Version May 2024
Note: Consult with a medical toxicologist or poison control center to determine the appropriate treatment. In patients who are deemed appropriate candidates for antivenom therapy, early use is recommended to prevent the severe and rapidly progressing respiratory depression associated with coral snake envenomation.
Micrurus fulvius (Eastern coral snake) or M. tener (Texas coral snake) envenomation: IV: 30 to 50 mL (3 to 5 vials) by slow injection (dependent on severity of signs/symptoms; some patients may need more than 10 vials).
Note: Each vial of antivenom neutralizes ~2 mg of venom; M. fulvius bites generally deliver ~5 mg of venom (Ref).
There are no dosage adjustments provided in the manufacturer’s labeling.
There are no dosage adjustments provided in the manufacturer’s labeling.
Refer to adult dosing.
(For additional information see "North American coral snake (Micrurus fulvius) antivenom: Pediatric drug information")
Note: Consult with a medical toxicologist or poison control center to determine the appropriate treatment. In patients who are deemed appropriate candidates for antivenom therapy, early use is recommended to prevent the severe and rapidly progressing respiratory depression associated with coral snake envenomation.
Micrurus fulvius (Eastern coral snake) or Micrurus tener (Texas coral snake) envenomation:
Children and Adolescents: IV: 30 to 50 mL (3 to 5 vials) by slow injection; dose dependent on severity of signs/symptoms (smaller children may end up requiring fewer vials); in severe cases, some patients may need more than 10 vials. Note: Each vial of antivenom neutralizes ~2 mg of venom; M. fulvius bites generally deliver ~5 mg of venom (Ref).
There are no dosage adjustments provided in manufacturer's labeling.
There are no dosage adjustments provided in manufacturer's labeling.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Frequency not defined.
Immediate reactions:
Immediate reactions may occur within 30 minutes and may start before needle is withdrawn. Symptoms include apprehension, collapse, cough, cyanosis, dyspnea, facial edema, flushing, laryngeal edema, pruritus, tongue edema, urticaria, vomiting.
Cardiovascular: Shock
Hypersensitivity: Anaphylaxis, hypersensitivity reaction
Delayed reactions:
Delayed reactions occur 5 to 24 days following administration. Symptoms include arthralgia, edema, fever, lymphadenopathy, malaise, nausea, urticaria, vomiting. Neurological symptoms (eg, amyotrophy, meningism, myasthenia, pain, and peripheral neuritis) may also occur.
Hypersensitivity: Serum sickness
Prophylactic administration in asymptomatic patients; hypersensitivity to horse serum unless the benefits outweigh the risks and appropriate management for anaphylactic reactions is readily available.
Note: There are no absolute contraindications in patients with life- or limb-threatening envenomation.
Concerns related to adverse effects:
• Hypersensitivity reactions:
Immediate reactions: Patients sensitive to antivenin (M. fulvius) or horse serum may develop anaphylaxis; in addition, patients who have received a prior course of treatment may be at higher risk for a hypersensitivity reaction. Carefully review allergies and history of exposure to products containing horse serum. All patients require close monitoring in a setting that has ready access to emergency medical care.
Delayed reactions: Delayed serum sickness may occur 1 to 3 weeks from administration (especially when large doses used) even with a negative allergic history.
Skin test: The manufacturer states that a skin test may be considered prior to administration in patients sensitive to antivenin (M. fulvius) or horse serum; however, the utility of skin tests to accurately identify patients at risk of early (anaphylactic) or late (serum sickness) hypersensitivity reactions to horse-derived antivenins has been questioned (Chuang 2020; Klaewsongkram 2009; WHO 2005). The absence of a skin hypersensitivity reaction does not exclude anaphylaxis or hypersensitivity following antivenin administration. False-negative rate for skin testing is 10% with similar agents. Conversely, hypersensitivity is not an absolute contraindication in a significantly envenomated patient.
Concurrent drug therapy issues:
• Sedatives: Use sedatives with extreme caution; opioids or other analgesics that suppress respiration should not be administered due to the risk of respiratory paralysis following envenomation.
