Envenomation and marine bites — branching viva

Opening (candidate)

This is a brown snake envenomation with venom-induced consumption coagulopathy, and my priorities are to keep the pressure-immobilisation bandage in place, confirm the coagulopathy and its pattern, and give brown snake antivenom intravenously at an initial one-vial dose while arranging paediatric retrieval. The unrecordable INR with a very high D-dimer and a low fibrinogen is a true defibrination from a prothrombin-activating venom. I send the full panel and repeat it, I prepare for an antivenom hypersensitivity reaction, and I explain to the family that the INR will take one to three days to recover because the antivenom stops the cause but the liver must resynthesise the factors. ^{[1] [4]}