REGIONALLY SPECIFIC SNAKEBITE TREATMENT SECTIONS

There are several different antivenoms included in this CPG for snakebite treatment in African Command (AFRICOM), Central Command (CENTCOM), Indonesia-Pacific Command (INDOPACOM), European Command (EUCOM), Northern Command (NORTHCOM), and Southern Command (SOUTHCOM). The coverage, initial dosing, preparation, and administration vary between products and details for each of them are included. Simplified algorithms for selecting and dosing each antivenom are also included in each regional section below.

Whenever possible, broad-spectrum, field-stable antivenoms are recommended to enable syndromic diagnosis and treatment at the point of injury without the need to identify the species responsible for the bite. Citations of the relevant literature on safety, efficacy, and dosing for each product are provided in the references section.

Determine the appropriate first line antivenom for your area of operations prior to deployment using this section, then refer back to the Universal Approach to Snakebite Assessment, Diagnosis, and Treatment earlier in the document for detailed instructions and a stepwise approach to snakebite management throughout the course of care. Abbreviated antivenom guidelines for each regional combatant command are included below.

CATEGORIZATION OF MEDICALLY SIGNIFICANT SNAKE SPECIES

The World Health Organization (WHO) classifies the risk posed by various venomous snakes by designating each species as either Category 1 or Category 2 as described below. WHO guidelines state that the “species listed in Category 1 within a country, territory or area should be considered as being of highest priority for antivenom production on the basis that available knowledge implicates them as being responsible for the greater burden in that particular setting.” 160

WHO Category 1: Venomous Snakes of Highest Medical Importance

Defined as “highly venomous snakes which are common or widespread and cause numerous snakebites, resulting in high levels of morbidity, disability or mortality.”

WHO Category 2: Venomous Snakes of Secondary Medical Importance

Defined as “highly venomous snakes capable of causing morbidity, disability or death, for which exact epidemiological or clinical data may be lacking; and/or which are less frequently implicated (due to their activity cycles, behavior, habitat preferences or occurrence in areas remote to large human populations).”

NOTE: Antivenom Infusion versus Direct Push: For most first line antivenoms in this CPG, administration using either a) 100, 250, or 500 mL IV bag of isotonic fluids (0.9% NS ideal; Lactated Ringers is acceptable) with 10-minute IV/IO infusion or b) direct IV push is recommended in order to get a full dose of antivenom onboard as quickly as possible and neutralize venom before further damage has occurred. However, if this is not possible you may dilute antivenom in any size bag of isotonic solution and give over 10 – 30 minutes. While the amount of antivenom given should not change based upon the patient’s size, smaller volumes of fluids may be indicated in pediatric patient’s to avoid volume overload.

CONTACT: For emergency consultations, or additional information about snake bite management or this CPG, call the ADVISOR telemedicine hotline 833-ADVSRLN (833-238-7756) / DSN: 312-429-9089 and select toxicology from the phone menu.