Page 70 - JSOM Summer 2020

neutralization but this has not been researched. 181–186 The 6 a. NEUROTOXIC initial dose = 2 vials
species listed below are the official treatment indications rec- b. HEMOTOXIC initial dose = 1–2 vials
ommended by the manufacturer: c. CYTOTOXIC initial dose = 1–2 vials
a. NEUROTOXIC: Walterinnesia aegyptia, Naja haje 4. Additional dosing: Additional doses of 1 vial VIPERFAV may
b. HEMOTOXIC and/or CYTOTOXIC: Bitis arietans, Echis be given at hours 2, 4, 6, 12, and 24 if needed.
coloratus, Echis carinatus, Cerastes cerastes 5. Preparation and administration: Dilute the entire dose of an-
2. Initial dosing by syndrome: tivenom in a single 100 mL bag of isotonic solution and ad-
a. NEUROTOXIC initial dose = 10 vials minister by intravenous infusion over 10 minutes.
b. HEMOTOXIC initial dose = 5 vials a. If a mild or moderate reaction occurs, slow the infusion and
c. CYTOTOXIC initial dose = 5 vials treat symptomatically with antihistamines, steroids, and/or
3. Additional dosing: Additional doses of 5 vials NAVPC-C may antiemetics as needed.
be given at hours 2, 4, 6, 12, and 24 if needed. b. If a severe reaction such as anaphylaxis occurs, stop the in-
4. Pretreatment: RECOMMENDED for this antivenom due to fusion and treat according to the anaphylaxis protocol listed
insufficient evidence for determining risk of EARs. Administer elsewhere in the CPG. Reassess the patient once the reaction
0.25 mg epinephrine injected SQ prior to beginning antivenom has been controlled and resume the infusion at a slower rate
infusion to reduce the risk of a serious reaction. Pediatric doses if any of the specific criteria for antivenom treatment listed
should be weight based at a dose of 0.01 mg/kg, up to 0.25 mg. elsewhere in the CPG have not completely resolved.
5. Preparation and administration: Dilute the entire dose of anti-
venom in a single 250–500 mL bag of isotonic solution and EUCOM – UK/SCANDINAVIA
administer by intravenous infusion over 10–30 minutes. FREEZE-DRIED/REFRIGERATED
a. If a mild or moderate reaction occurs, slow the infusion and Micropharm, UK: ViperaTAb (VIPERATAB) 200,204,207–209
treat symptomatically with antihistamines, steroids, and/or First line (EUCOM–UK/SCANDINAVIA): Single-source treat-
antiemetics as needed. ment option for neurotoxic, hemotoxic, and cytotoxic snake
b. If a severe reaction such as anaphylaxis occurs, stop the in- envenomations by the most medically and epidemiologically sig-
fusion and treat according to the anaphylaxis protocol listed nificant species in the UK and Scandinavia (Vipera berus) with
elsewhere in the CPG. Reassess the patient once the reaction paraspecific coverage against some other European Vipera species.
has been controlled and resume the infusion at a slower rate Second line (EUCOM–OUTSIDE OF UK/SCANDINAVIA): Sec-
if any of the specific criteria for antivenom treatment listed ond line treatment option for all neurotoxic, hemotoxic, and cy-
elsewhere in the CPG have not completely resolved.
totoxic snake envenomations in the EUCOM AOR outside of the
UK and Scandinavia if first line (VIPERFAV) is not available.
EUCOM – ANTIVENOM RECOMMENDATIONS
Feasibility of use in austere environments: NOT RECOM-
EUCOM – OUTSIDE UK/SCANDINAVIA
FREEZE-DRIED/REFRIGERATED MENDED for operational settings. Requires cold chain refrigera-
Sanofi-Pasteur, France: Viperfav (VIPERFAV) 200–206 tion between 2–8° C (35.6–46.4° F). Recommend storing several
First line (EUCOM–EUCOM OUTSIDE UK/SCANDINAVIA): vials at a small number of strategically located Role 2 & 3 facilities.
Likely to retain efficacy for several weeks in the field but should
Single-source treatment option for neurotoxic, hemotoxic, and
cytotoxic snake envenomations by the most medically and epide- be disposed of after that duration of time outside refrigeration.
miologically significant species in Europe (Vipera berus, V. aspis, Adverse reactions: High efficacy against UK/Scandinavian Euro-
V. ammodytes) with paraspecific coverage against other European pean viper (Vipera berus) envenomations and low incidence of
Vipera species. Can be used in the EUCOM AOR when the caus- serious adverse reactions based on current publications.
ative species is unknown or species for which this product is di- 1. Indications: Polyvalent antivenom directly indicated for the
rectly indicated. treatment of neurotoxic, hemotoxic, and cytotoxic envenom-
ation syndromes caused by Vipera berus. Has demonstrated
Second line (EUCOM–UK/SCANDINAVIA): Second line treat- efficacy against other species of European vipers (V. aspis,
ment option for all neurotoxic, hemotoxic, and cytotoxic snake V. ammodytes) as well but is not directly indicated for these
envenomations within the UK and Scandinavia if first line (VI- species.
PERATAB) is not available.
2. Pretreatment: NOT ROUTINELY INDICATED unless patient
Feasibility of use in austere environments: NOT RECOM- is unstable, asthmatic/atopic, known hypersensitivity or other
MENDED for operational settings. Requires cold chain refrigera- pretreatment criteria met. Low risk of severe allergic reactions
tion between 2–8° C (35.6–46.4° F). Recommend storing several and other EARs.
vials at a small number of strategically located Role 2 & 3 facilities. 3. Initial dosing by syndrome:
Likely to retain efficacy for several weeks in the field but should a. NEUROTOXIC initial dose = 2 vials
be disposed of after that duration of time outside refrigeration. b. HEMOTOXIC initial dose = 2 vials
c. CYTOTOXIC initial dose = 2 vials
Adverse reactions: High efficacy against all major syndromes 4. Additional dosing: Additional 2 vials VIPERATAB may be
and low incidence of serious adverse reactions based on current given at hours 2, 4, 6, 12, and 24 if needed.
publications.
1. Indications: Polyvalent antivenom directly indicated for the 5. Preparation and administration: Each box of VIPERATAB
comes with two 4 mL vials of antivenom (one box = one dose).
treatment of neurotoxic, hemotoxic, and cytotoxic envenom- Dilute the entire dose of antivenom in a single 100 mL bag of
ation syndromes caused by Vipera berus, V. aspis, V. ammo- isotonic solution and administer by intravenous infusion over
dytes but has demonstrated efficacy against other species of 10 minutes.
European vipers (genus Vipera) as well. a. If a mild or moderate reaction occurs, slow the infusion and
2. Pretreatment: NOT ROUTINELY INDICATED unless patient treat symptomatically with antihistamines, steroids, and/or
is unstable, asthmatic/atopic, known hypersensitivity or other antiemetics as needed.
pretreatment criteria met. Low risk of severe allergic reactions b. If a severe reaction such as anaphylaxis occurs, stop the in-
and other EARs.
3. Initial dosing by syndrome: fusion and treat according to the anaphylaxis protocol listed

68 | JSOM Volume 20, Edition 2 / Summer 2020