snake bite clinical pathways
DESCRIPTION
MedicalTRANSCRIPT
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ADULT PROTOCOLS & GUIDELINES Policy Number: NC-TWE-CLP-1716 Date Issued: 12/11/2004 Last Review Date: 01/06/2011 Next Review: 01/06/2013 Authority: Dr Robert Davies Network Director Emergency Medicine The Tweed / Byron Network
Authority Initial:
Page 1 of 9
SNAKEBITE MANAGEMENT
SUSPECTED OR ACTUAL SNAKE ENVENOMATION IS A MANDATORY NOTIFICATION
TO THE EMERGENCY PHYSICIAN ON DUTY OR ON CALL
Patients must be immediately assessed for signs of clinical envenoming.
REMEMBER THIS IS A POTENTIAL LIFE THREATENING EMERGENCY However most patients present with a history of possible bite and DO NOT require
immediate resuscitation. No clinical risk stratification that identifies patients who can be discharged early or
without laboratory investigations. Review NSW Health snake and spider bite guideline for more detailed information.
MAJOR FEATURES OF ENVENOMATION (See also TABLE 1Types of Snakes and Toxic Effects)
COAGULOPATHY
Can occur within 15/60 of bite. Is either secondary to procoagulant effect which stimulates fibrinolysis and results in complete defibrination (APTT/PT/Fibrinogen/FDPs) or due to anticoagulant effect which inhibits haemostatic system without fibrinolysis (APTT/PT but normal Fibrinogen). Evidence of bleeding may be seen from bite site, venepuncture sites, gums or urine. Risk of death exists from major haemorrhage particularly intracranial or gastrointestinal.
NEUROTOXICITY
Progressive flaccid paralysis of skeletal and respiratory muscles without affecting cardiac or smooth muscle. Can occur within 1 hour of bite but may be delayed up to 24 hours. Ptosis tends to occur first then ophthalmoplegia, dysarthria, dysphagia and drooling. Limb weakness follows then respiratory paralysis.
MYOTOXICITY
Potentially can cause widespread muscle destruction leading to secondary ARF and hyperkalaemia. Symptoms include muscle pain and tenderness. Myoglobinuria can occur. Note that dark urine positive for blood can indicate either coagulopathy or myoglobinuria.
CARDIOTOXICITY
Rare in Australian snakes. Persistent hypotension, collapse, pulmonary oedema and cardiac arrhythmias can occur. Remember that transient hypotension and collapse can be vasovagal in origin.
NECROTOXICITY
Extremely unusual with Australian snakes
Swelling at the bite site Headachecan be extremely severe Nausea & vomiting Abdominal Pain
Transient hypotension Transient LOC Tenderness or swelling over lymph nodes
NON SPECIFIC FEATURES OF ENVENOMATION
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ADULT PROTOCOLS & GUIDELINES Policy Number: NC-TWE-CLP-1716 Date Issued: 12/11/2004 Last Review Date: 01/06/2011 Next Review: 01/06/2013 Authority: Dr Robert Davies Network Director Emergency Medicine The Tweed / Byron Network
Authority Initial:
Page 2 of 9
SNAKEBITE MANAGEMENT
MANAGEMENT
DOES THE PATIENT HAVE ANY IMMEDIATELY LIFE THREATENING
SYMPTOMS OR SIGNS?
