3. Check for hemotoxic signs (bleeding). Look for bleeding at the bite that lasts over 30 minutes or bleeding from gums or other areas (mouth, gums or other mucosa).1,69–72

4. Check for neurotoxic signs (nerve issues).

5. Rapid examination for signs of neuromuscular weakness (neurotoxic syndrome)

- Evaluate respiratory muscle weakness by single breath count (SBC) testing 72 and repeat periodically to trend improvement or deterioration in respiratory function over time.
  - Ask the patient to take a deep breath and count out loud as high as they can without breathing again and repeat periodically to trend improvement or deterioration in respiratory function over time.
  - Normal SBC is approximately 50 and SBC < 20 is associated with the need for mechanical ventilation.
    - If spirometry is available, this can be used in place of the single breath count test by evaluating the negative inspiratory force (NIF) and/or forced vital capacity (FVC).
- Conduct gross assessment and pay particular attention to the following:
  - Signs and symptoms of descending flaccid paralysis: Ptosis (upper eyelid drooping), diplopia (double vision), neck flexor muscle weakness, bulbar weakness, difficulty speaking, difficulty swallowing, etc.1,54,73
    - Signs and symptoms of parasympathetic / cholinergic crisis: SLUDGE mnemonic - Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis.

6. Perform and/or check the clinical laboratory tests listed below (if available).

- Complete Blood Count (CBC), Hemoglobin, or Hematocrit.
- Clotting tests (PT, PTT, INR, Fibrinogen).
  - Simple coagulation test for austere environments: Use the Whole Blood Clotting Test (WBCT) as described in Appendix J to diagnose and monitor coagulopathy if advanced labs not available.
- Comprehensive Metabolic Panel (CMP) and Creatine Kinase (CK).