The American Association of Poison Control Centers (AAPCC) and the Association of Zoos and Aquariums have developed an online Antivenom Index that is accessible by accredited poison control centers and accredited zoos. Thus, contacting a poison control center can help to locate antivenom sources in emergency situations. It should be noted that dispensation of antivenom is at the discretion of the zoo that possesses said antivenom; a zoo’s decision to provide antivenom may include the costs associated with the desired antivenom and the availability of additional inventory so as not to compromise the safety of their own staff that works with venomous animals.
Cross-neutralization of coral snake (M. fulvius) venom has been demonstrated with Australian ANG Polyvalent Snake Antivenom (CSL Limited, Australia), Coralmyn (Instituto Bioclon, Mexico), and Central American Coral Snake antivenom (Micrurus nigrocinctus) (Instituto Clodomiro Picado, Costa Rica). These should be considered an effective alternative for use in coral snake envenomation in the United States (Arce 2003; McAninch 2019; Ramos 2017; Sanchez 2008; Yang 2017).
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Intravenous:
Generic: (1 ea)
Yes
IV: Have ready access to medications and equipment for resuscitation. An IV infusion of NS 250 to 500 mL should be started, and the doses of antivenin should be delivered by slow injection or via reservoir bottle. Inject the first 1 to 2 mL of antivenin over 3 to 5 minutes with careful observation for the development of a hypersensitivity reaction. The rate of infusion for the remaining antivenin will be regulated by tolerance to the antivenin, the severity of envenomation, and the maximum safe rate for IV fluids, based on body weight and condition of the patient (eg, 250 to 500 mL over 30 minutes in a previously healthy adult).
Parenteral:
Envenomation treatment: IV: Note: Immediate treatment for anaphylactoid and/or hypersensitivity reactions should be available during the infusion. An IV infusion of NS 250 to 500 mL should be started prior to administration of antivenin. Antivenin should be delivered by slow injection or via reservoir bottle. Inject the first 1 to 2 mL of antivenin over 3 to 5 minutes with careful observation for the development of a hypersensitivity reaction. The rate of infusion for the remaining antivenin will be regulated by tolerance to the antivenin, the severity of envenomation, and the maximum safe rate for weight and condition.
Small children: Allow first 100 mL to infuse rapidly, followed by a decrease in rate to ≤4 mL/minute.
Adult: Infuse 250 to 500 mL over 30 minutes.
Micrurus fulvius fulvius (Eastern coral snake) or M. f. tener (Texas coral snake) envenomation: Treatment of envenomation by an Eastern coral snake (M. f. fulvius) or Texas coral snake (M. f. tener).
Note: Antivenin (Micrurus fulvius) does not neutralize the venom of the Arizona or Sonoran coral snake (Micruroides euryoxanthus) and may not be effective in the management of envenomation from these other species (Ramos 2017).
None known.
There are no known significant interactions.
In general, medications used as antidotes should take into consideration the health and prognosis of the mother; antidotes should be administered to pregnant patients if there is a clear indication for use and should not be withheld because of fears of teratogenicity (Bailey 2003).
Available evidence suggests the main adverse pregnancy outcomes associated with a venomous snakebite (eg, fetal loss, placental abruption, preterm labor) are due to the direct effects of the toxin and resulting maternal illness. Antivenom administration in pregnancy should be considered when otherwise clinically indicated using a venom-specific approach, extended fetal and maternal monitoring, supportive care, and treatment of anaphylaxis if needed (Brown 2013).
It is not known if antivenin (Micrurus fulvius) is present in breast milk.
According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother.
Observe for resolution of symptoms of envenomation or emergence of symptoms of hypersensitivity to the antivenin (eg, urticaria, pruritus, erythema, angioedema, bronchospasm with wheezing or cough, stridor, laryngeal edema, hypotension, tachycardia); cardiac monitoring; signs of neurotoxicity (eg, compromised respiratory function/oxygenation); urine for hemoglobinuria.
Follow-up should be done for all patients for signs and symptoms of delayed allergic reactions or serum sickness (eg, rash, fever, myalgia, arthralgia).
Antibodies neutralize the venom components, thereby blocking the effects of the Eastern coral snake (Micrurus fulvius) and Texas coral snake (Micrurus tener) venom.
Note: In animal models, it has been demonstrated that IV administered coral snake IgG and F(ab’)2 antivenoms can extravasate blood vessels and slowly neutralize venom absorbed by lymphatics (Paniagua 2019).
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