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CROFAB (crotalidae polyvalent immune fab)

ADULT and PEDIATRIC

ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Indication: CroFab (crotalidae polyvalent immune fab) is indicated for envenomation resulting from Crotalids such as rattlesnakes, moccasins, cottonmouths, and copperheads.



  1. Contact local poison control center: 404-616-9000 or 1-800-222-1222

  2. Labs: CBC, PT/INR, PTT,CMP, Fibrinogen if not already done

  3. Place reference marks for measuring circumference of affected extremity to envenomation site. Measure q 15 min and trace leading edge of swelling with skin markers.

  4. Remove rings and constrictive items

  5. Vital signs: q hr until control of envenomation achieved

  6. Immobilize the affected extremity at or below the level of the heart

MEDICATIONS (Avoid aspirin and other anticoagulants for Crotalidae bites):

  1. Obtain IV access in unaffected limb (2 sites are possible)

  2. IV Fluids: _______________________________________________ at _____________ ml/hr

  3. CroFab (crotalidae polyvalent immune fab) Initial Dose (same dose for adults and pediatrics):

 4 vials  5 vials  6 vials

Mixed in 250 ml NS. Infuse slowly at 25 ml/hr for 10 min and monitor for signs of acute reaction.

If no signs of an allergic reaction increase rate to 250 ml/hr to infuse remainder over 60 min.

If all signs/symptoms of envenomation have not ceased after 1 hr of completion, notify physician. Physician may repeat additional bolus dose (4-6 vials) until initial control achieved (call pharmacy if additional bolus vials are needed).



  1. Maintenance Dose: After initial control, give CroFab 2 vials in 250 ml NS IV q 6 hrs x 3 doses

  2. > 7 years of age: Tetanus Diphtheria IM x 1 dose OR 6 weeks-6 year: Adacel (T-dap) IM x 1 dose

PRN MEDICATIONS (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06)

  1. Severe pain: (Adults):  Morphine 1-4 mg IV q 3 hrs prn

(Pediatrics):  Morphine ___ mg (0.1-0.2 mg/kg/dose) q 2 prn

  1. Moderate Pain (Adults):

 Lortab (HYDROcodone/acetaminophen) 5/500 mg 1-2 tabs or 10/500 mg 1 tab po q 4 hrs prn

 Percocet (oxyCODONE/acetaminophen) 5/325 mg 1-2 tabs or 10/325 mg 1 tab po q 4 hrs prn

Moderate pain (Pediatrics):

 Lortab (HYDROcodone/acetaminophen)

 < 2 y/o: ____ mg (0.1 – 0.2 mg/kg/dose, max 1.25 mg) po q 3 hrs prn

 2-12 y/o: 5 mg po prn q 3 hrs prn

 > 12 y/o: 10 mg po prn q 3 hrs prn

 Tylenol (acetaminophen 120 mg/5 ml) with codeine elixir (12 mg/5 ml) ____ ml po q 4 hr prn



  1. Nausea: (Adults) Zofran (ondansetron) 4 mg IV or po q 6 hrs prn

(Pediatrics, > 10 kg) Zofran (ondansetron) 4 mg ODT prn x 1 dose

(Pediatrics, 5-10 kg) Zofran (ondansetron) 1 mg ODT prn x 1 dose



  1. Itching:(Adults): Benadryl (diphenhydrAMINE) 25 -50 mg IV x 1 dose

(Pediatrics, 6-12 y/o) Benadryl (diphenhydrAMINE) 12.5-25 mg x 1 dose

(Pediatrics, up to 6 y/o) Benadryl (diphenhydrAMINE) 6.25-12.5 mg x 1 dose


______________ ___________________ _________________________________ __________

Date Time Physician Signature PID Number


Snakebite Severity Score

Criterion

Points

Pulmonary Symptoms

No symptoms/signs

Dyspnea, minimal chest tightness, mild or vague discomfort, or respirations of 20-25 breaths/minute

Moderate respiratory distress (tachypnea, 26-40 breaths/minute; accessory muscle use)

Cyanosis, air hunger, extreme tachypnea, or respiratory insufficiency/failure

0

1



2

3


Cardiovascular System

No symptoms/signs

Tachycardia (100-124 BPM), palpitations, generalized weakness, benign dysrhythmia, or hypotension

Tachycardia (126-175 BPM),or hypotension with SBP>100

Tachycardia (>175 BPM), hypotension with SBP<100, malignant dysrhythmia, or cardiac arrest

0

1



2

3


Local Wound

No symptoms/signs

Pain, swelling, or ecchymosis within 5-7.5 cm of bite site

Pain, swelling, or ecchymosis involving less than half the extremity (7.5-50 cm from bite site)

Pain, swelling, or ecchymosis involving half to all of extremity (50-100 cm from bite site)

Pain, swelling, or ecchymosis extending beyond affected extremity (more than 100 cm from bite site)


0

1



2

3

4




Gastrointestinal System

No symptoms/signs

Pain, tenesmus, or nausea

Vomiting or diarrhea

Repeated vomiting, diarrhea, hematemesis, or hematochezia

0

1



2

3


Hematologic symptoms

No symptoms/signs

Coagulation parameters slightly abnormal: PT<20 seconds, PTT <50 seconds, Platelets 100-150K, or fibrinogen 100-150 mcg/ml

Coagulation parameters abnormal: PT < 20-25 seconds, PTT <50-75 seconds; Platelets 50-100K, or fibrinogen 50-100 mcg/ml

Coagulation parameters abnormal: PT<50-100 seconds, PTT <75-100 seconds, Platelets 20-50 K, or fibrinogen < 50 mcg/ml

Coagulation parameters markedly abnormal, with serious bleeding or the threat of spontaneous bleeding; unmeasurable PT or PTT, Platelets <20 K, or undetectable fibrinogen


0

1


2
3
4

Central Nervous System

No symptoms/signs

Minimal apprehension, headache, weakness, dizziness, chills, or paresthesia

Moderate apprehension, headache, weakness, dizziness, chills, paresthesia, confusion, or fasciculation in area of bite site

Severe confusion, lethargy, seizure, coma, psychosis, or generalized fasciculation

0

1



2
3


Total Points





Snakebite Severity Score

Minimal: 0-3

Moderate: 4-7

Severe: 8-20




Not Part of Permanent Medical Record.



Send copy to pharmacy
*2-32532* FORM 2-32532 INITIATED 07/2012 Page 1 of 1


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