SIGNS OF ENVENOMING Any degree of cranial nerve paralysis Paralysis of large limb muscles Respiratory muscle paralysis respiratory failure Obvious myoglobinuria risk of rhabdomyolysis Evidence of active bleeding with uncontrolled haemorrhage
(severe VICC) Convulsions/seizures Hypotension
NO
ENVENOMING PATHWAY By evidence of immediate life threatening features
YES
See next page
Leave PIB in place until patient is stabilised, fully assessed and antivenom is given (if required)
FIRST AID (see Appendix A) Patient had had correct first aid applied
FIRST AID (see Appendix A) No effective first aid has been applied Apply PIB first aid
TREATMENT Triage to resuscitation area. Attend to ABC but be careful of causing bleeding. Cardiorespiratory support as indicated. Insert IV access x 2, give IV fluid load (if necessary) Laboratory investigations (See Tweed order sets). Collect urine and check for haemoglobin/myoglobin. Swab bite site (first line) or urine (second line) for
SVDK (See Appendix D) Commence IV antivenom (see table 2)
Do not wait for SVDK result take > 20 mins Start treatment with polyvalent antivenom. Once SVDK result obtained switch to
approved monovalent antivenom. Remove PIB half way through the antivenom infusion If further deterioration reapply PIB and continue therapy Consider tetanus immunoprophylaxis once patient stable
(e.g. only after coagulopahy resolved). Antibiotics not routinely given. Monitor fluid balance, catheterize if in doubt about urine
output.
ADMIT to ICU All patients who receive antivenom.
Repeat laboratory investigations every 12 hours after antivenom to monitor coagulopathy.
If coagulopathy not resolving and bleeding or high risk of bleeding - most likely Venom induced Consumptive coagulopathy (VICC) Consider coagulation factor replacement controversial. Seek advice from FACEM or toxicologist.
DO NOT
WASH BITE SITE
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ADULT PROTOCOLS & GUIDELINES Policy Number: NC-TWE-CLP-1716 Date Issued: 12/11/2004 Last Review Date: 01/06/2011 Next Review: 01/06/2013 Authority: Dr Robert Davies Network Director Emergency Medicine The Tweed / Byron Network
Authority Initial:
Page 3 of 9
YES
SNAKEBITE MANAGEMENT
MANAGEMENT
DO NOT
WASH BITE SITE
NO
Remember that in the absence of immediately life threatening symptoms or signs of envenoming you can wait for SVDK result to
allow selection of the appropriate monovalent antivenom.
DOES THE PATIENT HAVE ANY IMMEDIATELY LIFE THREATENING SYMPTOMS OR SIGNS?
SIGNS OF ENVENOMING Any degree of cranial nerve paralysis Paralysis of large limb muscles Respiratory muscle paralysis respiratory failure Obvious myoglobinuria risk of rhabdomyolysis Evidence of active bleeding with uncontrolled haemorrhage (severe
VICC) Convulsions/seizures Hypotension
Develops or has significant symptoms or signs or abnormal blood tests i.e. paralytic signs, coagulopathy, myolysis, renal impairment
D Dimer Elevated D Dimer suggests envenoming An isolated D Dimer with normal coagula-
tion study is NOT an indication for antivenom administration.
If D-Dimer > 5000 at any time, then further D Dimer testing is not required.
Proceed to ENVENOMING PATHWAY and give appropriate IV monovalent antivenom.
See previous page
TREATMENT Insert IV access x 2, give IV fluid load if required. Laboratory investigations (See Tweed order sets). Collect urine and check for haemoglobin/myoglobin. Collect swabs from bite site (first line) or urine (second
line) for SVDK testing (see Appendix D) BUT dont order SVDK testing in patients with no immediately life threatening symptoms or signs.
Consider tetanus immunoprophylaxis once patient stable (eg only after coagulopahy resolved).
Antibiotics not routinely given. Monitor fluid balance, catheterize if in doubt about urine
output. Suitable for observation in Emergency Department
Remains symptom free or minor general symptoms only and blood tests are normal. DO NOT GIVE ANTIVENOM
Remove PIB if first bloods normal and no signs of paralysis.
FIRST AID (see Appendix A) No effective first aid has been applied Apply PIB first aid. DO NOT APPLY PIB if > 1 hour post bite.
