Safe and effective broad-spectrum, field-stable antivenoms are available for all three syndromes of snake envenomation in Southeast Asia and several other areas within this AOR. Snakebite treatment in INDOPACOM as a whole is more complex than AFRICOM or CENTCOM due to the lack of a truly pan-Asian polyvalent product. Treatment in many places does not require identification of the species responsible, but products are syndrome specific and there is no single product for all 3 syndromes. Snakebite treatment at the point of injury is recommended for areas within the INDOPACOM AOR where field-stable antivenoms are available. 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 INDOPACOM - Southeast Asia: TRC-HPAV

Thai Red Cross, Thailand - Hemato Polyvalent Antivenom (TRC-HPAV) (Freeze dried/Unrefrigerated) 62,196, 197, 216–218:

  1. Field-stable. Broad-spectrum coverage multiple species of Hemo/Cyto.
  2. Broad-spectrum treatment option for all hemotoxic and cytotoxic snake envenomations by known or unknown species in Southeast Asia. Best regional polyvalent.
  3. Initial dose hemotoxic/cytotoxic only = 10 vials, additional doses = 5 vials as needed.

Feasibility of use in austere environments: Recommended for operational settings. Unrefrigerated storage at ambient tropical temperatures of ≤ 25º C / 77º F. Lyophilized product that likely retains stability at higher temperatures for short excursions (likely up to several months). Recommend carrying full dose into field on extended operations in austere environments and storing larger quantities at strategically located Role 2 & 3 facilities in INDOPACOM AOR.

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

Indications: Polyvalent antivenom directly indicated for the treatment of hemotoxic and cytotoxic envenomation syndromes caused by Calloselasma rhodostoma, Trimersurus albolabris, and Daboia russelli siamensis. Has demonstrated efficacy against other related species of Asian vipers within the same genera (Crytelytrops, Popeia, Daboia, etc.); is not directly indicated for these species but is the best hemotoxic / cytotoxic polyvalent in the region and should be tried as first line in most cases.

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:

  • NOT INDICATED FOR NEUROTOXIC
  • HEMOTOXIC initial dose = 10 vials
  • CYTOTOXIC initial dose = 10 vials

Additional dosing: Additional 2 vials TRC-HPAV 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 INDOPACOM - Southeast Asia Broad Spectrum Neurotoxic: TRC-NPAV

Thai Red Cross, Thailand - Neuro Polyvalent Antivenom (TRC-NPAV) (Freeze dried/Unrefrigerated) 62,196,217,219–221,:

  1. Field-stable. Broad-spectrum coverage multiple species of Neuro.
  2. Broad-spectrum treatment option for all neurotoxic snake envenomations by known or unknown species in Southeast Asia. Best regional polyvalent.
  3. Initial dose = 10 vials neurotoxic only, additional doses = 5 vials as needed.

Feasibility of use in austere environments: Recommended for operational settings. Unrefrigerated storage at ambient tropical temperatures of ≤ 25º C / 77º F. Lyophilized product that likely retains stability at higher temperatures for field excursions (likely stable for several months at higher temps based on data from similar products). Recommend carrying full dose into field on extended operations in austere environments and storing larger quantities at strategically located Role 2 & 3 facilities in INDOPACOM AOR.

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

Indications: Polyvalent antivenom directly indicated for the treatment of hemotoxic and cytotoxic envenomation syndromes caused by Ophiophagus hannah, Naja kaouthia, Bungarus candidus, and B. fasciatus candidus. Has demonstrated efficacy against other related species of Asian cobras and kraits; is not directly indicated for these species but is the best hemotoxic / cytotoxic polyvalent in the region and should be tried as the first line in most cases.

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 = 10 vials NOTE: King cobra (O. hannah) bites likely to require much higher doses of antivenom due to massive venom yield; it is not unusual to require dozens of vials in these cases.
  • NOT INDICATED FOR HEMOTOXIC
  • NOT INDICATED FOR CYTOTOXIC

Additional dosing: Additional 5 vials TRC-NPAV may be given at hours 2, 4, 6, 12, and 24 if needed. Bites from large king cobras may require several dozen vials or more due to massive venom yield.

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 INDOPACOM – Taiwan/Southeast China/N Laos/N Vietnam: NIPM-NBB

National Institute Preventative Medicine, Taiwan - Naja atra / Bungarus multicinctus Bivalent (NIPM-NBB) (Freeze dried/Refrigerated) 222–230:

  1. Liquid product but field-stable for short excursions. Broad-spectrum coverage multiple species of Neuro.
  2. Bivalent treatment option for neurotoxic cobra and krait envenomations in East Asia.
  3. Initial dose = 5 vials neurotoxic only, additional doses = 5 vials as needed.

Feasibility of use in austere environments: Conditionally recommended for operational settings during short excursions. Lyophilized but requires cold chain refrigeration below 10ºC (50 ºF); however, testing by Taiwanese CDC showed no loss of potency after 30 days of incubation at 35º C / 95º F and also after it was returned to refrigerated storage for 4 months thereafter. Recommend carrying full dose into field on extended operations in austere environments and storing larger quantities at regional Role 2 & 3 facilities.

