a) CASE REPORT: A 68-year-old man presented with hypotonia, atrial fibrillation with rapid ventricular response (130 beats/min), coagulopathy, rhabdomyolysis, acute renal failure, respiratory insufficiency, and hypotension after a tiger snake bite. Hypotension required an epinephrine infusion for 3 days to maintain a mean arterial pressure above 70 mmHg. He required continuous veno-venous hemodiafiltration for 16 days and mechanical ventilation for 18 days but eventually recovered (Jelinek et al, 1998).

a) Respiratory failure from either neurotoxicity or severe myopathy, but is not common.
b) INCIDENCE: In a series of 23 patients with tiger snake envenomation, 3 (13%) patients developed neurotoxicity, and one of those had a respiratory arrest (Scop et al, 2009).
c) CASE REPORT: A 44-year-old man was bitten on the left ankle. He developed weakness, dysarthria, respiratory insufficiency, severe rhabdomyolysis, compartment syndrome of the upper extremities, coagulopathy and renal failure. Urine testing was positive for tiger snake venom. He was treated with antivenom, transfusion, hemodialysis and mechanical ventilation. He required about 2 weeks of mechanical ventilation but recovered (Jolles et al, 1998).
d) CASE REPORT: A 44-year-old man was bitten by an unseen animal. He developed severe envenomation, with blurred vision, ptosis, weakness, respiratory failure, renal failure, severe rhabdomyolysis and compartment syndrome, and mild coagulopathy. Urine test was positive for tiger snake venom. He was bitten in a remote area in bad weather, so evacuation was complicated and he did not reach the hospital until nearly 24 hours after the bite. He required mechanical ventilation for 13 days and hemodialysis for 32 days but eventually recovered (Nocera et al, 1998).
e) CASE REPORT: A 68-year-old man presented with hypotonia, ptosis, ophthalmoplegia, and fixed pupils, coagulopathy, rhabdomyolysis, acute renal failure, respiratory insufficiency, and hypotension after a tiger snake bite. He required continuous veno-venous hemodiafiltration for 16 days and mechanical ventilation for 18 days for respiratory muscle weakness (Jelinek et al, 1998).

a) Headaches is common after tiger snake envenomation, and are often one of the earliest clinical manifestations.
b) INCIDENCE: In a series of 23 patients with tiger snake envenomation 17 (74%) patients complained of headache (Scop et al, 2009)

a) Paralysis can develop after envenomation by tiger snakes, rough scaled snakes, and probably copper heads. It is not expected after envenomation by Stephen's banded snakes (White, 2005). Manifestations can include generalized weakness, respiratory insufficiency, and cranial nerve palsies with ptosis, ophthalmoplegia, dysphagia or dysarthria. Recovery of neuromuscular function can be slow, requiring 2 to 3 weeks in some cases.
b) INCIDENCE: In a series of 23 patients with tiger snake envenomation, 2 (9%) patients developed ptosis and 1 (4%) had a respiratory arrest (Scop et al, 2009) .
c) CASE REPORT: A 44-year-old man was bitten on the left ankle. He developed weakness, dysarthria, respiratory insufficiency, severe rhabdomyolysis, compartment syndrome of the upper extremities, coagulopathy and renal failure. Urine testing was positive for tiger snake venom. He was treated with antivenom, transfusion, hemodialysis and mechanical ventilation. He required about 2 weeks of mechanical ventilation but recovered (Jolles et al, 1998).
d) CASE REPORT: A 44-year-old man was bitten by an unseen animal. He developed severe envenomation, with blurred vision, ptosis, weakness, respiratory failure, renal failure, severe rhabdomyolysis and compartment syndrome, and mild coagulopathy. Urine test was positive for tiger snake venom. He was bitten in a remote area in bad weather, so evacuation was complicated and he did not reach the hospital until nearly 24 hours after the bite. He required mechanical ventilation for 13 days and hemodialysis for 32 days but eventually recovered (Nocera et al, 1998).
e) CASE REPORT: A 67-year-old man was unconscious in a barn, and presented to the ED with severe epistaxis, mid-face trauma, hypoxia, coagulopathy, and rhabdomyolysis. He was intubated and treated with fresh frozen plasma. Puncture wounds were later noted on the right thigh and tiger snake venom was detected at the bite site. He was treated with 7 vials of tiger snake antivenom and 3 days later was extubated. At that time he complained of diplopia and blurred vision and was noted to have limitations of horizontal and vertical gaze. He gradually improved over a week (Ferdinands et al, 2006).
f) CASE REPORT: A 38-year-old woman was bitten on the right ankle. She developed nausea, abdominal pain, lightheadedness and numbness of the hands and feet. Bite site swab was positive for tiger snake venom. Her initial coagulation screen was normal. About 26 hours after the bite she had difficulty opening her jaw, and at 32 hours she had dysphagia and rhabdomyolysis (which peaked at a CK of 153,400 at 68 hour after the bite). She was unable to move her tongue, swallow, open her eyes or cough and had myalgias. She was treated with antivenom 36 hours after the bite and required at total of 5 vials of antivenom. She had ptosis and swallowing difficulties requiring NG feeding for 5 days but gradually recovered; she was discharged on day 27 (Gavaghan & Sparkes, 2003).
g) CASE REPORT: A 68-year-old man presented with hypotonia, ptosis, ophthalmoplegia, and fixed pupils, coagulopathy, rhabdomyolysis, acute renal failure, respiratory insufficiency, and hypotension after a tiger snake bite. He required continuous veno-venous hemodiafiltration for 16 days and mechanical ventilation for 18 days. Recovery of neuromuscular function was slow. Strength was 4/5 by the end of the 4th hospital day, distal motor strength recovered faster than proximal. Tendon reflexes were still depressed after 19 days. Ptosis, ophthalmoplegia and fixed pupils persisted through day 12 and were partly recovered by day 19 (Jelinek et al, 1998).

