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).