Envenomation JTS

JTS Global Snake Envenomation Management (CPG ID: 81)
GLOBAL SNAKE ENVENOMATION MANAGEMENT (CPG ID:81)
New JTS Clinical Practice Guidelines for Management of Snakebite Casualties Worldwide
1

Asclepius Snakebite Foundation
Snakebites casualties have already happened
Snakebites pose a serious risk in the austere and operational medicine environment!
Examples of snakebites reported by US Military
• Snakebite fatality in AFRICOM in 2015: US soldier killed by snakebite
(suspected mamba bite) while on base at Manda Bay, Kenya1
• Estimate at least 400 US service members treated for snakebites during Vietnam
war2
• Pit viper envenomation in MWD3
• Numerous documented cases of local partner forces and local nationals treated
at US hospitals in Afghanistan/Iraq4,5
• One US military study estimated monthly snakebite incidence of 4.9 bites per
10,000 US soldiers from 2005 – 2006 in Iraq/Afghanistan6
2

Snakebites casualties have already happened
A few additional examples from French, British, Israeli militaries…
Recent data from French Military:
• French soldier died of presumed cardiovascular collapse in < 1 hour after confirmed
burrowing asp bite in Senegal (early 2000’s)7
• French soldier bitten by spitting cobra in Mali (2013)7,8
• 9 snakebites treated with antivenom during operations in Africa 2015 – 20178
• 3 viper bites in northern Mali
• 1 green mamba bite in Ivory Coast
• 5 viper bites in Djibouti
British Military: UK soldier w/viper bite on Iran/Iraq border in 20049, another with horned
viper envenomation Croatia 20179, spitting cobras/others in Africa, etc
Israel (IDF): annual incidence of 32 – 52 snakebite cases/100,000 soldiers (1993 – 97)10
3

Austere environments + long or unpredictable
evacuation times = recipe for disaster
Key to preventing death and disability is early treatment!
• There is no benefit to delaying antivenom treatment until
the patient arrives at Role 2 or Role 3.
• Treatment delays only enable preventable injuries to
progress until antivenom is given.
Why do we need to change the way these bites are managed?
Every hour wasted between bite and antivenom
treatment = ↑ risk death / permanent disability
Early antivenom can prevent the following:
NEUROTOXINS bind receptors and cause respiratory paralysis
HEMOTOXINS interfere with clotting and cause systemic internal
and external bleeding (GI, brain, abdomen, hemorrhagic shock)
CYTOTOXINS cause irreversible tissue injury/necrosis
4

Modern antivenoms enable safe & effective field treatment
Modern antivenoms recommended in this CPG have
evolved significantly from their predecessors:
• SAFETY: Risk of anaphylaxis has decreased from >50% in many older
products to <1% with most recommended 1st line antivenoms in CPG
• SIMPLICITY: Broad-spectrum polyvalent antivenoms enable treatment
based on clinical syndrome rather than snake species and enable non-
experts to diagnose and treat appropriately
• FIELD STABILITY: JTS working group has identified field-stable, freeze-
dried antivenom options for every COCOM except EUCOM at this time
(EUCOM expected to be resolved shortly).
Photo by Thomas Nicolon for
National Geographic
5

What has changed with the new snakebite CPGs?
1) Early administration of the appropriate regionally- and syndrome-specific antivenom is
the standard of care for snake envenomation treatment worldwide.
2) In AFRICOM/CENTCOM/INDOPACOM/SOUTHCOM, recommended first line antivenoms
listed for each region in this CPG should be:
i. Stocked in the aid station and carried into the field by all units with qualified
paramedic-level and higher providers (including 18D, SOCM, PJ, IDC, IDMT, etc.)
ii. Administered ASAP in the field, at or near the point of injury, prior to medevac for
all patients meeting treatment criteria in order to neutralize circulating venom
before significant and potentially irreversible damage has occurred
3) Additional stock of the appropriate antivenoms listed in this CPG should be maintained
in all role 2/3 settings worldwide
New standard of care for snakebite patients worldwide recommended
by the JTS envenomation working group in CPG 81:
6

What is in the new CPGs and how should you use them?
7

HEMO
COAGULOPATHY
(VICC)
LOCAL
BLEEDING
SYSTEMIC
BLEEDING
CYTO
SEVERE
PAIN
PROGRESSIVE
EDEMA
TISSUE
DESTRUCTION
NEURO
BILATERAL
PTOSIS
DESCENDING
PARALYSIS
DYSPNEA
/ AMS
3 major syndromes  3 major signs of each
1. Every snake that can kill or injure you worldwide will ultimately present with one or more of the three major
syndromes of snake envenomations.
2. Snakebite management in the CPGs is guided by the envenomation syndrome rather than the snake species
8