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

Indications: Polyvalent antivenom directly indicated for the treatment of hemotoxic and cytotoxic envenomation syndromes caused by Naja atra and Bungarus multicinctus. Has demonstrated efficacy against other related species of Asian cobras and kraits 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 = 5 vials
  • NOT INDICATED FOR HEMOTOXIC
  • NOT INDICATED FOR CYTOTOXIC

Additional dosing: Additional 5 vials NIPM-NBB 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 100 – 500 mL bag of isotonic solution and administer by intravenous infusion over 10 – 30 minutes.

FIRST LINE INDOPACOM - Japan: CSTRI-HABU

Chemo-Sero Therapeutic Research Institute, Japan - Kaketsuken Habu Antivenom (CSTRI-HABU) (Freeze dried/Refrigerated) 231–235:

  1. Not field-stable. Not broad-spectrum. Habu coverage only.
  2. First line treatment option for Habu envenomation (Protobothrops spp.).
  3. Initial dose = 1 – 2 vials, additional doses = 1 vial as needed

Feasibility of use in austere environments: Not recommended for operational settings. Lyophilized but requires cold chain refrigeration below 10ºC (50 ºF); likely to retain efficacy for short excursions lasting several weeks in the field but should be disposed of and replaced after extended time outside refrigeration. Recommend storing several vials at a small number of strategically located Role 2 & 3 facilities.

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

Indications: Directly indicated for the treatment of hemotoxic and cytotoxic envenomation syndromes caused by the Japanese Habu (Protobothrops [Trimeresurus] flavoviridis)

Pretreatment: Not routinely Indicated unless patient is unstable, asthmatic/atopic, known hypersensitivity or other pretreatment criteria met; however, total reactions (~11% overall; ~25% serum sickness) higher than other regional products. Consider pretreatment on an individual basis.

Initial dosing by syndrome:

  • NOT INDICATED FOR NEUROTOXIC
  • HEMOTOXIC = 1 - 2 vials
  • CYTOTOXIC = 1 - 2 vials

Additional dosing: Additional 1 vial CSTRI-HABU 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 INDOPACOM - Japan: CSTRI-MAMU

Chemo-Sero Therapeutic Research Institute, Japan - Kaketsuken Mamushi Antivenom (CSTRI-MAMU) (Freeze dried/Refrigerated) 231–235:

  1. Not field-stable. Not broad-spectrum. Japanese Mamushi coverage only.
  2. First line treatment option for hemotoxic and cytotoxic envenomation syndromes caused by the Japanese Mamushi (Gloydius blomhoffi).
  3. Initial dose = 1 – 2 vials, additional doses = 1 vial as needed

Feasibility of use in austere environments: Not recommended for operational settings. Lyophilized but requires cold chain refrigeration below 10ºC (50 ºF); likely to retain efficacy for short excursions lasting several weeks in the field but should be disposed of and replaced after extended time outside refrigeration. Recommend storing several vials at a small number of strategically located Role 2 & 3 facilities.

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

Indications: Directly indicated for the treatment of hemotoxic and cytotoxic envenomation syndromes caused by the Japanese Mamushi, Gloydius blomhoffi.

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:

  • NOT INDICATED FOR NEUROTOXIC
  • HEMOTOXIC = 1 - 2 vials
  • CYTOTOXIC = 1 - 2 vials

Additional dosing: Additional 1 vial CSTRI-MAMU 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 (INDOPACOM – Japan/China/N Korea/S Korea/Vietnam/E Russia): JSI-AYA

Japan Snake Institute, Japan - Anti-Yamakagashi Antivenom (JSI-AYA) (Freeze dried/Refrigerated) 231–233:

  1. Not field-stable. Not broad-spectrum. Keelback coverage only.
  2. First line treatment option for hemotoxic and cytotoxic envenomation syndromes caused by the Tiger Keelback (Rhabdophis tigrinus) and other East Asian keelback species.
  3. Initial dose = 1 – 2 vials, additional doses = 1 vial as needed

Feasibility of use in austere environments: Not recommended for operational settings. Lyophilized but requires cold chain refrigeration below 10ºC (50 ºF); likely to retain efficacy for short excursions lasting several weeks in the field but should be disposed of and replaced after extended time outside refrigeration. Recommend storing several vials at a small number of strategically located Role 2 & 3 facilities.

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

Indications: Directly indicated for the treatment of hemotoxic and cytotoxic envenomation syndromes caused by the Tiger Keelback (Rhabdophis tigrinus) and other East Asian keelbacks.

