Page 69 - JSOM Summer 2020

CENTCOM – MIDDLE EAST/CENTRAL ASIA Directly or indirectly covers all WHO category 1 species in the
LIQUID/REFRIGERATED region. Directly or indirectly covers some of the WHO category
Shanghai Institute of Biological Products, China: Agkistrodon 1 and category 2 snakes in this region for which an antivenom
(Gloydius) halys Monovalent Antivenom (SIOBP-G): currently exists.
Note that this product is listed as Agkistrodon halys on the SIOBP
website and product packaging but the taxonomy for this species Feasibility of use in austere environments: NOT RECOM-
MENDED for operational settings. Requires cold chain refrigera-
has changed. Agkistrodon halys was moved to the genus Gloydius tion. Recommend storing small quantities at strategically located
and should be listed as Gloydius halys as it is listed elsewhere. Role 2 & 3 facilities in CENTCOM AOR or selecting alternative
The product is abbreviated as SIOBP-G in the CPGs to account
for this correction. second line from this CPG.
Adverse reactions: Limited evidence but appears to be low based
First line (CENTCOM–MIDDLE EAST/CENTRAL ASIA): Mon- on current publications. 192–199
ovalent for the WHO category 2 species Gloydius halys. Indicated
only for confirmed envenomation by Gloydius halys or related 1. Indications: This polyvalent can be used to treat neurotoxic
and cytotoxic envenomations by 6 different species of Mid-
Gloydius species. Does not provide coverage against any other
WHO category 1 or category 2 species. dle Eastern, North African, and Central Asian snakes. It may
be able to neutralize venom from additional species through
Second line (CENTCOM–MIDDLE EAST/CENTRAL ASIA): In- paraspecific neutralization but this has not been researched.
dicated for unknown cytotoxic and/or hemotoxic envenomation The 6 species listed below are the official treatment indications
in Middle East or Central Asia with no signs of improvement after recommended by the manufacturer:
10 vials of POLYSERP-M. a. NEUROTOXIC: Naja oxiana
b. HEMOTOXIC and/or CYTOTOXIC: Pseudocerastes per-
Feasibility of use in austere environments: NOT RECOM- sicus fieldi, Echis carinatus, Vipera albicornuta, Vipera leb-
MENDED for operational settings. Requires cold chain refrigera-
etina obtusa, Agkistrodon (Gloydius) halys
tion. Recommend storing small quantities at strategically located 2. Pretreatment: NOT ROUTINELY INDICATED unless patient
Role 2 & 3 facilities in CENTCOM AOR.
is unstable, asthmatic/atopic, known hypersensitivity or other
Incidence of adverse reactions: Low to moderate rates of EARs pretreatment criteria met.
and serum sickness are anticipated but clinical evidence is 3. Initial dosing by syndrome:
limited. 187–189 a. NEUROTOXIC initial dose = 10 vials
1. Indications: This monovalent can be used to treat cytotoxic and b. HEMOTOXIC initial dose = 5 vials
hemotoxic envenomations by Gloydius halys, a pit viper native c. CYTOTOXIC initial dose = 5 vials
to the Middle East and Central Asia. It will most likely neutral- 4. Additional dosing: Additional doses of 5 vials RAZI-P may be
ize venom from related species in the genus Gloydius through given at hours 2, 4, 6, 12, and 24 if needed.
paraspecificity, but this has not been tested in detail. There are 5. Preparation and administration: Dilute the entire dose of an-
several publications indicating that it may also have paraspeci- tivenom in a single 250–500 mL bag of isotonic solution and
ficity against some of the Southeast Asian green pit vipers from administer by intravenous infusion over 10–30 minutes.
the genera Cryptelytrops and Trimeresurus. 190,191 However, it is a. If a mild or moderate reaction occurs, slow the infusion and
not currently indicated by the manufacturer for these species. treat symptomatically with antihistamines, steroids, and/or
a. HEMOTOXIC AND/OR CYTOTOXIC: Gloydius halys antiemetics as needed.
2. Initial dosing by syndrome: b. If a severe reaction such as anaphylaxis occurs, stop the in-
a. NOT INDICATED FOR NEUROTOXIC fusion and treat according to the anaphylaxis protocol listed
b. HEMOTOXIC initial dose = 2 vials elsewhere in the CPG. Reassess the patient once the reaction
c. CYTOTOXIC initial dose = 2 vials has been controlled and resume the infusion at a slower rate
3. Additional dosing: Additional doses of 2 vials SIOBP-G may if any of the specific criteria for antivenom treatment listed
be given at hours 2, 4, 6, 12, and 24 if needed. elsewhere in the CPG have not completely resolved.
4. Pretreatment: NOT ROUTINELY INDICATED unless patient
is unstable, asthmatic/atopic, known hypersensitivity or other CENTCOM – ARABIAN PENINSULA
pretreatment criteria met. LIQUID/REFRIGERATED
5. Preparation and administration: Dilute the entire dose of an- National Antivenom & Vaccine Production Center, Saudi
tivenom in a single 100 mL bag of isotonic solution and ad- Arabia: Polyvalent Snake Antivenom (NAVPC-P)
minister by intravenous infusion over 10 minutes. Second line (CENTCOM–ARABIAN PENINSULA): Unknown
a. If a mild or moderate reaction occurs, slow the infusion and neurotoxic, hemotoxic, or cytotoxic envenomation with no in-
treat symptomatically with antihistamines, steroids, and/or dications of improvement after 10 vials of POLYSERP-M. Only
antiemetics as needed. for Arabian Peninsula, very limited utility further East. Directly
b. If a severe reaction such as anaphylaxis occurs, stop the in- or indirectly covers most of the WHO category 1 and category
fusion and treat according to the anaphylaxis protocol listed 2 snakes in this region for which an antivenom currently exists.
elsewhere in the CPG. Reassess the patient once the reaction Feasibility of use in austere environments: NOT RECOMMENDED
has been controlled and resume the infusion at a slower rate
if any of the specific criteria for antivenom treatment listed for operational settings. Requires refrigeration, moderate to high
rates of adverse reactions are anticipated. Better alternatives exist.
elsewhere in the CPG have not completely resolved.
If purchased it should be kept at Role 2 & 3 facilities in the Arabian
Peninsula.
CENTCOM – MIDDLE EAST/CENTRAL ASIA
LIQUID/REFRIGERATED Adverse reactions: Insufficient evidence to determine risk of ad-
Razi Serum and Vaccine Research Institute, Islamic Republic of verse reactions at this time.
Iran: Polyvalent Snake Antivenom (RAZI-P) 1. Indications: This polyvalent can be used to treat neurotoxic and
Second line (CENTCOM–MIDDLE EAST/CENTRAL ASIA): cytotoxic envenomations by 6 different species of Middle East-
Unknown neurotoxic, hemotoxic, or cytotoxic envenomation with ern, North African, and Central Asian snakes. It may be able to
no indications of improvement after 10 vials of POLYSERP-M. neutralize venom from additional species through paraspecific

Global Snake Envenomation Management | 67