Universal approach to snakebite: Part I
The first half of the new CPGs = UNIVERSAL
APPROACH to all snakebite patients worldwide
1. Clinical triads for the 3 major syndromes
2. Initial priorities and resuscitation
3. Snakebite-specific focused assessment and
tests for austere and advanced care settings
4. Transport decisions
9

Table 1: Simplified universal diagnosis and
treatment criteria for snakebite worldwide
• Provides S/Sx, severity scale, and treatment
criteria for all 3 major snakebite syndromes
First line antivenoms recommended for each
region are summarized in table 2
• Flowcharts for which antivenom to use are
provided later in the regional sections
10
1

Adjunct treatments and supportive care section
covers all non-antivenom treatments such as
airway management, blood products, analgesia,
wound care, etc… …and also covers ongoing monitoring and
treatment information and discharge
guidelines
11

Universal approach to snakebite: Part II
Criteria for initial antivenom treatment & repeat doses:
= longer and more detailed version of the information
summarized in table 1 earlier
Table 1 is the quick reference version
12

Universal approach to snakebite: Part III
The next sections cover the prevention and management of all
early and late adverse reactions to antivenom treatment
NOTE: anaphylaxis treatment protocol is listed in this section.
Anaphylaxis should be very rare (a fraction of 1% of patients)
with first line antivenoms recommended in this CPG
13

Universal approach to snakebite: Part IV
Universal approach section ends with the following information:
• What to do if antivenom is unavailable
• Treatment of snakebites in military
working dogs
• Give same doses of same
antivenoms as recommended for
humans in the CPG
• Late presentations
• No time limit for when antivenom
can be given
• Outdated interventions you should not
perform (i.e. cut and suck, tourniquet,
etc)
• Spitting cobras are found in Africa and
Asia and are can cause blindness by
spitting venom into the eyes from
several meters away
• Spitting cobra venom in the eyes should
be treated with irrigation like a chemical
exposure and should not be treated
with antivenom
• Bites from spitting cobras should
receive antivenom
14

How to use regionally-specific treatment guideline sections
15

How to use the regionally-specific treatment guidelines
To simplify management decisions, each COCOM has a separate treatment section that
covers which antivenoms to stock, what to use for each syndrome, and how to use them
Whenever possible, broad-spectrum,
field-stable antivenoms have been
recommended to enable syndromic
diagnosis and treatment at the point
of injury without the need to identify
the species responsible for the bite!
16

How to use the regional treatment guidelines
The first paragraph contains brief summary detailing:
1. If a broad-spectrum, field-stable antivenom option exist for this COCOM
2. If treatment in this COCOM can be based solely on syndrome without requiring snake ID
3. If field treatment at the point of injury is recommended for this COCOM
17

Simplified Dx & Tx summary table with
first line antivenoms for each COCOM:
1. These tables list the recommended
1st line antivenoms for each
syndrome
Note that 1st line antivenoms for
SOUTHCOM are divided into neurotoxic
syndrome and hemotoxic/cytotoxic
syndromes because no single-source
treatment option exists…
18

Simplified Dx & Tx summary table with
first line antivenoms for each COCOM:
1. These tables list the recommended
1st line antivenoms for each
syndrome
In AFRICOM, the 1st line antivenom
section is not divided because there is a
single-source antivenom that covers all
three syndromes
19

Algorithms for each COCOM simplify antivenom selection
To select the appropriate antivenom for your
deployment location, follow the COCOM-
specific antivenom algorithms!
These algorithms cover all antivenom options
for each COCOM, not just 1st line options
20

Select the appropriate antivenom from the regional algorithm
Important:
Algorithms start with REGION and then move to
SYNDROME. Both of these must be accounted for
to ensure correct antivenom is selected
21

The most complex antivenom algorithm is in
INDOPACOM due to regional coverage gaps
between antivenoms designed for Southeast
Asia vs East Asia.
22

Yellow backgrounds indicate that an antivenom is
both broad-spectrum and field-stable.
SOUTHCOM example:
• There is a broad-spectrum, freeze-dried/field-
stable antivenom that covers all hemotoxic and
cytotoxic syndromes in SOUTHCOM
• For neurotoxic syndromes, there is one neuro
polyvalent for Central American and another
for South America (and neither product is
freeze-dried)
23

