Page 71 - JSOM Summer 2020

elsewhere in the CPG. Reassess the patient once the reaction temperatures of ≤ 25° C/77° F. Lyophilized product that likely re-
has been controlled and resume the infusion at a slower rate tains stability at higher temperatures for field excursions (likely
if any of the specific criteria for antivenom treatment listed stable for several months at higher temps based on data from simi-
elsewhere in the CPG have not completely resolved. lar products). Recommend carrying full dose into field on extended
operations in austere environments and storing larger quantities at
INDOPACOM – ANTIVENOM RECOMMENDATIONS strategically located Role 2 & 3 facilities in INDOPACOM AOR.
INDOPACOM – SOUTHEAST ASIA (BROAD-SPECTRUM Adverse reactions: High efficacy and low incidence of serious ad-
HEMO/CYTOTOXIC) FREEZE-DRIED/UNREFRIGERATED verse reactions based on current publications.
Thai Red Cross, Thailand: Hemato Polyvalent Antivenom 1. Indications: Polyvalent antivenom directly indicated for the
(TRC-HPAV) 61,190,191,210–212 treatment of hemotoxic and cytotoxic envenomation syn-
First line (INDOPACOM–SOUTHEAST ASIA): Broad-spectrum dromes caused by Ophiophagus hannah, Naja kaouthia, Bun-
treatment option for all hemotoxic and cytotoxic snake enven- garus candidus, and B. fasciatus candidus. Has demonstrated
omations by known or unknown species in Southeast Asia. Best efficacy against other related species of Asian cobras and
regional polyvalent. kraits; is not directly indicated for these species but is the best
hemotoxic/cytotoxic polyvalent in the region and should be
Feasibility of use in austere environments: RECOMMENDED for tried as the first line in most cases.
operational settings. Unrefrigerated storage at ambient tropical 2. Pretreatment: NOT ROUTINELY INDICATED unless patient
temperatures of ≤ 25° C/77° F. Lyophilized product that likely re- is unstable, asthmatic/atopic, known hypersensitivity or other
tains stability at higher temperatures for short excursions (likely pretreatment criteria met. Low risk of severe allergic reactions
up to several months). Recommend carrying full dose into field and other EARs.
on extended operations in austere environments and storing larger 3. Initial dosing by syndrome:
quantities at strategically located Role 2 & 3 facilities in INDO- a. NEUROTOXIC initial dose = 10 vials
PACOM AOR.
i. King cobra (O. hannah) bites likely to require much
Adverse reactions: High efficacy against and low incidence of seri- higher doses of antivenom due to massive venom yield;
ous adverse reactions based on current publications. it is not unusual to require dozens of vials in these cases.
1. Indications: Polyvalent antivenom directly indicated for the b. NOT INDICATED FOR HEMOTOXIC
treatment of hemotoxic and cytotoxic envenomation syn- c. NOT INDICATED FOR CYTOTOXIC
dromes caused by Calloselasma rhodostoma, Trimersurus 4. Additional dosing: Additional 5 vials TRC-NPAV may be
albolabris, and Daboia russelli siamensis. Has demonstrated given at hours 2, 4, 6, 12, and 24 if needed. Bites from large
efficacy against other related species of Asian vipers within king cobras may require several dozen vials or more due to
the same genera (Crytelytrops, Popeia, Daboia, etc.); is not massive venom yield.
directly indicated for these species but is the best hemotoxic/ 5. Preparation and administration: Dilute the entire dose of an-
cytotoxic polyvalent in the region and should be tried as first tivenom in a single 250–500 mL bag of isotonic solution and
line in most cases. administer by intravenous infusion over 10–30 minutes.
2. Pretreatment: NOT ROUTINELY INDICATED unless patient a. If a mild or moderate reaction occurs, slow the infusion and
is unstable, asthmatic/atopic, known hypersensitivity or other treat symptomatically with antihistamines, steroids, and/or
pretreatment criteria met. Low risk of severe allergic reactions antiemetics as needed.
and other EARs. b. If a severe reaction such as anaphylaxis occurs, stop the
3. Initial dosing by syndrome: infusion and treat according to the anaphylaxis protocol
a. NOT INDICATED FOR NEUROTOXIC listed elsewhere in the CPG. Reassess the patient once the
b. HEMOTOXIC initial dose = 10 vials reaction has been controlled and resume the infusion at
c. CYTOTOXIC initial dose = 10 vials a slower rate if any of the specific criteria for antivenom
4. Additional dosing: Additional 2 vials TRC-HPAV may be given treatment listed elsewhere in the CPG have not completely
at hours 2, 4, 6, 12, and 24 if needed. resolved.
5. Preparation and administration: Dilute the entire dose of an-
tivenom in a single 250–500 mL bag of isotonic solution and INDOPACOM – SOUTHEAST CHINA/NORTH LAOS/
administer by intravenous infusion over 10–30 minutes. NORTH VIETNAM FREEZE-DRIED/REFRIGERATED
a. If a mild or moderate reaction occurs, slow the infusion and National Institute Preventative Medicine, Taiwan: Naja atra/
treat symptomatically with antihistamines, steroids, and/or Bungarus multicinctus Bivalent (NIPM-NBB) 216–224
antiemetics as needed. First line (INDOPACOM–TAIWAN/SOUTHEAST CHINA/
b. If a severe reaction such as anaphylaxis occurs, stop the in- NORTH LAOS/NORTH VIETNAM): Bivalent treatment option
fusion and treat according to the anaphylaxis protocol listed for neurotoxic cobra and krait envenomations in East Asia.
elsewhere in the CPG. Reassess the patient once the reaction Feasibility of use in austere environments: CONDITIONALLY
has been controlled and resume the infusion at a slower rate
if any of the specific criteria for antivenom treatment listed RECOMMENDED for operational settings during short excur-
sions. Lyophilized but requires cold chain refrigeration below
elsewhere in the CPG have not completely resolved.
10° C (50° F); however, testing by Taiwanese CDC showed no loss
of potency after 30 days of incubation at 35° C/95° F and also af-
INDOPACOM – SOUTHEAST ASIA (BROAD-SPECTRUM
NEUROTOXIC) FREEZE-DRIED/UNREFRIGERATED ter it was returned to refrigerated storage for 4 months thereafter.
Thai Red Cross, Thailand: Neuro Polyvalent Antivenom Recommend carrying full dose into field on extended operations
(TRC-NPAV) 61,190,211,213–215 in austere environments and storing larger quantities at regional
Role 2 & 3 facilities.
First line (INDOPACOM–SOUTHEAST ASIA): Broad-spectrum
treatment option for all neurotoxic snake envenomations by known Adverse reactions: High efficacy and low incidence of serious ad-
or unknown species in Southeast Asia. Best regional polyvalent. verse reactions based on current publications.
1. Indications: Polyvalent antivenom directly indicated for the
Feasibility of use in austere environments: RECOMMENDED for treatment of hemotoxic and cytotoxic envenomation syndromes
operational settings. Unrefrigerated storage at ambient tropical

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