Page 68 - JSOM Summer 2020

AFRICOM – NORTH AFRICA LIQUID/REFRIGERATED causative species is either unknown or among the 27 snakes for
National Antivenom & Vaccine Production Center, Saudi which this product is directly indicated. Directly or indirectly cov-
Arabia: Polyvalent Snake Antivenom (NAVPC-P) ers all WHO category 1 species in the region. Directly or indirectly
Second line (AFRICOM–NORTH AFRICA): Unknown neuro- covers all category 2 snakes in this region for which an antivenom
toxic, hemotoxic, or cytotoxic envenomation with no indications currently exists except for Gloydius halys, which is covered by
of improvement after 10 vials of POLYSERP-M. Directly or indi- Shanghai SIOBP-G or Iranian RAZI-P. Paraspecific neutralization
rectly covers some of the WHO category 1 and category 2 snakes against Gloydius unknown but not anticipated.
in this region for which an antivenom currently exists.
Feasibility of use in austere environments: RECOMMENDED for
Second line (CENTCOM–ARABIAN PENINSULA): Unknown use in operational settings and specifically designed to fill the ca-
neurotoxic, hemotoxic, or cytotoxic envenomation with no in- pability gap for ground medics operating in these areas. Updated
dications of improvement after 10 vials of POLYSERP-M. Only version of Inoserp MENA made specifically for the austere and
for Arabian Peninsula, very limited utility further East. Directly operational medicine environment. Freeze-dried, unrefrigerated,
or indirectly covers most of the WHO category 1 and category stable at temperatures > 100° F for at least 180 days without loss
2 snakes in this region for which an antivenom currently exists. of efficacy. Broad coverage and simple dosing enable adminis-
tration in the field for any symptomatic snakebite by unknown
Feasibility of use in austere environments: NOT RECOM- species in this region. Special operations and conventional units
MENDED for operational settings. Requires refrigeration, mod-
erate to high rates of adverse reactions are anticipated. Better deploying to austere operational environments and areas with
critical threat venomous species should carry 8 vials per medic.
alternatives exist. If purchased it should be kept at Role 2 & 3
facilities in the Arabian Peninsula. It is recommended that a reserve quantity is stocked in all role 2
and role 3 facilities in AFRICOM in case additional antivenom
Adverse reactions: Insufficient evidence to determine risk of ad- is needed upon arrival, and also to restock field medics that have
verse reactions at this time. used their supply.
1. Indications: This polyvalent can be used to treat neurotoxic and Adverse reactions: High efficacy against all major syndromes and
cytotoxic envenomations by 6 different species of Middle East- low incidence of serious adverse reactions of approximately 1%
ern, North African, and Central Asian snakes. It may be able based on current publications. 165–172
to neutralize venom from additional species through paraspe-
cific neutralization but this has not been researched. 181–186 The 1. Indications: Broad spectrum polyvalent directly indicated for
the treatment of neurotoxic, hemotoxic, and cytotoxic enven-
6 species listed below are the official treatment indications rec-
ommended by the manufacturer: omation syndromes caused by 27 different species of Middle
Eastern, North African, and Central Asian snakes from the
a. NEUROTOXIC: Walterinnesia aegyptia, Naja haje
b. HEMOTOXIC and/or CYTOTOXIC: Bitis arietans, Echis families Elapidae and Viperidae. First line for snake envenom-
ations in this region when the causative species is unknown or
coloratus, Echis carinatus, Cerastes cerastes
2. Initial dosing by syndrome: among the species for which the product is directly indicated.
a. NEUROTOXIC: Naja haje, N. oxiana; Walterinnesia
a. NEUROTOXIC initial dose = 10 vials
aegyptia
b. HEMOTOXIC initial dose = 5 vials b. CYTOTOXIC and/or HEMOTOXIC: Bitis arietans; Cer-
c. CYTOTOXIC initial dose = 5 vials
3. Additional dosing: Additional doses of 5 vials NAVPC-C may astes cerastes, C. vipera, C. gasperettii; Daboia palestinae,
D. mauritanica, D. deserti; Echis. carinatus sochureki, E.
be given at hours 2, 4, 6, 12, and 24 if needed.
4. Pretreatment: RECOMMENDED for this antivenom due to coloratus, E. khosatskii, E. leucogaster, E. megalocephalus,
E. omanensis, E. pyramidum; Macrovipera lebetina obtusa,
insufficient evidence for determining risk of EARs. Administer
0.25 mg epinephrine injected SQ prior to beginning antivenom M. l. transmediterranea, M. l. turanica; Montivipera born-
muelleri, M. raddei kurdistanica; Naja nubiae, N. pallida;
infusion to reduce the risk of a serious reaction. Pediatric doses
should be weight based at a dose of 0.01 mg/kg, up to 0.25 mg. Pseudocerastes persicus persicus, P. fieldi; Vipera latastei
5. Preparation and administration: Dilute the entire dose of an- 2. Pretreatment: NOT ROUTINELY INDICATED unless patient
tivenom in a single 250–500 mL bag of isotonic solution and is unstable, asthmatic/atopic, known hypersensitivity or other
pretreatment criteria met. Low risk of severe allergic reactions
administer by intravenous infusion over 10–30 minutes.
and other EARs.
a. If a mild or moderate reaction occurs, slow the infusion and 3. Initial dosing by syndrome:
treat symptomatically with antihistamines, steroids, and/or
antiemetics as needed. a. NEUROTOXIC initial dose = 6 vials
b. If a severe reaction such as anaphylaxis occurs, stop the b. HEMOTOXIC initial dose = 6 vials
c. CYTOTOXIC initial dose = 6 vials
infusion and treat according to the anaphylaxis protocol 4. Additional dosing: Additional doses of 2 vials POLYSERP-M
listed elsewhere in the CPG. Reassess the patient once the
may be given at hours 2, 4, 6, 12, and 24 if needed.
reaction has been controlled and resume the infusion at 5. Preparation and administration: Reconstitute every 2 vials of
a slower rate if any of the specific criteria for antivenom
treatment listed elsewhere in the CPG have not completely POLYSERP-M in the same 10 mL syringe by mixing the first
vial, drawing it back up into syringe, and injecting it into the
resolved.
second vial to yield 2 vials/1 syringe (6 vial dose = 3 syringes
total). Administer sequentially via slow, continuous direct IV
CENTCOM – ANTIVENOM RECOMMENDATIONS
or IO push over approximately 2 minutes each. If a reaction
CENTCOM – MIDDLE EAST/CENTRAL ASIA/ARABIAN occurs stop the push, treat the reaction, reassess response to
PENINSULA FREEZE-DRIED/UNREFRIGERATED treatment criteria. Dilute remaining dose in a 100 mL bag of
POLYSERP/Inosan, Spain: POLYSERP MENA Polyvalent isotonic fluids and administer via slow IV or IO infusion over
(POLYSERP-M) 30 minutes if needed.
First line (CENTCOM–ARABIAN PENINSULA/MIDDLE EAST/ a. Direct push is recommended for convenience, but POLY-
CENTRAL ASIA): BROAD-SPECTRUM treatment option for all SERP-M may also be administered via IV or IO infusion.
neurotoxic, hemotoxic, and cytotoxic snake envenomations in the Mix in a 50 mL or 100 mL bag of isotonic fluids and ad-
Arabian Peninsula, the Middle East, and Central Asia when the minister the entire bag over 5–10 minutes.
66 | JSOM Volume 20, Edition 2 / Summer 2020