Delayed double reading of whole blood clotting test (WBCT) results at 20 and 30 minutes enhances diagnosis and treatment of viper envenomation

Table 5 Resumption and resolution of coagulopathy by WBCT20 and WBCT30 in seven patients with Echis envenomations

Case No.	^aDiscrepancies in secondary events	Secondary resumption –WBCT20 at H_a	Secondary resumption –WBCT30 at H_a	Recurrence of symptoms	Additional AA given	Final control WBCT20 at H_a	Final control WBCT30 at H_a	Resolution of symptoms
1	Initial detection (Group 3a)	Remained normal	H₆	No, patient improving	No	H_3, no resumption	H₂₄	H₆
2	No	H₇₂	H₇₂	Diffuse pain and headache	2 vials at H₇₂	H₁₂₀	H₁₂₀	≤ H₉₆
^a3	Final resolution (Group 3b)	H₇₂	H₇₂	Edema and blistering	No, due to H₀ anaphylaxis	H₁₄₄	H₁₉₂	H₁₉₂
^b10	Initial detection (Group 3a)	H₄₈	H₂₇	Internal bleeding	2 vials at H₄₈	H₁₂₀	H₁₂₀	≤ H₇₂
12	Initial detection (Group 3a)	Remained normal	H₂₄	No, patient improving	No	H₆, no resumption	H₄₈	H₆
^c19	No	H₂₄	H₂₄	Gingival bleeding	2 vials at H₂₄	H₇₂	H₇₂	H₂₇
^d22	Transient resolution (Group 3b)	H₉₆ and H₁₆₈	H₉₆	Internal bleeding	2 vials at H₁₂₀ 2 vials at H₁₆₈	H₂₄₀	H₂₄₀	H₁₉₂

^a3 = We elected to manage the secondary recurrence of envenomation symptomatically for as long as possible because the patient had already experienced two separate anaphylactoid reactions and there were very limited resources on hand for resuscitating a pediatric cardiac arrest
^b10 = The patient presented with a subarachnoid hemorrhage at H₀ which initially resolved by H₁₉, but signs and symptoms returned at H₂₇ in conjunction with a recurrence of coagulopathy by WBCT30. At H₄₈, his WBCT20 also turned positive. He was treated with additional two vials of antivenom at this time and made a full recovery without sequelae
^c19 = Gingival bleeding resumed at H₂₄ after initially resolving at H₆
^d22 = Two separate resumptions occurred with this patient. Resumption of WBCT20 and WBCT30 was recorded at H₉₆, but most likely began around H₇₂ when signs of intraperitoneal hemorrhage began to occur. The test was normal at H₄₈, but could not be collected at H₇₂

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