Page 74 - JSOM Summer 2020

pretreatment criteria met. Low risk of severe allergic reactions BTG Therapeutics, United States: CroFab (CROFAB) 94,95,101,236,237
and other EARs. a. FREEZE-DRIED/REFRIGERATED
5. Preparation and administration: Dilute the entire dose of anti- b. Indications: Envenomation by all Pit Viper species (rattle-
venom in a single 100 mL bag of isotonic solution and admin- snakes, copperheads, cottonmouths) in North America.
ister by intravenous infusion over 10 minutes. Freeze-dried; requires refrigeration but one study has
a. If a mild or moderate reaction occurs, slow the infusion and demonstrated that it will maintain efficacy under field con-
treat symptomatically with antihistamines, steroids, and/or ditions for ≥ 90 days if needed.
antiemetics as needed. c. Initial dosing: 4–6 vials
b. If a severe reaction such as anaphylaxis occurs, stop the in- RDT/Instituto Bioclon, United States/Mexico: ANAVIP
fusion and treat according to the anaphylaxis protocol listed (ANAVIP) 92
elsewhere in the CPG. Reassess the patient once the reaction a. FREEZE-DRIED/UNREFRIGERATED
has been controlled and resume the infusion at a slower rate b. Indications: Currently only indicated by FDA for rattle-
if any of the specific criteria for antivenom treatment listed snake envenomations. Not currently indicated for copper-
elsewhere in the CPG have not completely resolved.
head or cottonmouth envenomations, although this may
INDOPACOM – MALUKU ISLANDS/ change in the near future depending on results of upcoming
WEST PAPUA ISLANDS LIQUID/REFRIGERATED studies. Freeze dried and field-stable at room temperature
of 25° C/77° F.
Commonwealth Serum Laboratories, Australia: Polyvalent (CSL-P) c. Initial dosing: 10 vials
First Line (INDOPACOM–MALUKU/WEST PAPUA ISLANDS
ONLY): Neurotoxic envenomation in INDOPACOM by Austral- Pfizer, United States: North American Coral Snake Antivenom
asian elapids or unknown species occurring East of Wallace’s line. (NACSA) 238
a. FREEZE-DRIED/REFRIGERATED
Feasibility of use in austere environments: NOT RECOM-
MENDED for operational settings. Requires cold chain refrigera- b. Indications: Indicated for envenomations by North Ameri-
can coral snake species in the United States including East-
tion between 2–8° C (35.6–46.4° F). Recommend storing several
vials at a small number of strategically located Role 2 & 3 fa- ern coral snake (Micrurus fulvius) and Texas coral snake
(Micrurus tener). Store between 2–8° C/35.6–46.4° F; how-
cilities. Likely to retain efficacy during short excursion at higher
ever, likely retains stability for short excursions in the field.
temperatures for several weeks in the field but should be disposed c. Initial dosing: 5 vials
of and replaced afterwards.
Adverse reactions: High-quality product with low rates of reac- SOUTHCOM – ANTIVENOM RECOMMENDATIONS
tions anticipated. SOUTHCOM – ENTIRE AOR
1. Indications: This polyvalent can be used to treat neurotoxic FREEZE-DRIED/UNREFRIGERATED
envenomations by the most medically significant species of Instituto Bioclon, Mexico: ANTIVIPMYN-TRI
Australasian elapid snakes found East of Wallace’s line. 239–243
2. Initial dosing by syndrome: (BIOCL-AVT)
a. NEUROTOXIC syndrome initial dose = 3 vials First Line (SOUTHCOM–ENTIRE SOUTHCOM AOR):
BROAD-SPECTRUM treatment option for all hemotoxic and
b. HEMOTOXIC syndrome initial dose = 3 vials cytotoxic snake envenomations anywhere in the SOUTHCOM
c. NOT INDICATED for cytotoxic envenomations AOR when the causative species is either unknown or among the
3. Additional dosing: Additional doses of 1 vials CSL-P may be ≥ 14 snakes for which this product is directly indicated. Directly
given at hours 2, 4, 6, 12, and 24 if needed. or indirectly covers most of the WHO category 1 and category 2
4. Pretreatment: NOT ROUTINELY INDICATED unless patient snakes in this region.
is unstable, asthmatic/atopic, known hypersensitivity or other
pretreatment criteria met. Low risk of severe allergic reactions Feasibility of use in austere environments: RECOMMENDED for
and other EARs. operational settings. Unrefrigerated storage at ambient tropical
5. Preparation and administration: Dilute the entire dose of an- temperatures of ≤ 37° C/98.6° F. Lyophilized product that likely
tivenom in a single 100 mL bag of isotonic solution and ad- retains stability at higher temperatures for short excursions. Rec-
minister by intravenous infusion over 10 minutes. ommend carrying full dose or loading dose (≥ 5 vials) into field on
a. If a mild or moderate reaction occurs, slow the infusion and extended operations in austere environments and storing larger
treat symptomatically with antihistamines, steroids, and/or quantities at strategically located Role 2 & 3 facilities in SOUTH-
antiemetics as needed. COM AOR.
b. If a severe reaction such as anaphylaxis occurs, stop the in- Adverse reactions: High-quality product with low rates of reac-
fusion and treat according to the anaphylaxis protocol listed tions anticipated.
elsewhere in the CPG. Reassess the patient once the reaction 1. Indications: This broad-spectrum polyvalent can be used to
has been controlled and resume the infusion at a slower rate treat hemotoxic and cytotoxic envenomations by more than 14
if any of the specific criteria for antivenom treatment listed different species of Central and South American snakes. It may
elsewhere in the CPG have not completely resolved.
be able to neutralize venom from additional species through
NORTHCOM – ANTIVENOM RECOMMENDATIONS paraspecific neutralization but this has not been officially de-
termined. The species listed below are the official treatment
NORTHCOM – UNITED STATES/CANADA indications recommended by the manufacturer:
FOR ALL NORTHCOM ANTIVENOMS, REFER TO THE a. HEMOTOXIC and/or CYTOTOXIC: Crotalus durissis
PACKAGE INSERT IN THE ANTIVENOM BOX FOR SPE- terrificus; Bothrops asper, B. atrox, B. neuwiedii, B. alter-
CIFIC USAGE INSTRUCTIONS AS PER FDA REGULATIONS natus, B. jararacussu, B. venezulensis, B. pictus, B. brazili;
FOR DOMESTICALLY APPROVED PRODUCTS. Lachesis muta muta, L. m. stenophyrs; Sistrurus spp.; Agk-
istrodon spp.
Also see Unified treatment algorithm for the management of cro- 2. Pretreatment: NOT ROUTINELY INDICATED unless patient
taline snakebite in the United States (Lavonas et al. 2011) for spe- is unstable, asthmatic/atopic, known hypersensitivity or other
cific dosing and management guidelines on pit viper bites. 101,235
pretreatment criteria met.

72 | JSOM Volume 20, Edition 2 / Summer 2020