Successful treatment of presumed death‐adder neurotoxicity using anticholinesterases

We present the first reported case in Australia of anticholinesterases being used successfully in conjunction with antivenom to treat neurotoxicity following death‐adder envenomation. A 49‐year‐old man was bitten by his pet death adder. He developed significant neurotoxicity due to delayed presentation and suboptimal first aid. Following one ampoule of polyvalent antivenom which produced an allergic reaction, administration of neostigmine and atropine facilitated aeromedical evacuation without the need for mechanical ventilation. After three ampoules of monovalent death‐adder antivenom at the receiving hospital, antivenom supplies were exhausted. Further neostigmine and atropine resulted in complete resolution of paralysis, allowing discharge. Anticholinesterases may reduce the dose of antivenom required to treat death‐adder envenomation. They may also be of use in cases of allergic reactions to antivenom, and in reducing the need for endotracheal intubation.