FIRST AID (see Appendix A) Patient had had correct first aid applied
POSSIBLE SNAKEBITE PATHWAY Patient is symptoms free or has only mild or nonspecific
features of envenoming such as headache, nausea, vomiting or abdominal pain
Check patient for signs of envenoming and repeat laboratory investigations at 1 hour post removal of PIB first aid then 6 and 12 hours post bite
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ADULT PROTOCOLS & GUIDELINES Policy Number: NC-TWE-CLP-1716 Date Issued: 12/11/2004 Last Review Date: 01/06/2011 Next Review: 01/06/2013 Authority: Dr Robert Davies Network Director Emergency Medicine The Tweed / Byron Network
Authority Initial:
Page 4 of 9
ANTIVENOM ADMINISTRATION
(MONOVALENT ANTIVENOM IS RECOMMENDED IN PREFERENCE TO POLYVALENT ANTIVENOM (See Appendix B) Mandatory notification FACEM if administration of antivenom. Continuous cardiorespiratory monitoring is mandatory. Premedication to prevent allergic reactions is NOT routinely indicated (see Appendix C). Be prepared to treat potential anaphylaxis. Have 1 Litre N/Saline via a pump set attached to a second cannula. Dilute monovalent antivenom and administer as directed (see table 2). Remove PIB (if in place) once antivenom infusion half way through. If anaphylaxis occurs:- TREAT ANAPHALAXISSEE BOX BELOW) Infusion of antivenom is recommended cautiously as soon as clinical manifestations of anaphylaxis are controlled. Rarely does ongoing administration of adrenaline by titrated infusion may be necessary to complete antivenom
administration. Following antivenom administration
Monitor patients clinical status Repeat laboratory investigations (INR, APTT, Fibrinogen and CK) at12 hours and then every 12 hours until
normalized Mandatory admission to ICU for monitoring.
Further doses of antivenom are unlikely to be required unless the patients clinical condition appears to be deteriorating. Discuss with toxicologist.
All patients who receive snake antivenom must be counseled about the possibility of serum sickness 4 to 21 days after antivenom administration (see Appendix C)
TREAT ANAPHYLAXIS
Cease antivenom ( usually only temporarily). Call for assistance from toxicologist or FACEM Give oxygen Give IV fluids (administer 20ml/kg boluses if hypotension) Give IM adrenaline 0.01mg/kg (max 0.5mg) to lateral thigh. Lie flat/elevate legs if tolerated Treat as per anaphylaxis protocol BUT use adrenaline cautiously as injudicious use can cause intracranial haemorrhage
in coagulopathic patients secondary to hypertension. Give IV hydrocortisone 1mg/kg. If there is an inadequate response or further deterioration
Commence IV adrenaline infusion (1mg of adrenaline in 100ml 0.9% saline and commence at 0.5 to 1 ml/kg/hour and then titrate to response)
Or repeat IMI adrenaline 0.01mg/kg (max 0.5mg) every 3 to 5 minutes as needed. If persistent hypotension, repeat 0.9% saline boluses 1-20 ml/kg up to 50ml/kg over 30 minutes.
If severe bradycardia, administer atropine IV 0.02mg/kg If bronchospasm, administer continuous salbutamol nebulisers and hydrocortisone IV 5mg/kg If upper airway obstruction, administer adrenaline nebulised 5mg in 5ml.
CONSIDER PREMEDICATION
Consider premedication to minimize the risk of anaphylaxis (NOTE: Premedication is controversial. Discuss with the ED FACEM on duty or on call or the toxicologist)
Adrenaline 0.3mg s/c 5 minutes prior to antivenom administration (0.01mg/kg to a maximum of 0.3mg in children) Promethazine 0.3mg/kg IV (optional) Hydrocortisone 1mg/kg (if using polyvalent antivenom or patient has previously had exposure to antivenom) More likely to be considered if polyvalent snake antivenom or multiple ampoules of monovalent snake antivenom is
administered or if the patient has a past history of exposure to equine protein (e.g. snake antivenom)
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ADULT PROTOCOLS & GUIDELINES Policy Number: NC-TWE-CLP-1716 Date Issued: 12/11/2004 Last Review Date: 01/06/2011 Next Review: 01/06/2013 Authority: Dr Robert Davies Network Director Emergency Medicine The Tweed / Byron Network
Authority Initial:
Page 5 of 9
Intervention/Outcome INITIAL
Patient presented at _______ hours with/without pressure bandage in situ.
