In rare cases, a patient may rapidly deteriorate in the first 5 - 30 minutes after the bite and present with profound hypotension, tachycardia, angioedema, altered level of consciousness, etc.^1,122–130 These patients should be aggressively treated for severe anaphylaxis and severe envenomation simultaneously. Treat anaphylaxis aggressively according to anaphylaxis protocols. Treat the envenomation with an initial high dose (at least 6 vials) of antivenom by rapid IV push, and support the patient with airway management, fluids, and other interventions as appropriate.^{122,123,125,131,132} Most patients presenting with hypotension or angioedema are responsive to epinephrine, but may require IV epinephrine infusions to achieve this effect if they are unresponsive to IM epinephrine.¹²²

SUDDEN COLLAPSE SYNDROME TREATMENT PROTOCOL

Patient presents within 30 minutes of the bite with rapid onset shock (hypotension with inadequate tissue perfusion) ± angioedema, altered mental status, systemic bleeding, and/or diarrhea.¹ Stabilize with IM or IV epinephrine and fluids as per anaphylaxis protocols.

4. Intubate for airway edema if not rapidly responsive to epinephrine.

5. Follow epinephrine immediately with a high dose of the appropriate regional antivenom given by rapid IV or IO push during the resuscitation.

6. Maintain blood pressure with IV or IO fluids and epinephrine until antivenom has taken effect to reverse the hypotension.