Expanding on my comments from the recent 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.
“Snakebites, cocktails, and a girl with a stomach ache”
“Neostigmine for the treatment of neurotoxicity following envenomation by the asiatic cobra”
“Neostigmine in the treatment of snake accidents caused by Micrurus frontalis: a report of two cases(1)”
It doesn’t appear to work for all snakes though.
“Role of neostigmine and polyvalent antivenom in Indian common krait (Bugarus caeruleus) bite”