Pathology samples taken on admission for Coagulation tests (INR, aPTT, Fibrinogen D-dimer), FBE, Urea, Creatinine, Electrolytes, CK SVDK swab taken from bite site or urine collected (second option).
Pathology results reviewed within 1 hour, and within normal limits. If pathology results are abnormal or neurotoxicity develops EXIT THIS PATHWAY, ADMIT PATIENT AND TREAT AS PER ENVENOMING PATHWAY.
If patient results are within normal limits and the patient has no signs of neurotoxicity (ptosis, bulbar signs, respiratory or distal paralysis) then remove pressure bandage with immobilisation if present, observe for any symptoms. Replace the pressure immobilisation bandage if there is evidence of worsening symptoms or signs.
If pressure bandage removed, repeat blood tests 1 hour after removal: Coagulation tests (INR, aPTT) and CK, D dimer unless already > 5000 on previous testing..
Pathology results from 1 hour after removal of PIB reviewed and within normal limits The patient has no signs of neurotoxicity (ptosis, bulbar signs, respiratory or distal paralysis) If pathology results are abnormal OR neurotoxicity develops, EXIT THIS PATHWAY, ADMIT PATIENT AND TREAT AS PER ENVENOMING PATHWAY.
Repeat blood tests 6 hours post time of bite (unless already > 6 hours): Coagulation tests (INR, aPTT, fibrinogen) and CK, D dimer unless already > 5000 on previous test-ing.
Pathology results from 6 hours post time of bite are reviewed and within normal limits The patient has no signs of neurotoxicity If pathology results are abnormal OR neurotoxicity develops, EXIT THIS PATHWAY, ADMIT PATIENT AND TREAT AS PER ENVENOMING PATHWAY.
Final blood tests 12 hours post time of bite Coagulation tests (INR, aPTT, fibrinogen) and CK, D dimer unless already > 5000 on previous test-ing.
Pathology results 12 hours post time of bite reviewed and within normal limits The patient has no signs of neurotoxicity If pathology results are abnormal OR neurotoxicity develops, EXIT THIS PATHWAY, ADMIT PATIENT AND TREAT AS PER ENVENOMING PATHWAY.
Patient discharged with normal INR, aPTT, fibrinogen and CK with no neurotoxicity at ________ hours
INR = international normalised ratio, aPTT = activated partial thromboplastin time, CK = creatinine kinase, SVDKsnake venom detection kit. A bite site swab should be collected and stored, but only tested if there is envenoming. Signs of neurotoxicity can be subtle and it is important to include both looking for ptosis and assess-ing for fatigue (e.g. eyelid droop from failure to maintain an upward gaze)
Appendix A (Print out this page if you find it helpful as a guide in managing the patients). Clinical Pathway Possible Snakebite: All patients should be observed and have serial blood testing conducted for 12 hours to exclude severe envenom-ing, using the following pathway. DATE: Signature initial for YES
Patient bitten at ________ hours.
Pressure immobilisation bandage applied at _________ hours.