a) Abdominal pain develops in many patients with tiger snake envenomation and may be severe (Casamento & Isbister, 2011; Gavaghan & Sparkes, 2003).
b) INCIDENCE: In a series of 23 patients with tiger snake evenomation, 11 (48%) patients developed abdominal pain (Scop et al, 2009).

a) Nausea and vomiting are common after tiger snake envenomation, and are often some of the earliest signs of envenomation (Parkin et al, 2002).
b) INCIDENCE: In a series of 23 patients with tiger snake evenomation, 17 (74%) patients developed nausea and/or vomiting (Scop et al, 2009).

a) Myoglobinuria is often noted in patients who develop severe myopathy and rhabdomyolysis (Sutherland & Coulter, 1977; Hood & Johnson, 1975). Urine will be dark, and is positive for blood on dipstick without evidence of hematuria on microscopic examination.

a) Acute renal failure can develop in patients with severe myopathy and rhabdomyolysis. Patients often require hemodialysis but generally renal function recovers over several weeks.
b) CASE REPORT: A 44-year-old man was bitten by an unseen animal. He developed severe envenomation, with neurologic toxicity, respiratory failure, acute renal failure, severe rhabdomyolysis and compartment syndrome, and mild coagulopathy. Urine test was positive for tiger snake venom. He was bitten in a remote area in bad weather, so evacuation was complicated and he did not reach the hospital until nearly 24 hours after the bite. He required mechanical ventilation for 13 days and hemodialysis for 32 days but eventually recovered (Nocera et al, 1998).
c) CASE REPORT: A 68-year-old man presented with hypotonia, atrial fibrillation with rapid ventricular response (130 beats/min), coagulopathy, rhabdomyolysis, acute renal failure, respiratory insufficiency, and hypotension after a tiger snake bite. He required continuous veno-venous hemodiafiltration for 16 days and mechanical ventilation for 18 days but eventually recovered (Jelinek et al, 1998).
d) INCIDENCE: In a series of 23 patients with tiger snake envenomation, 1 (4%) patient developed acute renal failure (Scop et al, 2009).

