Snakebite and Neostigmine

Expanding on my comments from the ALiEM Patwari Academy post on snakebites, here is some data behind neostigmine use in elapidae bites. Of course, this isn’t new, it’s just new to us. They’ve been doing it since 1950 in Brazil.

The idea is that the presynaptic attack on the NMJ is irreversible, but the post synaptic is competitive and reversible. Thus, treating the condition similarly to myasthenia gravis may prevent progressive neuro symptoms and respiratory failure. Current recommendations include giving atropine prior to neostigmine to prevent muscarinic effects, concurrent with antivenom. Sadly, most of the human data is in the form of case reports.

Bawaskar HS, Bawaskar PH. Snakebite, cocktails, and a girl with a stomach ache. Lancet. 2008 Feb 23;371(9613):696. [PMID 18295031]

Gold BS. Neostigmine for the treatment of neurotoxicity following envenomation by the Asiatic cobra. Ann Emerg Med. 1996 Jul;28(1):87-9. [PMID 8669746]

Vital Brazil O, Vieira RJ. Neostigmine in the treatment of snake accidents caused by Micrurus frontalis: report of two cases. Rev Inst Med Trop Sao Paulo. 1996 Jan-Feb;38(1):61-7. [PMID 8762642]

It doesn’t appear to work for all snakes though.

Anil A, Singh S, Bhalla A, Sharma N, Agarwal R, Simpson ID. Role of neostigmine and polyvalent antivenom in Indian common krait (Bungarus caeruleus) bite. J Infect Public Health. 2010;3(2):83-7. [PMID 20701896]