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ADULT PROTOCOLS & GUIDELINES Policy Number: NC-TWE-CLP-1716 Date Issued: 12/11/2004 Last Review Date: 01/06/2011 Next Review: 01/06/2013 Authority: Dr Robert Davies Network Director Emergency Medicine The Tweed / Byron Network
Authority Initial:
Page 6 of 9
APPENDIX C SERUM SICKNESS Serum sickness is due to the deposition of immune complexes. Serum sickness is a recognized complication of the administration of foreign protein solutions
such as antivenoms. Relatively benign and self limiting complication. Serum sickness following the administration of Australian antivenoms was reported in 3 out of a
total of 70 cases in one series. Manifestations of serum sickness include fever, flu-like illness, rash, arthralgia and myalgia Can occur 4 to 21 days after antivenom administration Treat confirmed cases with prednisolone 1-2 mg/kg/day (up to 50mg/day) to ameliorate symp-
toms. Consider administering Prednisolone 1mg/kg/day (up to 50mg/day) for 5 days on discharge to
attenuate the severity of serum sickness if a large volume of antivenom, such as polyvalent snake antivenom or multiple ampoules of monovalent snake antivenom, is administered, if the patient has a past history of exposure to equine protein or previous serum sickness.
All patients should be educated about this potential complication prior to discharge so that it may be recognized and treated early.
PROVIDE THE PATIENT WITH INFORMATION ABOUT SERUM SICKNESS ON DISCHARGE if antivenom has been administered.
APPENDIX B MONOVALENT VS POLYVALENT ANTIVENOM. More specific Cheaper Safer
1% risk of severe anaphylactic or anaphylactoid reaction vs. 5% for polyvalent Have 10 - 40% incidence of acute allergic or anaphylactic reaction though depending on
the type of antivenom Associated with lower probability of serum sickness. Reasons for polyvalent antivenom
Appropriate monovalent antivenoms not available No SVDK result available and range of possible snakes requires the mixing of 3 or more
monovalent antivenoms Severe envenoming, there is insufficient time to wait for SVDK results and the range of
possible snakes would require mixing of 3 or more monovalent antivenoms Exhausted monovalent antivenom stocks.
APPENDIX A BASIC CARE INCLUDING PRESSURE IMMOBILISATION BANDAGE Apply PIB if not already applied to entire limb or check that applied properly Immobilize limb Immobilize whole patient Keep patient as calm as possible Do not wash wound PIB not to be removed until
Patient fully assessed and found to show no objective evidence of envenoming (normal initial physical examination and normal initial laboratory investigations)
Antivenom administration has commenced if patient found to be envenomed. On discharge ensure patient or family have information/instructions on PIB (see discharge instructions)
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ADULT PROTOCOLS & GUIDELINES Policy Number: NC-TWE-CLP-1716 Date Issued: 12/11/2004 Last Review Date: 01/06/2011 Next Review: 01/06/2013 Authority: Dr Robert Davies Network Director Emergency Medicine The Tweed / Byron Network
Authority Initial:
Page 7 of 9
TREATMENT OF MICROANGIOPATHIC HAEMOLYTIC ANAEMIA and THROMBOCYTOPAENIA Beyond the scope of this guideline Seek expert advice Poisons information 131126
APPENDIX E VENOM INDUCED CONSUMPTIVE COAGULOPATHY (VICC) Fibrinogen levels and coagulation factors may remain low for 10 to 20 hours or longer after administration of
antivenom. Despite this further antivenom is not usually required or effective in reversing VICC. Treatment of VICC is usually not required unless there is a high risk of bleeding or major bleeding occurs. However
administration of clotting factors (FFP and cryoprecipitate) after AV administration is associated with earlier recovery from VICC and could be considered. SEEK EXPERT ADVICE.
Head injury, snake bite envenoming and the risk of intracranial haemorrhage. More related to presence of coagulopathy and history of head traumaeg syncope and head trauma at the time of the snake bite. If there is evidence of head injury or history of collapse with the presence of coagulopathy then serious consideration should be given to investigate with CT scan or very closely monitor neurologically for any deterioration.
Seek expert advice before initiating further treatment of VICC after antivenom. Research is currently being undertaken in this area.
