Safe and effective broad-spectrum, refrigerated antivenoms are available for all three syndromes of snake envenomation due to European viper species in this AOR and treatment does not require identification of the species responsible. Snakebite treatment at the point of injury is not routinely recommended for EUCOM. This section provides specifics about antivenoms use in this region

Adverse Reaction Management

  • If a mild or moderate reaction occurs, slow the infusion and treat symptomatically with antihistamines, steroids, and/or antiemetics as needed.
  • If a severe reaction such as anaphylaxis occurs, stop the infusion and treat according to the anaphylaxis protocol listed elsewhere in the CPG. Reassess the patient once the reaction has been controlled and resume the infusion at a slower rate if any of the specific criteria for antivenom treatment listed elsewhere in the CPG have not completely resolved.

Sudden Collapse Syndrome Treatment Protocol

Patient presents within 30 minutes of the bite with rapid onset shock ± angioedema, altered mental status, systemic bleeding, and diarrhea.1

  1. Stabilize with IM or IV epinephrine and fluids as per anaphylaxis protocols
  2. Intubate for airway edema not rapidly responsive to epinephrine
  3. Follow epinephrine immediately with a high dose of the appropriate regional antivenom given by rapid IV or IO push during the resuscitation
  4. Maintain blood pressure with IV or IO fluids and epinephrine until antivenom has taken effect to reverse the hypotension.

See Sudden Collapse Syndrome section for more information.

 

CONTACT

For emergency consultations, call the ADVISOR telemedicine hotline (866-972-9966) and select toxicology from the phone menu.

For additional information about snake bite management or this CPG, email jordan@snakebitefoundation.org or call 415-218-2211.

 

FIRST LINE EUCOM - Outside UK/Scandinavia: VIPERFAV

SECOND LINE EUCOM - Inside UK/Scandinavia: VIPERFAV

Sanofi-Pasteur, France - Viperfav (VIPERFAV) (Freeze dried/Refrigerated) 206-212:

  1. Not field-stable. Broad-spectrum coverage against multiple European vipers.
  2. First line treatment option (EUCOM - EUCOM OUTSIDE UK / SCANDINAVIA): Single-source treatment option for neurotoxic, hemotoxic, and cytotoxic snake envenomations by the most medically and epidemiologically significant species in Europe (Vipera berus, V. aspis, V. ammodytes) with paraspecific coverage against other European Vipera species. Can be used in the EUCOM AOR when the causative species is unknown or species for which this product is directly indicated.
  3. Second line treatment option (EUCOM - UK / SCANDINAVIA) for all neurotoxic, hemotoxic, and cytotoxic snake envenomations within the UK and Scandinavia if first line (VIPERATAB) is not available.
  4. Initial dose = 1 – 2 vials all syndromes, additional doses = 1 vial as needed.

Feasibility of use in austere environments: Not recommended for operational settings. Requires cold chain refrigeration between 2 - 8 ºC (35.6 - 46.4 ºF). Recommend storing several vials at a small number of strategically located Role 2 & 3 facilities. Likely to retain efficacy for several weeks in the field but should be disposed of after that duration of time outside refrigeration.

Adverse reactions: High efficacy against all major syndromes and low incidence of serious adverse reactions based on current publications.

Indications: Polyvalent antivenom directly indicated for the treatment of neurotoxic, hemotoxic, and cytotoxic envenomation syndromes caused by Vipera berus, V. aspis, V. ammodytes but has demonstrated efficacy against other species of European vipers (genus Vipera) as well.

Pretreatment: Not routinely indicated unless patient is unstable, asthmatic/atopic, known hypersensitivity or other pretreatment criteria met. Low risk of severe allergic reactions and other EARs.       

Initial dosing by syndrome:

  • NEUROTOXIC initial dose = 2 vials
  • HEMOTOXIC initial dose = 1 - 2 vials
  • CYTOTOXIC initial dose = 1 - 2 vials

Additional dosing: Additional doses of 1 vial VIPERFAV may be given at hours 2, 4, 6, 12, and 24 if needed.

Preparation and administration: Dilute the entire dose of antivenom in a single 250 - 500 mL bag of isotonic solution and administer by intravenous infusion over 10 - 30 minutes.

  

FIRST LINE EUCOM – Inside UK/Scandinavia: VIPERATAB

SECOND LINE EUCOM – Outside UK/Scandinavia: VIPERATAB

Micropharm, UK - ViperaTAb (VIPERATAB) (Freeze dried/Refrigerated) 206,210,213–215:

  1. Not field-stable. Broad-spectrum coverage against several European vipers.
  2. First line (EUCOM - UK / SCANDINAVIA): Single-source treatment option for neurotoxic, hemotoxic, and cytotoxic snake envenomations by the most medically and epidemiologically significant species in the UK and Scandinavia (Vipera berus) with paraspecific coverage against some other European Vipera species.
  3. Second line treatment option (EUCOM - OUTSIDE OF UK / SCANDINAVIA) for all neurotoxic, hemotoxic, and cytotoxic snake envenomations in the EUCOM AOR outside of the UK and Scandinavia if first line (VIPERFAV) is not available.
  4. Initial dose = 2 vials all syndromes, additional doses = 2 vials as needed. Each box = 2 vials.

Feasibility of use in austere environments: Not recommended for operational settings. Requires cold chain refrigeration between 2 - 8 ºC (35.6 - 46.4 ºF). Recommend storing several vials at a small number of strategically located Role 2 & 3 facilities. Likely to retain efficacy for several weeks in the field but should be disposed of after that duration of time outside refrigeration.

Adverse reactions: High efficacy against UK / Scandinavian European viper (Vipera berus) envenomations and low incidence of serious adverse reactions based on current publications.

Indications: Polyvalent antivenom directly indicated for the treatment of neurotoxic, hemotoxic, and cytotoxic envenomation syndromes caused by Vipera berus. Has demonstrated efficacy against other species of European vipers (V. aspis, V. ammodytes) as well but is not directly indicated for these species.

Pretreatment: Not routinely indicated unless patient is unstable, asthmatic/atopic, known hypersensitivity or other pretreatment criteria met. Low risk of severe allergic reactions and other EARs.       

Initial dosing by syndrome:

  • NEUROTOXIC initial dose = 2 vials
  • HEMOTOXIC initial dose = 2 vials
  • CYTOTOXIC initial dose = 2 vials

Additional dosing: Additional 2 vials VIPERATAB may be given at hours 2, 4, 6, 12, and 24 if needed.

Preparation and administration: Each box of VIPERATAB comes with two 4 mL vials of antivenom (one box = one dose). Dilute the entire dose of antivenom in a single 100 - 500 mL bag of isotonic solution and administer by intravenous infusion over 10 - 30 minutes.