Monocled Cobra bite

Wed Jul 2 15:44:05 BST 2008

Hmmm... so here's the open question (I don't propose to have the answer to
this, although I think there's potential for a great study here):

In COBRA envenomation, in a CRITICAL CARE environment, what is the better
course of action in a ventilated patient (with regards to rate of
improvement and decreased incidence of adverse events) between supportive
management (ventilation, sedation, fluid balance, etc), supportive
management plus NEOSTIGMINE and supportive management plus POLYVALENT
ANTIVENIN?

R.

Dr Ross Hofmeyr
Expedition Leader  & Doctor
South African National Antarctic Expedition

> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-
> bounces at trauma.org] On Behalf Of Timothy Craig Hardcastle
> Sent: 02 July 2008 02:37 PM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: Monocled Cobra bite
> 
> Rob
> 
> They get episodes of hypertension / tachycardia and hyperpyrexia,
> unrelated to infection and similar to the autonomic dysreflexia seen in
> spinal cord patients.
> 
> Tim
> Dr Timothy C Hardcastle
> M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
> Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
> Deputy director: Trauma Unit and Trauma ICU
> Inkosi Albert Luthuli Central Hospital / UKZN
> 800 Bellair Road
> Mayville, Durban
> 
> Postal: PostNet Suite 27
> Private Bag X05
> Malvern, 4055
> KwaZulu Natal
> 
> timothyhar at ialch.co.za
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert F. Smith
> Sent: 02 July 2008 16:34
> To: 'Trauma &amp; Critical Care mailing list'
> Subject: RE: Monocled Cobra bite
> 
> Tim,
> 
> Thanks for your patience. I'm old and slow. So if it doesn't shorten the
> vent time, what is the autonomic dysfunction that it is important that
> it
> helps with?
> 
> Rob
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Timothy Craig Hardcastle
> Sent: Wednesday, July 02, 2008 8:05 AM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: Monocled Cobra bite
> 
> Rob
> 
> The antivenin is to prevent the ongoing autonomic dysfunction related to
> the venom and to decrease the incidence of prolonged symptoms - while
> there is no "Level 1" evidence that it shortens ventilator time it does
> in the reported case series benefit overall recovery.
> 
> Apart from Dr Blalock, who did both an M.Med Sci and a PhD on snake
> bites, the other well respected local toxicologist who has written
> extensively about these and spider bites is Dr G Muller, who published a
> number of papers in the SAMJ during the late 80's and 90's. He is also
> the co-author of the booklet "The diagnosis and treatment of
> envenomation in South Africa" available from SA Institute for Medical
> Research and originally published in 1996.
> 
> Tim
> Dr Timothy C Hardcastle
> M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
> Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
> Deputy director: Trauma Unit and Trauma ICU
> Inkosi Albert Luthuli Central Hospital / UKZN
> 800 Bellair Road
> Mayville, Durban
> 
> Postal: PostNet Suite 27
> Private Bag X05
> Malvern, 4055
> KwaZulu Natal
> 
> timothyhar at ialch.co.za
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert F. Smith
> Sent: 02 July 2008 13:55
> To: 'Trauma &amp; Critical Care mailing list'
> Subject: RE: Monocled Cobra bite
> 
> Tim,
> 
> So is the use of antivenin recommended because the effects usually take
> so
> long to wear off? Unlike Dr. Mattox's case? I was confused about that in
> the
> algorhythm.
> 
> Rob Smith
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Timothy Craig Hardcastle
> Sent: Monday, June 30, 2008 2:16 AM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: Monocled Cobra bite
> 
> Ken
> 
> Cobras are genus Naja. They are almost exclusively neurotoxic and can
> cause
> death from respiratory arrest within 45 - 120 minutes post bite.
> They are endemic in South Africa and we see their bites with some
> frequency.
> 
> In South Africa a polyvalent antivenin for Cobra, Mamba (Dendroaspis)
> and
> puff adder bites (Bitis) is available and the recommended dose is 80
> - 120 ml IVI as soon as possible. You may repeat the dose once, being
> prepared for allergic reaction.
> 
> Remember the patient is usually paralysed, but conscious, so sedatrion
> is
> required.
> 
> Slow recovery over several weeks is the usual course of the pathology
> when
> an adult snake is the assailant, but can be less severe with juveniles.
> Extensive early physical therapy is advised.
> 
> I am not specifically aware of any issues other than these with the
> monocled
> cobra (what is its species name?)
> 
> Hope this helps.
> 
> Attached is a recent article with a syndromic approach to snake bites.
> 
> Tim
> Dr Timothy C Hardcastle
> M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA) Principal
> Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care Deputy
> director:
> Trauma Unit and Trauma ICU Inkosi Albert Luthuli Central Hospital / UKZN
> 800
> Bellair Road Mayville, Durban
> 
> Postal: PostNet Suite 27
> Private Bag X05
> Malvern, 4055
> KwaZulu Natal
> 
> timothyhar at ialch.co.za
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of KMATTOX at aol.com
> Sent: 30 June 2008 05:20
> To: trauma-list at trauma.org
> Cc: SURGINET at listserv.utoronto.ca; ccm-l at ccm-l.org
> Subject: Monocled Cobra bite
> 
> For the endemic and usual kinds of poisonous snake bites in the United
> States I have always proposed to be very sparingly in using  antivenin.
> Today we
> received a patient arriving less than 40  minutes after being bitten on
> the
> finger by a monocled cobra.     He breeds and raises these snakes and
> his
> business is known to the authorities  and the game warden near his
> house.
> 
> Shortly after arrival his respiration just stopped and he was
> intubated.
> He was sedated as if he had been given a muscle  relaxant.   His
> BP,clotting
> studies were basically normal.    His TEG was normal.     He required no
> 
> pressors.    He had basically NO swelling or discoloration  at the site
> of the bite
> as we usually see in US poisonous  snakes.     We called around the
> country
> and the  consensus was that he should receive specific antivenin.    The
> 
> closest antivenin was 1/4 the way across Texas (None in Houston or
> Galveston),  so it was flown here and he has received 6 vials of Naja
> specific
> antivenin.
> He is in the ICU and being supported with the  usual ICU care.
> 
> 
> The reason I am posting this is for several reasons:
> 
> 1.    Cobra bites are RARE in the United States
> 2.    I find that cobra breeders and sellers are fairly  common in the
> United
> States
> 3.    I found that the NEUROLOGIC paralysis was rapid  and sure, and the
> 
> hematological and coagulopathies effects of the antivenin  were not
> seen.
> 4.    Several of you on this web site have seen cobra  bites.
> 
> I am seeking wisdom and advice as well as long range outcomes  and
> effects.
>    I feel certain that we will  receive a large variety of opinion and
> advice.   We will receive and  welcome any and all and will weigh all
> advice against
> his clinical  course.
> 
> Thanks in advance.
> 
> 
> 
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