REFERENCES: 1. CSL Antivenom Handout. 2. Australian Animal Toxins 2nd Edition : Sutherland and Tibballs. 3. Snakebite & Spiderbite Clinical Management Guidelines 2007 Department of Health, NSW Health; Document
Number: GL2007_006; www.health.nsw.gov.au 4. Toxicology Handbook second edition 2011: Murray et al. Churchill Livingstone. 5. Ireland et al. Changes in serial lab tests in snake bite patients, MJA 193, 6,9, 2010
DISCHARGE INSTRUCTIONS If antivenom givendischarge information about serum sickness. Family or patient educated about PIB and given PIB fact sheet found at http://www.avru.org/files/imported/firstaid/factsheet_pib.pdf
TREATMENT OF RHABDOMYOLISIS Observe for this if the toxin causes rhabdomyolisis Treatment beyond the scope of this guideline. Seek expert advice - Poisons information 131126
APPENDIX D SVDK (Snake Venom Detection Kit) Do not use SVDK to determine whether or not a patient has had a snakebite. Mandatory to be performed by Pathology Laboratory technician according to the SVDK enclosed instruction sheet. Is performed using a bite site swab (access by cutting a key-hole in PIB). Also allows visual access to the wound. [Only performed on urine (second line) - if no bite site swab available AND the patient has systemic envenoming features]. Should not be performed on blood or serum. Indicates the right monovalent antivenom to use once a decision has been made to give antivenom. False positive and negative SVDK can occur and this is why the bite site swab should be collected and stored and
only tested if there is evidence of envenoming. Do not delay antivenom administration on severely envenomed patient by waiting for SVDK result. This may take
> 20 minutes. Use monovalent or polyvalent as clinically indicated or advised. If SVDK does not match the clinical pictureTREAT THE PATIENT NOT THE SVDK RESULT If there is doubt about the snake responsible for the envenoming and SVDK is not helpful 2 monovalent antivenoms
are superior to polyvalent antivenom.
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ADULT PROTOCOLS & GUIDELINES Policy Number: NC-TWE-CLP-1716 Date Issued: 12/11/2004 Last Review Date: 01/06/2011 Next Review: 01/06/2013 Authority: Dr Robert Davies Network Director Emergency Medicine The Tweed / Byron Network
Authority Initial:
Page 8 of 9
TAB
LE 1
C
linic
al e
ffect
of A
ustr
alia
n El
apid
ae s
nake
s
KN
OW
YO
UR
SN
AK
ES
THIS
IS A
GU
IDE
ON
LY
Ca
teg
ory
F
ea
ture
s
VIC
C
Se
e
Ap
pe
nd
ix E
N
eu
roto
xic
ity
(pre
-syn
ap
tic)
Ne
uro
tox
icit
y
(post-
synapti
c)
Rh
ab
do
myo
lysis
R
en
al
fail
ure
O
the
r e
ffe
cts
BLA
CK
Not
e th
at th
e m
ost
impo
rtant
mem
bers
of t
his
grou
p ar
e no
t bla
ck in
co
lour
e.g
. Mul
ga S
nake
(K
ing
Bro
wn)
, Col
letts
S
nake
.
Not
pre
sent
M
ild
antic
oagu
lant
ef
fect
may
be
seen
with
rais
ed
AP
TT
Fibr
inog
en
rem
ains
nor
mal
NO
T PR
ESEN
T N
OT
PRES
ENT
May
dev
elop
ove
r ho
urs
to d
ays
May
be
seve
re a
nd
resu
lt in
rena
l fai
lure
Sec
onda
ry to
rh
abdo
myo
lysi
s
Bite
site
pai
n m
ay b
e si
gnifi
cant
with
ofte
n se
vere
sw
ellin
g of
affe
cted
lim
b.
