Snake Bite Clinical Pathways

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:

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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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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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YES


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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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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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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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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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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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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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

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Snake Bite Clinical Pathways

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Transcript of Snake Bite Clinical Pathways