Safe and effective antivenoms are available for all neurotoxic/hemo/cytotoxic pit viper envenomations and for neurotoxic coral snake envenomations in this AOR. Treatment does not require identification of the species responsible. Snakebite treatment at the point of injury is not routinely recommended for NORTHCOM.

For all NORTHCOM antivenoms, refer to the package insert in the antivenom box for specific usage instructions as per FDA regulations for domestically approved products. Also see Unified treatment algorithm for the management of crotaline snakebite in the U.S. (Lavonas et al. 2011) for dosing and management guidelines on pit viper bites.101 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.

BTG Therapeutics, USA – CroFab

(Freeze-dried/Refrigerated) 94,95,101,249-250 :

  • Indications: Envenomation by all Pit Viper species (rattlesnakes, copperheads, cottonmouths) in North America. Freeze-dried; requires refrigeration but one study has demonstrated that it will maintain efficacy under field conditions for ≥ 90 days if needed.
  • Initial dosing: 4 – 6 vials

RDT/Instituto Bioclon, USA/Mexico – ANAVIP

(Freeze-dried/Unrefrigerated) 92

  • Indications: Currently only indicated by FDA for rattlesnake envenomations.
  • Not currently indicated for copperhead or cottonmouth envenomations, although this may change in the near future depending on results of upcoming studies. Freeze dried and field-stable at room temperature of 25º C / 77º F.
  • Initial dosing: 10 vials

Pfizer, USA – North American Coral Snake Antivenom (NACSA)

(Freeze-dried/Refrigerated) 251

  • Indications: Indicated for neurotoxic envenomations by North American coral snake (NACSA) species in the United States including Eastern coral snake (Micrurus fulvius) and Texas coral snake (Micrurus tener). Store between 2 – 8º C / 35.6 - 46.4 ºF; however, likely retains stability for short excursions in the field.
  • Initial dosing: 5 vials