Safe and effective broad-spectrum, field-stable antivenoms are available for all three syndromes of snake envenomation in this AOR and treatment does not require identification of the species responsible. Snakebite treatment at the point of injury is recommended for CENTCOM due to potential for prolonged evacuation times, high incidence of snakebites, and the high risk of death or permanent disability from many venomous snakes in the AOR if early antivenom treatment is not available.
Adverse Reaction Management
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
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 CENTCOM - Arabian Peninsula/Middle East/Central Asia: POLYSERP-M
POLYSERP / Inosan, Spain - POLYSERP MENA Polyvalent (POLYSERP-M) (Freeze dried/Unrefrigerated) 162–172
Feasibility of use in austere environments: Recommended for use in operational settings and specifically designed to fill the capability gap for ground medics operating in these areas. Updated version of Inoserp MENA made specifically for the austere and operational medicine environment. Freeze-dried, unrefrigerated, stable at temperatures >100º F for at least 180 days without loss of efficacy. Broad coverage and simple dosing enable administration in the field for any symptomatic snakebite by unknown species in this region. Special operations and conventional units deploying to austere operational environments and areas with critical threat venomous species should carry 8 vials per medic. It is recommended that a reserve quantity is stocked in all role 2 and role 3 facilities in AFRICOM in case additional antivenom is needed upon arrival, and also to restock field medics that have used their supply.
Adverse reactions: High efficacy against all major syndromes and low incidence of serious adverse reactions of approximately 1% based on current publications.
Indications: Broad spectrum polyvalent directly indicated for the treatment of neurotoxic, hemotoxic, and cytotoxic envenomation syndromes caused by 27 different species of Middle Eastern, North African, and Central Asian snakes from the families Elapidae and Viperidae. First line for snake envenomations in this region when the causative species is unknown or among the species for which the product is directly indicated.
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:
Additional dosing: Additional doses of 2 vials POLYSERP-M may be given at hours 2, 4, 6, 12, and 24 if needed.
Preparation and administration: Reconstitute every 2 vials of POLYSERP-M in the same 10 mL syringe by mixing the first vial, drawing it back up into syringe, and injecting it into the second vial to yield 2 vials/1 syringe (6 vial dose = 3 syringes total). Administer sequentially via slow, continuous direct IV or IO push over approximately 2 minutes each. If a reaction occurs stop the push, treat the reaction, reassess response to treatment criteria. Dilute remaining dose in a 100 mL bag of isotonic fluids and administer via slow IV or IO infusion over 30 mins if needed.
Direct push is recommended for convenience, but POLYSERP-M may also be administered via IV or IO infusion. Mix in a 50 mL or 100 mL bag of isotonic fluids and administer the entire bag over 5 – 10 mins.
FIRST LINE & SECOND LINE CENTCOM - Middle East/Central Asia: SIOBP-G
Shanghai Institute of Biological Products, China - Agkistrodon (Gloydius) halys Monovalent Antivenom (SIOBP-G): (Liquid/Refrigerated)194–196:
NOTE: This product is listed as Agkistrodon halys on the SIOBP website and product packaging but the taxonomy for this species has changed. Agkistrodon halys was moved to the genus Gloydius and should be listed as Gloydius halys as it is listed elsewhere. The product is abbreviated as SIOBP-G in the CPGs to account for this correction.
First line (CENTCOM - MIDDLE EAST / CENTRAL ASIA): Monovalent for the WHO category 2 species Gloydius halys. Indicated only for confirmed envenomation by Gloydius halys or related Gloydius species. Does not provide coverage against any other WHO category 1 or category 2 species.
Second line (CENTCOM - MIDDLE EAST / CENTRAL ASIA): Indicated for unknown cytotoxic and/or hemotoxic envenomation in Middle East or Central Asia with no signs of improvement after 10 vials of POLYSERP-M.
Feasibility of use in austere environments: Not recommended for operational settings. Requires cold chain refrigeration. Recommend storing small quantities at strategically located Role 2 & 3 facilities in CENTCOM AOR.
Incidence of adverse reactions: Low to moderate rates of EARs and serum sickness are anticipated but clinical evidence is limited.
Indications: This monovalent can be used to treat cytotoxic and hemotoxic envenomations by Gloydius halys, a pit viper native to the Middle East and Central Asia. It will most likely neutralize venom from related species in the genus Gloydius through paraspecificity, but this has not been tested in detail. There are several publications indicating that it may also have paraspecificity against some of the Southeast Asian green pit vipers from the genera Cryptelytrops and Trimeresurus.196,197 However, it is not currently indicated by the manufacturer for these species.
Initial dosing by syndrome:
Additional dosing: Additional doses of 2 vials SIOBP-G may be given at hours 2, 4, 6, 12, and 24 if needed.
Pretreatment: Not routinely indicated unless patient is unstable, asthmatic/atopic, known hypersensitivity or other pretreatment criteria met.
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.
SECOND LINE CENTCOM - Middle East/Central Asi): RAZI-P
Razi Serum and Vaccine Research Institute, Islamic Republic of Iran - Polyvalent Snake Antivenom (RAZI-P) (Liquid/refrigerated)198-205:
Feasibility of use in austere environments: Not recommended for operational settings. Requires cold chain refrigeration. Recommend storing small quantities at strategically located Role 2 & 3 facilities in CENTCOM AOR or selecting alternative second line from this CPG.
Adverse reactions: Limited evidence but appears to be low based on current publications.
Indications: This polyvalent can be used to treat neurotoxic and cytotoxic envenomations by 6 different species of Middle Eastern, North African, and Central Asian snakes. It may be able to neutralize venom from additional species through paraspecific neutralization but this has not been researched. The 6 species listed below are the official treatment indications recommended by the manufacturer:
Pretreatment: Not routinely indicated unless patient is unstable, asthmatic/atopic, known hypersensitivity or other pretreatment criteria met.
Initial dosing by syndrome:
Additional dosing: Additional doses of 5 vials RAZI-P 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.
SECOND LINE CENTCOM - Arabian Peninsula: NAVPC-C
National Antivenom & Vaccine Production Center, Saudi Arabia - Polyvalent Snake Antivenom (NAVPC-P) (Liquid/Refrigerated) 187-192 :
Feasibility of use in austere environments: Not recommended for operational settings. Requires refrigeration, moderate to high rates of adverse reactions are anticipated. Better alternatives exist. If purchased it should be kept at Role 2 & 3 facilities in the Arabian Peninsula.
Adverse reactions: Insufficient evidence to determine risk of adverse reactions at this time.
Indications: This polyvalent can be used to treat neurotoxic and cytotoxic envenomations by 6 different species of Middle Eastern, North African, and Central Asian snakes. It may be able to neutralize venom from additional species through paraspecific neutralization but this has not been researched. The 6 species listed below are the official treatment indications recommended by the manufacturer:
Initial dosing by syndrome:
Additional dosing: Additional doses of 5 vials NAVPC-C may be given at hours 2, 4, 6, 12, and 24 if needed.
Pretreatment: RECOMMENDED for this antivenom due to insufficient evidence for determining risk of EARs. Administer 0.25 mg epinephrine injected SQ prior to beginning antivenom infusion to reduce the risk of a serious reaction. Pediatric doses should be weight based at a dose of 0.01 mg/kg, up to 0.25 mg.
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.