FOLLOWUP - Cobra bite

[KMATTOX at aol.com]

Thirty (30) hours after admission, our cobra bite (Naja sp sp) patient is  
doing well and extubated.    I have several clinical and  literature items to 
share with these three lists.   I duplicate send  as all of these groups might 
see patients with snake bite and might in some  small way benefit from my 
observations, which I will attempt to keep as  objective as possible.  
 
Clinical status:
      The monocled cobra is about 20 inches  long
     The snake struck when a water  dish  was being changed out
       It took 10 minutes for the  ambulance to arrive after the snake bite
       From snake bite to arrival at the  hospital is now known to be 20 
minutes
        The patient was beginning  to feel numb and to have trouble breathing 
as the ambulance reached the  hospital
            He  was having trouble focusing and taking a breath as he was put 
on the shock room  table        
          Patient was  intubated immediately upon presentation to the hospital
        It was 3.5 hours after  arrival at the hospital before the out of 
town obtained antivenin was given 
        He had almost no local  reaction at the site of the bite
        ALL laboratory tests were  normal and remained normal including 
repeat CBCs and TEGs
        Cardiac and renal status  was unaffected
        He was extubated 24 hours  after admission
        He stated that he  remembered and heard everything.   We gave him 
sleep level versed  repeatedly during the 24 hours
        When asked to repeat any  conversation that he heard, he cited he 
heard talking, but could not cite  anything specifically
        He had received 6 amps of  specific antivenin in two of three amp 
batches
        He has no apparent visual  or neurologic impairment now
        He was not in pain nor  apprehensive during his intubation
        He stated that while he was  intubated he could not feel nor move his 
lips, hands or feet
        We did give tetanus  prophylaxis and broad spectrum antibiotics 
 
 
Snake identification
        We discovered everyone  agrees on the genus of this snake (Naja), but 
we found at least 4 different  names of species and sub species associated 
with the Monocled  Cobra.     
 
        We found strong support  for ventilatory support, but in the 
literature and  internet  recommendations, we could NOT find any consistent reason why 
antivenin should be  used.    We heard and read many urban legends, and read 
several  scientific papers with no real comparison and a lot of expert opinion
 
        We received many warnings  in the literature and from advisors that 
we must watch for serum sickness as  they thought it would occur in 3-6 weeks 
in almost every case of antivenin  use.     
 
k mattox



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