a) Metabolic acidosis can develop with severe envenomation but is not common.
b) CASE REPORT: A 44-year-old man was bitten by an unseen animal. He developed severe envenomation, with neurologic toxicity, respiratory failure, renal failure, severe rhabdomyolysis and compartment syndrome, and mild coagulopathy. Urine test was positive for tiger snake venom. He was bitten in a remote area in bad weather, so evacuation was complicated and he did not reach the hospital until nearly 24 hours after the bite. Laboratory findings on admission included metabolic acidosis with a pH of 7.16, pCO2 44 mmHg, bicarbonate 15 mmol/L, and base excess of negative 13. He required mechanical ventilation for 13 days and hemodialysis for 32 days but eventually recovered (Nocera et al, 1998).
c) CASE REPORT: A 68-year-old man presented with hypotonia, atrial fibrillation with rapid ventricular response (130 beats/min), coagulopathy, rhabdomyolysis, acute renal failure, respiratory insufficiency and hypotension. Laboratory studies revealed metabolic acidosis with a pH of 7.13, a base excess of negative 10 and a lactate concentration of 6.1 mmol/L; tiger snake venom was detected in urine. He required continuous veno-venous hemodiafiltration for 16 days and mechanical ventilation for 18 days but eventually recovered (Jelinek et al, 1998).

a) Respiratory acidosis can develop in patients with respiratory failure from either neurotoxicity or severe myopathy.

a) Coagulopathy often develops in severe envenomation. Characteristic findings include markedly prolonged INR and aPTT, markedly decreased fibrinogen concentrations, elevated D-dimer, normal platelet counts, and decreased concentrations of factors V, VIII, and protein C (Parkin et al, 2002).
b) ONSET: In a study of 90 patients with venom induced consumptive coagulopathy (45 definite brown snake and 45 definite tiger snake), patients bitten by tiger snake had almost complete depletion of fibrinogen, and factors V and VIII within 2 hours, compared to within 1 hour for the brown snake group (Isbister et al, 2010).
c) DURATION: Once venom-induced consumptive coagulopathy develops, it generally does not resolve for 12 to 18 hours after antivenom administration, because of the time required for resynthesis of clotting factors and fibrinogen (Isbister, 2010).

a) Spontaneous bleeding is not common, but bleeding at venipuncture sites or other areas of trauma is common in patients who develop coagulopathy (White, 2005).
b) INCIDENCE: In a series of 23 patients with tiger snake envenomation, 6 (26%) patients developed bleeding, 4 from the bite site, 1 epistaxis and 1 hematemesis (Scop et al, 2009).

a) Microangiopathic hemolytic anemia has been reported after tiger snake envenomation but is not common. It is characterized by acute renal failure, anemia, thrombocytopenia, and evidence of fragmented red cells on peripheral smear. Onset is generally 2 or 3 days after the bite, after recovery from the initial consumption coagulopathy.
b) CASE REPORT: A 55-year-old woman was bitten on the left small toe. She develop headache, nausea, vomiting, decreased fibrinogen, elevated aPTT and INR and the bite site swab was positive for tiger snake venom. She was treated with tiger snake antivenom and coagulopathy resolved at 19 hours after envenomation. Over the next 2 days she developed anemia, thrombocytopenia, renal failure with fragmented red cells on blood smear. She was treated with plasma exchange and hemodialysis and recovered over 19 days (Casamento & Isbister, 2011).
c) CASE REPORT: A 46-year-old man was bitten on the right thumb by his pet tiger snake. He developed headache, nausea and vomiting, and coagulopathy. He was treated with tiger snake antivenom and coagulopathy improved 17 hours post bite. Over the next 2 days he developed renal failure, and thrombocytopenia and had fragmented red cells on blood smear. He received continuous renal replacement therapy from day 4 to day 10 after the bite and then intermittent hemodialysis for 7 weeks (Casamento & Isbister, 2011).

a) Pain at the bite site develops in many patients with tiger snake envenomation and may be severe.
b) INCIDENCE: In a series of 23 patients with tiger snake evenomation, 10 (43%) patients developed pain at the bite site (Scop et al, 2009).

a) Bites from tiger snakes and the rough scaled snake generally result in mild swelling, erythema and bruising after 3 hours (White, 2005).

