Acute Severe Anaphylaxis in Nepali Patients with Neurotoxic Snakebite Envenoming Treated with the VINS Polyvalent Antivenom
Table 4
Clinical notes on the five patients with neurotoxic envenoming who survived.
Patient #
SCAD
Antivenom dose
Clinical description
Commentary
Gender/
Age
#5 Female 23 y
N
H
1.55h after IV push & during AV infusion, developed acute wheezing & rash on forehead. AV stopped. Treated with nebulised salbutamol. 5m later, wheeze became worse, P-144/m, BP fell to 90/50, SaO2 90%. AV stopped immediately. Treated with IV hydrocortisone, chlorphenamine & N saline, followed by IMAd (6m delay). Transferred to ICU for observation. ARA resolved fully after 95m. AV restarted with no further ARAs.
Developed classic features of ARA. Additional doses of AV did not result in additional ARAs despite no prophylactic SCAd or IVAI.
#4 Male 20 y
N
H
1.5h after IV push & during AV infusion, developed acute restlessness, wheezing & cyanosis. Respiratory rate 32/m, SpO2 50%, P-76 BP160/100. AV stopped immediately. Treated with IMAd, IV hydrocortisone, oxygen, then intubated in ICU. Needed two boluses of AV in the ICU; both covered with SCAd. No additional ARAs & made a full recovery.
Developed classic features of life threatening ARA with rapid decline in respiratory function necessitating intubation.
#3 Female 53 y
N
L
10m after start of IV AV push, developed itchy red rash on upper arms, chest abdomen with respiratory distress. Tachycardia and fall in blood pressure (no measurements recorded). AV stopped immediately. Treated with 0.5 mg IVAd x 2, IV hydrocortisone & chlorphenamine & intubation. Rash resolved completely. IVAV restarted 15m after rash resolved under cover of IVAI started to cover. No additional ARAs. Extubated & made full recovery.
Developed classic features of life threatening ARA with rapid decline in respiratory function necessitating intubation. IV rather than IMAd given to treat ARA.
#2 Male 52 y
N
H
15m after start of IV AV push, developed urticaria. Treated with SCAd but AV not stopped. 5m after rash, patient became shocked with an unrecordable BP and cool peripheries. AV stopped. Treated with 1 mg IVAd, hydrocortisone, saline bolus, atropine, second dose of neostigmine & atropine. Stabilised & after 10m signs were P-99/m, BP 90/50, SpO2 90%. AV infusion restarted followed 10m later by a pyrogenic reaction (fever & chills). Treated symptomatically & with dose of neostigmine & atropine, AV stopped temporarily then continued until resolution of envenoming. No additional ARAs noted.
Initial ARA was a red rash that was treated with SCAd rather than IMAd. AV not stopped and may have resulted in life threatening ARA. Recommencement of AV not covered by adrenaline but no additional ARAs. Pyrogenic reaction was short lived.
#1 Male 51 y
Y
L
40m after IV push & during AV infusion, developed red rash. AV stopped & treated with 0.5 mg IVAd, IV hydrocortisone & chlorphenamine. Rash resolved after 20m & AV infusion restarted under IVAI. 35m later developed cough, noisy breathing & fall in SpO2 to 63%. Acute laryngeal oedema suspected and transferred to ICU for intubation.
ARA started with a red rash and resolved with treatment. AV infusion restarted with IVAI but it did not prevent laryngeal oedema.