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:

  • NOT INDICATED FOR NEUROTOXIC
  • HEMOTOXIC = 1 - 2 vials
  • CYTOTOXIC = 1 - 2 vials

Additional dosing: Additional 1 vial JSI-AYA 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 (INDOPACOM - N Korea/S Korea/E. China): KOVAX-AKA

Korea Vaccine, Korea - Agkistrodon Mamushi Antivenom (KOVAX-AKA) (Freeze dried/Refrigerated) 234–240:

  1. Not field-stable. Not broad-spectrum. Korean Mamushi coverage only.
  2. First line treatment option of hemotoxic and cytotoxic envenomation syndromes caused by the major species of Mamushi in the Korean Peninsula (Gloydius brevicaudus, G. ussuriensis, G. intermedius). May neutralize other related species.
  3. Initial dose = 1 – 2 vials, additional doses = 1 vial as needed

Feasibility of use in austere environments: Not recommended for operational settings. Lyophilized but requires cold chain refrigeration below 10ºC (50 ºF); likely to retain efficacy for short excursions lasting several weeks in the field but should be disposed of and replaced after extended time outside refrigeration. Recommend storing several vials at a small number of strategically located Role 2 & 3 facilities.

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

Indications: Directly indicated for the treatment of hemotoxic and cytotoxic envenomation syndromes caused by the major species of Mamushi in the Korean Peninsula (Gloydius brevicaudus, G. ussuriensis, G. intermedius). May neutralize other related 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:

  • NOT INDICATED FOR NEUROTOXIC
  • HEMOTOXIC = 1 - 2 vials
  • CYTOTOXIC = 1 - 2 vials

Additional dosing: Additional 1 vial KOVAX-AKA 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 (INDOPACOM - Taiwan/SE China/N Vietnam/Laos): NIPM-SNV

National Institute Preventative Medicine, Taiwan - Sharp-nosed Viper Monovalent (NIPM-SNV) (Freeze dried/Refrigerated) 223,235–240:

  1. Freeze-dried product requiring cold chain but likely to be field-stable for short excursions. Not broad-spectrum. Sharp-nosed viper only.
  2. First line monovalent antivenom directly indicated for the treatment of hemotoxic and cytotoxic envenomation syndromes caused by the sharp-nosed viper (Deinagkistrodon acutus).
  3. Initial dose = 2 vials, additional doses = 1 vial as needed

Feasibility of use in austere environments: Conditionally recommended for operational settings during short excursions. Lyophilized but requires cold chain refrigeration below 10ºC (50 ºF); however, testing by Taiwanese CDC showed no loss of potency after 30 days of incubation at 35º C / 95º F and also after it was returned to refrigerated storage for 4 months thereafter. Recommend carrying full dose into field on extended operations in austere environments and storing larger quantities at regional Role 2 and 3 facilities.

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

Indications: Monovalent antivenom directly indicated for the treatment of hemotoxic and cytotoxic envenomation syndromes caused by Deinagkistrodon acutus.

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:

  • NOT INDICATED FOR NEUROTOXIC
  • HEMOTOXIC initial dose = 2 vials
  • CYTOTOXIC initial dose = 2 vials

Additional dosing: Additional 1 vials NIPM-SNV 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 (INDOPACOM – Marine Environments Only): CSL-SS

Commonwealth Serum Laboratories, Australia - Sea Snake (CSL-SS) (Liquid/Refrigerated) 231-245 :

  1. Not field-stable. Broad-spectrum coverage against Indo-Pacific sea snakes only.
  2. Neurotoxic envenomation in INDOPACOM by sea snakes or unknown species occurring in a strictly marine environment.
  3. Initial dose = 3 vials, 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-quality product with low rates of reactions anticipated.

Indications: This polyvalent can be used to treat neurotoxic envenomations by most major species of sea snakes in Australasia.

Initial dosing by syndrome:

  • NEUROTOXIC syndrome initial dose = 3 vials
  • NOT INDICATED for hemotoxic envenomations
  • NOT INDICATED for cytotoxic envenomations

Additional dosing: Additional doses of 1 vials CSL-SS 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. Low risk of severe allergic reactions and other EARs.       

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 (INDOPACOM – Maluku/West Papua Islands only): CSL-P

Commonwealth Serum Laboratories, Australia - Polyvalent (CSL-P) (Liquid/Refrigerated) 61, 241, 245-248:

  1. Not field-stable. Broad-spectrum coverage.
  2. First line antivenom indicated for neurotoxic/hemotoxic envenomation in INDOPACOM by Australasian elapids or unknown species occurring East of Wallace’s line.
  3. Initial dose = 3 vials, 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 during short excursion at higher temperatures for several weeks in the field but should be disposed of and replaced afterwards.

Adverse reactions: High-quality product with low rates of reactions anticipated.

Indications: This polyvalent can be used to treat neurotoxic envenomations by the most medically significant species of Australasian elapid snakes found East of Wallace’s line.

Initial dosing by syndrome:

  • NEUROTOXIC syndrome initial dose = 3 vials
  • HEMOTOXIC syndrome initial dose = 3 vials
  • NOT INDICATED FOR CYTOTOXIC ENVENOMATIONS

Additional dosing: Additional doses of 1 vials CSL-P 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. Low risk of severe allergic reactions and other EARs.       

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.