Env
enom
ing
usua
lly
asso
ciat
ed w
ith n
ause
a,
vom
iting
, abd
omin
al p
ain
and
head
ache
BR
OW
N
Usu
ally
pai
nles
s bi
te/li
ttle
loca
l rea
ctio
n 50
% b
ites
caus
e si
gnifi
cant
env
enom
atio
n (b
igge
r fan
gs)
Alw
ays
pres
ent
with
sig
nific
ant
enve
nom
ing
Def
ibrin
atio
n ca
n oc
cur
Slow
ons
et
over
hou
rs
(pos
sibl
y up
to
12 to
24
hour
s)
Usu
ally
pr
ogre
ssiv
e fla
ccid
par
alys
is
NO
T PR
ESEN
T
Slow
ons
et o
ver
hour
sM
ay b
e se
vere
and
re
sult
in re
nal
failu
re
Unc
omm
on
Prim
ary
mec
hani
sm
poor
ly u
nder
stoo
d Ma
y al
so o
ccur
se
cond
ary
to
rhab
dom
yoly
sis
MA
HA
and
th
rom
bocy
tope
nia
NO
TE:
1.
Nev
er re
ly o
n yo
ur o
wn
abili
ty to
iden
tify
a sn
ake.
2.
N
ever
rely
on
the
patie
nts
abi
lity
to id
entif
y a
snak
e.
3.
Nev
er re
ly o
n th
e am
ateu
r her
peto
logi
sts
abi
lity
to id
entif
y a
snak
e.
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ADULT PROTOCOLS & GUIDELINES Policy Number: NC-TWE-CLP-1716 Date Issued: 12/11/2004 Last Review Date: 01/06/2011 Next Review: 01/06/2013 Authority: Dr Robert Davies Network Director Emergency Medicine The Tweed / Byron Network
Authority Initial:
Page 9 of 9
TAB
LE 2
SN
AK
E G
RO
UP
AN
TIVE
NO
M (A
V)
DO
SAG
E
AD
MIN
ISTR
ATI
ON
All
snak
es
Pol
yval
ent S
nake
AV
Equ
ine
IgG
FA
B
One
am
poul
e 10
00 u
nits
Bro
wn
snak
e 30
00 u
nits
Tig
er
6000
uni
ts D
eath
Add
er
1200
0 un
its T
aipa
n 18
000
units
Bla
ck
Dilu
te 1
:10
ratio
ant
iven
om to
0.9
% s
alin
e IV
ove
r 20
min
utes
as
per
pro
duct
info
rmat
ion
C
AN
BE
GIV
EN
AS
RA
PID
IV P
US
H IN
UN
STA
BLE
PA
-TI
EN
T O
R IN
CA
RD
IAC
AR
RE
ST.
Bla
ck s
nake
(inc
lude
s)
Mul
ga s
nake
B
utle
rs M
ulga
sna
ke
Col
lett
s sn
ake
Pap
uan
blac
k sn
ake
Red
-bel
lied
blac
k sn
ake
Blu
e be
llied
bla
ck s
nake
S
potte
d bl
ack
snak
e
CS
L B
lack
Sna
ke A
V
Equ
ine
IgG
FA
B
Tiger
sna
ke A
V h
as b
een
reco
mm
ende
d as
an
alte
rna-
tive
to b
lack
sna
ke A
V in
tre
atm
ent o
f red
-bel
lied
and
blue
-bel
lied
blac
k sn
akes
.
One
am
poul
e (1
8000
0 un
its)
D
ilute
1:1
0 ra
tio a
ntiv
enom
to 0
.9%
sal
ine
IV o
ver 2
0 m
inut
es
as p
er p
rodu
ct in
form
atio
n.
Bro
wn
snak
e (in
clud
es)
Eas
tern
bro
wn
snak
e W
este
rn b
row
n sn
ake
or
Gw
arda
r D
ugite
O
ther
Pse
udon
aja
spec
ies
CS
L B
row
n sn
ake
AV
Equ
ine
IgG
FA
B
AV D
OE
S N
OT
HA
STE
N
RE
CO
VE
RY
FR
OM
VIC
C
2 am
poul
es (1
000
units
eac
h)
Dilu
te 1
:10
ratio
ant
iven
om to
0.9
% s
alin
e IV
ove
r 20
min
utes
as
per
pro
duct
info
rmat
ion
CA
N B
E G
IVE
N A
S R
AP
ID IV
PU
SH
IN U
NS
TAB
LE P
A-
TIE
NT
OR
IN C
AR
DIA
C A
RR
ES
T.