a) Local tissue necrosis is not common but has occurred.
b) CASE REPORT: A 20-month-old boy was bitten by an unseen reptile on the right leg and wrist. Shortly, thereafter he collapsed and had an apparent seizure. On arrival to the hospital he was drowsy, and blood tested positive for tiger snake venom. He developed coagulopathy and rhabdomyolysis, and was treated with tiger snake antivenom and fresh frozen plasma. The following day an area of necrotic skin was noted around the leg bite. The area was surgically explored, revealing necrotic skin and some underlying devitalized fat, and pale somewhat mottled underlying muscle that was not necrotic with no compartment syndrome. Pathology revealed extensive necrosis of the skin and underlying fat with thrombosis of small to medium sized vessels. The child required skin grafting but recovered (Penington & Johnstone, 1997).

a) INCIDENCE: In a series of 23 patients with tiger snake envenomation, 6 (26%) patients developed rhabdomyolysis (Scop et al, 2009).
b) CASE REPORT: A 47-year-old man was bitten on the hand by a tiger snake. He was treated with 3,000 units of tiger snake antivenom. Over the next 2 days he developed severe myopathy with rhabdomyolysis and focal necrotizing myopathy on biopsy, anuric renal failure and hyperkalemia. He was intubated and mechanically ventilated for about 10 days, and required hemodialysis for about a month. He had severe weakness and muscle wasting but eventually recovered (Hood & Johnson, 1975).

a) Compartment syndrome is rare but has been reported. It has occurred as a complication of severe diffuse myopathy in muscles remote from the location of the bite.
b) CASE REPORT: A 44-year-old man was bitten on the ankle by an unseen animal. He developed severe envenomation, with neurologic toxicity, respiratory failure, renal failure, mild coagulopathy, severe rhabdomyolysis, and compartment syndrome requiring fasciotomy of both forearms and hands. Urine test was positive for tiger snake venom. He was bitten in a remote area in bad weather, so evacuation was complicated and he did not reach the hospital until nearly 24 hours after the bite. He required mechanical ventilation for 13 days and hemodialysis for 32 days but eventually recovered (Nocera et al, 1998).
c) CASE REPORT: A 44-year-old man was bitten on the ankle and developed weakness, dysarthria, respiratory failure, severe rhabdomyolysis (CK 287,000 units/L), renal failure and coagulopathy. On presentation his muscles were tense and edematous, and he required bilateral forearm fasciotomies (right forearm pressure 67 mmHg and left forearm pressure 56 mmHg) (Jolles et al, 1998).

a) Place a few millimeters of venous blood in a GLASS tube
b) Leave undisturbed for 20 minutes at room temperature
c) Tip the vessel once:
d) FALSE NEGATIVE results could occur if clot identification is read beyond 20 minutes (Stone et al, 2006).
e) FALSE POSITIVE results could occur if polypropylene or polyethylene tubes are used instead of glass (Stone et al, 2006).

a) Monitor vital signs, neurologic exam and mental status. Monitor for clinical evidence of bleeding (eg, hematuria, GI bleeding, epistaxis, bruising, bleeding from venipuncture sites or gums, altered mentation suggesting intracranial bleeding).

a) If there is any question as to the type of snake involved, use the venom detection kit on the bite site and/or urine to identify the species involved. The presence of venom at the bite site does NOT mean that systemic envenomation has occurred. Many centers advocate obtaining a swab of the bite site or specimen of urine to be held on presentation, and only using the venom detection kit if there is clinical or laboratory evidence of envenomation develops (Jelinek et al, 2004; Isbister & Currie, 2003; Jelinek et al, 1991).
b) Venom detection in urine usually is associated with systemic envenomation, but a few cases have been reported where venom was detected in urine or blood in the absence of clinical or laboratory evidence of significant envenomation (Jelinek et al, 1991). Blood samples have been found to be unreliable for testing for the presence of venom and should not be used (White, 1995).
c) In an in vitro study, the venom or saliva of other Australian snakes that are considered venomous, mildly venomous, and non-venomous were found to yield positive results for tiger snake venom on the venom detection kit. The venomous Black snakes mulga (Pseudoechis asutralis) and spotted mulga (Pseudoechis butleri), the mildly venomous Gould's hooded snake (Parasuta gouldii) and the non-venomous Black-headed python (Aspidites melanocephalus) all yielded positive results for tiger snake venom (Jelinek et al, 2004).