3. In the new treatment protocols, providers are instructed to contact DoD ADVISOR to discuss need for additional antivenom after the equivalent of TWO high doses or FOUR low doses have been given to patient (a high dose for most recommended products is defined as ~10 vials and a low dose is ~5 vials, meaning that providers are strongly advised to seek toxicology consult if considering more than 20 vials).

This recommendation exists for several reasons:

a. Most products recommended in the CPGs are high potency and rarely require more than 20 vials equivalent.

b. In some cases, providers may not realize that control has been achieved (e.g. inappropriately re-dosing for persistent laboratory coagulopathy without clinical bleeding). In others, there may be a need to switch to an alternative 2nd line antivenom or the patient is an exceptional case with very large amounts of venom injected requiring higher than usual antivenom dosing (e.g. multiple bites, very large snake that bit and held on, etc.).

4. Persistent coagulopathy without bleeding: If coagulopathy persists (without bleeding) 24 hours after antivenom was given, contact DoD ADVISOR toxicologist to discuss need for additional antivenom.

5. Continuous monitoring for recurrence of symptoms must be performed. Occasionally, pockets of venom can be trapped in swollen tissue compartments and escape into the bloodstream once circulation has improved. This is called recurrence and is most common within the first 6 - 24 hours after a severe bite with extensive swelling and blistering.78,87–93 Recurrence is addressed in the symptomatic NEURO & HEMO/CYTO and Control algorithms.

a. Continuous clinical monitoring includes hourly checks of vital signs, urine output, and detailed assessment for new or worsening signs of neurotoxic, hemotoxic, or cytotoxic envenomation.

b. Serial laboratory studies including CBC, CMP, PT/PTT/INR, CK, fibrinogen levels (or WBCT if no advanced testing available) may be repeated every 2 hours while signs of envenomation persist.

c. If indications of recurrence are detected, treat according to the recurrence pathways in the symptomatic NEURO and HEMO/CYTO algorithms.

d. When control has been achieved again, return to the Control Algorithm and restart the 48-hour timer to disposition decision. Control must be maintained for a full 48h without recurrence to discharge a previously symptomatic snakebite. Contact DoD ADVISOR toxicologist for advice in these cases.