Dea
th A
dder
C
SL
Dea
th A
dder
AV
Equ
ine
IgG
FA
B
One
am
poul
e (6
000
units
) Su
bstit
ute
poly
vale
nt A
V if
CS
L de
ath
adde
r A
V n
ot a
vaila
ble.
Mo
nito
r clin
ical
ly w
ith s
eria
l spi
rom
etry
or
peak
flow
. If
ther
e is
a c
linic
al d
eter
iora
-tio
ns a
furth
er d
ose
of o
ne a
mpo
ule
is in
di-
cate
d.
Dilu
te 1
:10
ratio
ant
iven
om to
0.9
% s
alin
e IV
ove
r 20
min
utes
as
per
pro
duct
info
rmat
ion
Sea
Sna
ke
CS
L S
ea S
nake
AV
Equ
ine
IgG
FA
B
One
am
poul
e (1
000
units
) - If
not
ava
ilabl
e 3
ampo
ule
of ti
ger s
nake
AV
or p
olyv
alen
t A
V is
equ
ival
ent t
o 1
ampo
ule
of s
ea s
nake
A
V
In th
e pr
esen
ce o
f pro
gres
sive
neu
rolo
gica
l de
terio
ratio
n 3
ampo
ules
of s
ea s
nake
an
tiven
om s
houl
d be
adm
inis
tere
d.
Mon
itor c
linic
ally
with
ser
ial s
piro
met
ry o
r pe
ak fl
ow.
If th
ere
is a
clin
ical
det
erio
ra-
tions
a fu
rther
dos
e of
one
am
poul
e is
indi
-ca
ted.
Dilu
te 1
:10
ratio
ant
iven
om to
0.9
% s
alin
e IV
ove
r 20
min
utes
as
per
pro
duct
info
rmat
ion
CAN
BE
GIV
EN
AS
RA
PID
IV P
US
H IN
UN
STA
BLE
PA
-TI
EN
T O
R IN
CA
RD
IAC
AR
RE
ST.
Taip
an (i
nclu
des)
C
oast
al ta
ipan
P
apua
n ta
ipan
S
mal
l sca
led
or fi
erce
sna
ke
CS
L ta
ipan
AV
Equ
ine
IgG
FA
B
One
am
poul
e (1
2000
uni
ts)
Repe
at d
ose
of 1
am
poul
e gi
ven
if cl
inic
al
dete
riora
tion
(pro
gres
sion
of p
aral
ysis
)
Dilu
te 1
:10
ratio
ant
iven
om to
0.9
% s
alin
e IV
ove
r 20
min
utes
as
per
pro
duct
info
rmat
ion
CA
N B
E G
IVE
N A
S R
AP
ID IV
PU
SH
IN U
NS
TAB
LE P
A-
TIE
NT
OR
IN C
AR
DIA
C A
RR
ES
T.
Tige
r sna
ke (i
nclu
des)
C
omm
on ti
ger s
nake
W
este
rn ti
ger s
nake
S
teph
ens
ban
ded
snak
e P
ale-
head
ed s
nake
B
road
-hea
ded
snak
e S
mal
l-eye
d sn
ake
Rou
gh-s
cale
d sn
ake
Cop
per h
ead
snak
es
CS
L tig
er s
nake
AV
Equ
ine
IgG
FA
B
2 am
poul
es (3
000u
nits
eac
h)
Dilu
te 1
:10
ratio
ant
iven
om to
0.9
% s
alin
e IV
ove
r 20
min
utes
as
per
pro
duct
info
rmat
ion
CAN
BE
GIV
EN
AS
RA
PID
IV P
US
H IN
UN
STA
BLE
PA
-TI
EN
T O
R IN
CA
RD
IAC
AR
RE
ST.