Next step: refer to specific instructions for the antivenom you selected
Each antivenom in the CPG has it’s own
page covering indications, geographic
coverage, safety, efficacy, dosing,
preparation, and administration
Always refer to the individual product
sheets for useful information and specific
instructions prior to administration!
24

Breakdown of the information on each specific antivenom product page
Formulation and storage requirements; peer-
reviewed references for this antivenom
Header format =
1st/2nd/3rd line (COCOM – Specific areas
covered): Product Abbreviation
Quick summary: field-
stability, indications, dosing
Recommendation on whether to carry this product
in the field; details on storage requirements
Additional info on safety, species coverage, and
recommendations on whether to pretreat for reactions
Initial and additional dosing for each syndrome
Instructions for how to mix and
administer this specific antivenom
Manufacturer – Official
Product Name
25

1st line antivenoms may be indicated as 2nd or 3rd line for a different region
Some products are indicated as 1st line for one region and 2nd or 3rd line for a different region
26

Conclusions
• New CPGs enable every qualified provider to safely and effectively diagnose and treat
snakebites in the field using broad-spectrum, regionally-specific antivenoms and targeted
supportive measures
• They also eliminate the need to identify the species of snake responsible for the bite and facilitate
treatment based entirely off of the clinical presentation and evolution of the patient
• Refer to the Universal Approach to Snakebite for detailed instructions and a stepwise
approach to snakebite management throughout the course of care.
• Determine the appropriate first line antivenom for your area of operations prior to deployment
using the individual antivenom algorithms for your combatant command
• Refer to specific product sheets for all relevant information on how and when to use the
antivenoms you have on hand
• Goal of the new CPGs is to eliminate all preventable snakebite death and disability by bringing
antivenom treatment to the point of injury
27

Time to shift the thinking on antivenoms
is to is to
as
Antivenom for snakebites = whole blood and a surgeon for trauma
New field stable antivenoms and a symptom-driven syndromic approach to
snakebite management make field treatment the new standard of care
(…and you don’t need to identify the snake)
28

Final wisdom from the late herpetologist Sanda Ashe
“Antivenom is like the Texan’s gun – he doesn’t need
it often, but when he does he needs it real bad”
Don’t be afraid to give it in the field when it is needed!
29

Contact the working group for additional information
CONTACT INFORMATION
• For emergency consultations, call the DoD ADVISOR
telemedicine hotline (866-972-9966) and select toxicology
from the phone menu.
• For additional information about snakebite management or
this CPG, contact the first author by email or phone
• Email: jordan@snakebitefoundation.org
• Phone: +1-415-218-2211
30

1. https://www.stripes.com/news/soldier-died-of-venomous-snake-bite-autopsy-confirms-1.334382
2. Berlinger FG, Flowers HH. Some Observations on the Treatment of Snakebites in Vietnam. Mil Med. 1973;138(3):139-143. doi:10.1093/milmed/138.3.139
3. Cline CR, Goodnight ME. Pit viper envenomation in a military working dog. US Army Med Dep J. January 2013:28-33.
4. Roszko PJD, Kavanaugh MJ, Boese ML, Longwell JJ, Earley AS. Rotational thromboelastometry (ROTEM) guided treatment of an Afghanistan viper envenomation at a NATO military hospital. Clin Toxicol
. 2017;55(3):229-230.
5. Heiner JD, Bebarta VS, Varney SM, Bothwell JD, Cronin AJ. Clinical effects and antivenom use for snake bite victims treated at three US hospitals in Afghanistan. Wilderness Environ Med.
2013;24(4):412-416.
6. Shiau DT, Sanders JW, Putnam SD, et al. Self-reported incidence of snake, spider, and scorpion encounters among deployed U.S. military in Iraq and Afghanistan. Mil Med. 2007;172(10):1099-1102.
7. Larréché S, Aigle L, Puidupin M, et al. Animaux venimeux terrestres en opérations extérieures: présentation des principaux risques et du Comité technique des envenimations. Médecine et Armées.
2018;46(1):63-72.
8. Bomba A, Favaro P, Haus R, et al. Review of Scorpion Stings and Snakebites Treated by the French Military Health Service During Overseas Operations Between 2015 and 2017. Wilderness Environ
Med. 2020;31(2):174-180
9. Wilkins D, Burns DS, Wilson D, Warrell DA, Lamb LEM. Snakebites in Africa and Europe: a military perspective and update for contemporary operations. J R Army Med Corps. 2018;164(5):370-379.
10. Haviv J, Huerta M, Shpilberg O, Klement E, Ash N, Grotto I. Poisonous animal bites in the Israel Defense Forces. Public Health Rev. 1998;26(3):237-245.
References cited in this presentation
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