Safe and effective antivenoms are available for all hemo/cytotoxic pit viper envenomations and for neurotoxic coral snake envenomations in this AOR. Treatment does not require identification of the species responsible but does require identification of the syndrome. Snakebite treatment at the point of injury is recommended for SOUTHCOM. 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 (Entire SOUTHCOM AOR): BIOCL-AVT

Instituto Bioclon, Mexico – ANTIVIPMYN-TRI (BIOCL-AVT) (Freeze dried/Unrefrigerated) 251-255:

  1. Field-stable. Broad-spectrum coverage 14 species Hemo/Cyto.
  2. First line treatment option for all hemotoxic and cytotoxic snake envenomations anywhere in the SOUTHCOM AOR when the causative species is either unknown or among the ≥ 14 snakes for which this product is directly indicated. Directly or indirectly covers most of the WHO category 1 and category 2 snakes in this region.
  3. Initial dose = 10 vials hemotoxic/cytotoxic only, additional doses = 5 vials as needed.

Feasibility of use in austere environments: Recommended for operational settings. Unrefrigerated storage at ambient tropical temperatures of ≤ 37º C / 98.6º F. Lyophilized product that likely retains stability at higher temperatures for short excursions. Recommend carrying full dose or loading dose (≥ 5 vials) into field on extended operations in austere environments and storing larger quantities at strategically located Role 2 & 3 facilities in SOUTHCOM AOR.

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

Indications: This broad-spectrum polyvalent can be used to treat hemotoxic and cytotoxic envenomations by more than 14 different species of Central and South American snakes. It may be able to neutralize venom from additional species through paraspecific neutralization but this has not been officially determined. The species listed below are the official treatment indications recommended by the manufacturer:

  • HEMOTOXIC and/or CYTOTOXIC: Crotalus durissis terrificus; Bothrops asper, B. atrox, B. neuwiedii, B. alternatus, B. jararacussu, B. venezulensis, B. pictus, B. brazili; Lachesis muta muta, L. m. stenophyrs; Sistrurus spp.; Agkistrodon spp.

Pretreatment: Not routinely indicated unless patient is unstable, asthmatic/atopic, known hypersensitivity or other pretreatment criteria met.      

Initial dosing by syndrome:

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

Additional dosing: Additional doses of 5 vials BIOCL-AVT 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 (SOUTHCOM – Central America/South America): BIOCL-COR

SECOND LINE (SOUTHCOM – South America): BIOCL-COR

Instituto Bioclon, Mexico - CORALMYN (BIOCL-COR) (Liquid/Refrigerated) 256-262:

  1. Not field-stable. Broad-spectrum coverage neuro in Central America.
  2. First line treatment option for neurotoxic envenomation in Central America by coral snakes or unknown species (coral snakes are only strictly neurotoxic snakes in SOUTHCOM AOR). Second line treatment option for coral snake / unknown neurotoxic envenomation in South America if first line (INS-AAP) is not available.
  3. Initial dose = 10 vials neurotoxic only, additional doses = 5 vials as needed.

First Line (SOUTHCOM – Central America): Neurotoxic envenomation in Central America by coral snakes or unknown species (coral snakes are only strictly neurotoxic snakes in SOUTHCOM AOR).

Second Line (SOUTHCOM – South America): May treat some coral snakes in South America but major coverage gaps in that region compared to the first line for South America (INS-AAP).

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 in South America. 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 Central American coral snakes from the genus Micrurus.

  • NEUROTOXIC: Central American coral snakes (Micrurus spp.)

Initial dosing by syndrome:

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

Additional dosing: Additional doses of 5 vials BIOCL-COR 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 (SOUTHCOM – South America): INS-AAP

SECOND LINE (SOUTHCOM – Central America): INS-AAP

Instituto Nacional de Salud, Colombia - Antiveneno Anticoral Polivalente (INS-AAP) (Liquid/Refrigerated) 260-2:

  1. Not field-stable. Broad-spectrum coverage Neuro in South America.
  2. First line treatment option for neurotoxic envenomation in South America by coral snakes or unknown species (coral snakes are only strictly neurotoxic snakes in SOUTHCOM AOR). Second line treatment option for coral snake / unknown neurotoxic envenomation in Central America if first line (INS-AAP) is not available.
  3. Initial dose = 10 vials neurotoxic only, additional doses = 5 vials as needed.

First Line (SOUTHCOM – South America): Broadest efficacy against neurotoxic snake bites by coral snakes or unknown species in South America. Coral snakes are the only strictly neurotoxic species in SOUTHCOM.

Second Line (SOUTHCOM – Central America): Should treat most coral snake species in Central America but will have some coverage gaps compared to the first line for Central America (BIOCL-COR).

Feasibility of use in austere environments: Not recommended for operational settings. Liquid product that requires cold chain refrigeration between 4 - 8 ºC / 39.2 - 46.4 ºF. Recommend storing several vials at a small number of strategically located Role 2 & 3 facilities in South America. 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 South American coral snakes from the genus Micrurus as well as some Central American species.

  • NEUROTOXIC: South American coral snakes (Micrurus spp.) including Micrurus dumerilii, M. mipartitus, M. surinamensis, M. isozonus, M. lemniscatus, M. spixi, M. Medemi

Initial dosing by syndrome:

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

Additional dosing: Additional doses of 5 vials INS-AAP 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.