Page 50 - JSOM Summer 2020

2. Standard epinephrine pretreatment protocol: 1. Serum sickness may be uncomfortable but it is not dangerous.
a. Adult dose is 0.25 mg of 1:1000 epinephrine given by SQ in- a. Management is either symptomatic with antihistamines,
jection several minutes prior to antivenom administration. acetaminophen, etc or with a course of oral steroids for
b. Pediatric doses should be weight based at a dose of 0.01 patients who are in significant discomfort 94,95,97–99
mg/kg, up to 0.25 mg. 60,134,135,137,138
c. Patients with signs of shock should be given epinephrine by
IM injection in the lateral thigh Special Situations
How to Proceed if Antivenom Is Not Available
– Antivenom is the gold standard of care for symptomatic snake
Management of Mild, Moderate, and envenomations and early treatment is the best strategy to pre-
Severe Antivenom Reactions vent death, amputation, or other serious disability. Manage-
If signs and symptoms of an early adverse reaction develop ment of snake envenomations when antivenom is not available
during administration of antivenom: should be directed at getting the patient to the antivenom (or
a. Mild or moderate reaction during infusion: vice versa) as quickly as possible to prevent irreversible dam-
i. Stop the infusion and manage mild or moderate reac- age to organs and tissues.
tions (e.g. nausea, vomiting, urticaria, pruritus, chills, – Mission planning before deployment should include research and
fever, etc) symptomatically as needed with antiemetics, procurement of the appropriate regionally specific antivenom(s)
antihistamines, steroids, etc. Reassess the patient once recommended in this CPG for your area of operation. If currently
the reaction has been controlled; if the antivenom treat- deployed without antivenom, efforts to acquire the appropriate
ment criteria for cytotoxic, hemotoxic, or neurotoxic antivenom(s) recommended in this CPG for your area of oper-
syndromes have not resolved completely then resume ations should be initiated through proper channels as fake or
the infusion at a slower rate over 30 minutes. low-quality antivenoms are frequently found in local pharmacies
ii. If giving via push, dilute the remaining dose of anti- throughout Africa and elsewhere in the developing world.
venom in a 100 mL bag of normal saline and give as – For specific management until antivenom can be obtained,
30-minute infusion. follow the checklist and skip the steps related to antivenom
b. Severe reaction (anaphylaxis) during infusion: administration until it has been obtained.
i. Stop the infusion and treat according to the anaphylaxis – Refer to step No. 11 for specific recommendations on support-
treatment protocol. Reassess the patient once the reac- ive care measures
tion has been controlled; if the antivenom treatment cri- Military Working Dogs/Multipurpose Canines
teria for cytotoxic, hemotoxic, or neurotoxic syndromes – All antivenoms can be administered to MWDs/MPCs accord-
have not resolved completely then resume the infusion ing to the same treatment criteria and initial doses listed in
at a slower rate over 30 minutes. this CPG; all other management should be based on the MWD
ii. If giving via push, dilute the remaining dose of anti- CPG.
venom in a 100–250 mL bag of normal saline and give
as 30-minute infusion. Late Presentations and Treatment Delays
c. If the reaction reoccurs: – There is NO DEFINED TIME LIMIT to antivenom therapy
i. Stop the infusion and consult a physician expert via tele- for a symptomatic snakebite. Early antivenom within the first
medicine to discuss next steps for management. minutes or hours after a bite is the best means of preventing
morbidity or mortality, but antivenom remains effective at re-
Anaphylaxis Treatment Protocol 15,60,94,98,127,128,139–145 solving reversible issues like coagulopathy and preventing fur-
NOTE: Intubate for airway edema not rapidly responsive to ther irreversible tissue damage even in patients who present
epinephrine. many hours or days after the snakebite. 56,69,78,146,147
1. If anaphylaxis occurs after antivenom administration, treat ac-
cording to the following protocol: Outdated Interventions That Should Not Be Performed
a. First line treatment of anaphylaxis is rapid administration – DO NOT cut, suck, electrocute, burn, or use chemicals on the
of 1:1000 epinephrine (initial adult dose = 0.5 mg IM in envenomation site.
the lateral thigh for rapid absorption). Epinephrine can be – DO NOT apply constricting bandages, tourniquets or other
repeated as needed until the patient has stabilized and/or circulation-reducing interventions
an intravenous or intraosseous infusion administered as – DO NOT use venom extractors or other commercial snakebite
per standard protocols if the patient fails to respond to IM first aid kits 148–152
doses. – DO NOT administer test doses of antivenom to check for hy-
i. Epinephrine should always be given prior to antihista- persensitivity as these are ineffective and waste both time and
mines or steroids to counter the immediate life-threats antivenom. 60–63
of bronchospasm and vasodilation. – DO NOT administer antihistamines or steroids as prophylac-
b. After epinephrine has been given: tic pretreatment for prevention of anaphylaxis or other early
i. Give methylprednisolone 125 mg IV. adverse reactions (EARs) to antivenom as neither is effective as
ii. Give diphenhydramine or promethazine 50 mg IV. a premedication. 133,134
iii. Consider adding an H2 antihistamine such as ranitidine.
2. If anaphylaxis occurs during administration of antivenom, Management of Ocular Envenomation by
stop the antivenom administration to treat the reaction then Spitting Cobras (Venom Opthalmia)
resume the antivenom administration as described below.
Spitting cobras have modified fangs that allow them to spray
Management of Late Reactions to Antivenom venom into the eyes of a predator or perceived threat. 153–155 The
(Serum Sickness) venom spray widens like buckshot as it travels and the snakes aim
Serum sickness is characterized by flu-like symptoms ± rash that at the glint of sunlight reflecting off of the target’s eyes. The venom
typically develops between 1–3 weeks after antivenom administra- is harmless unless it enters the eyes (causing instantaneous burning,
tion. Serum sickness may be uncomfortable but it is not dangerous. lacrimation, blurred vision, etc.) or the bloodstream by injection

48 | JSOM Volume 20, Edition 2 / Summer 2020