to antivenom. PLoS One 2012; 07: e38739.
    CrossrefPubMedGoogle Scholar
  • 10 de Silva HA, Pathmeswaran A, Ranasinha CD. et al. Low-dose adrenaline, promethazine, and hydrocortisone in the prevention of acute adverse reactions to antivenom following snakebite: a randomised, double-blind, placebo-controlled trial. PLoS Med 2011; 08: e1000435.
    CrossrefPubMedGoogle Scholar
  • 11 Isbister GK, Maduwage K, Shahmy S. et al. Diagnostic 20-min whole blood clotting test in Russell’s viper envenoming delays antivenom administration. QJM 2013; 106: 925-932.
    CrossrefPubMedGoogle Scholar
  • 12 Sano-Martins IS, Fan HW, Castro SC. et al. Reliability of the simple 20 minute whole blood clotting test (WBCT20) as an indicator of low plasma fibrinogen concentration in patients envenomed by Bothrops snakes. Butantan Institute Antivenom Study Group Toxicon 1994; 32: 1045-1050.
    CrossrefPubMedGoogle Scholar
  • 13 Warrell DA. Snake bite. Lancet 2010; 375: 77-88.
    CrossrefPubMedGoogle Scholar
  • 14 Kulawickrama S, O’Leary MA, Hodgson WC. et al. Development of a sensitive enzyme immunoassay for measuring taipan venom in serum. Toxicon 2010; 55: 1510-1518.
    CrossrefPubMedGoogle Scholar
  • 15 Maduwage KP, O’Leary MA, Silva A, Isbister GK. Detection of Snake Venom in Post-Antivenom Samples by Dissociation Treatment Followed by Enzyme Immunoassay. Toxins. 2016 Epub ahead of print.
    PubMedGoogle Scholar
  • 16 Ariaratnam CA, Sheriff MH, Arambepola C. et al. Syndromic approach to treatment of snake bite in Sri Lanka based on results of a prospective national hospital-based survey of patients envenomed by identified snakes. Am J Trop Med Hyg 2009; 81: 725-731.
    CrossrefPubMedGoogle Scholar
  • 17 Myint L, Warrell DA, Phillips RE. et al. Bites by Russell’s viper (Vipera russelli siamensis) in Burma: haemostatic, vascular, and renal disturbances and response to treatment. Lancet 1985; 02: 1259-1264.
    PubMedGoogle Scholar
  • 18 Warrell DA, Davidson NM, Greenwood BM. et al. Poisoning by bites of the saw-scaled or carpet viper (Echis carinatus) in Nigeria. Quart J Med 1977; 46: 33-62.
    PubMedGoogle Scholar
  • 19 Kularatne SA. Epidemiology and clinical picture of the Russell’s viper (Daboia russelii russelii) bite in Anuradhapura, Sri Lanka: a prospective study of 336 patients. Southeast Asian J Trop Med Public Health 2003; 34: 855-862.
    PubMedGoogle Scholar
  • 20 Kularatne SA, Sivansuthan S, Medagedara SC. et al. Revisiting saw-scaled viper (Echis carinatus) bites in the Jaffna Peninsula of Sri Lanka: distribution, epidemiology and clinical manifestations. Trans R Soc Trop Med Hyg 2011; 105: 591-597.
    CrossrefPubMedGoogle Scholar
  • 21 Otero-Patino R. Epidemiological, clinical and therapeutic aspects of Bothrops asper bites. Toxicon 2009; 54: 998-1011.
    CrossrefPubMedGoogle Scholar
  • 22 Otero-Patino R, Cardoso JL, Higashi HG. et al. A randomized, blinded, comparative trial of one pepsin-digested and two whole IgG antivenoms for Bothrops snake bites in Uraba, Colombia. The Regional Group on Antivenom Therapy Research (REGATHER). Am J Trop Med Hyg 1998; 58: 183-189.
    CrossrefPubMedGoogle Scholar
  • 23 Smalligan R, Cole J, Brito N. et al. Crotaline snake bite in the Ecuadorian Amazon: randomised double blind comparative trial of three South American polyspecific antivenoms. Br Med J 2004; 329: 1129.
    CrossrefPubMedGoogle Scholar
  • 24 Chippaux JP, Massougbodji A, Stock RP. et al. Clinical trial of an F(ab’)2 polyvalent equine antivenom for African snake bites in Benin. Am J Trop Med Hyg 2007; 77: 538-546.
    PubMedGoogle Scholar
  • 25 Warrell DA, Looareesuwan S, Theakston RD. et al. Randomized comparative trial of three monospecific antivenoms for bites by the Malayan pit viper (Calloselasma rhodostoma) in southern Thailand: clinical and laboratory correlations. Am J Trop Med Hygiene 1986; 35: 1235-1247.
    PubMedGoogle Scholar
  • 26 Visser LE, Kyei-Faried S, Belcher DW. et al. Failure of a new antivenom to treat Echis ocellatus snake bite in rural Ghana: the importance of quality surveillance. Trans R Soc Trop Med Hyg 2008; 102: 445-450.
    CrossrefPubMedGoogle Scholar
  • 27 Kularatne SA, Silva A, Weerakoon K. et al. Revisiting Russell’s viper (Daboia russelii) bite in Sri Lanka: is abdominal pain an early feature of systemic envenoming?. PLoS One 2014; 09: e90198.
    CrossrefPubMedGoogle Scholar
  • 28 Maduwage K, O’Leary MA, Isbister GK. Diagnosis of snake envenomation using a simple phospholipase A2 assay. Sci Rep 2014; 04: 4827.
    PubMedGoogle Scholar