Monocled Cobra bite

[McSwain, Norman E Jr.]

Ken
As you are aware, most poisonous snakes produce their venom in an analog
of the parotid gland. As such the venom for all is made up of the same
constituents. These digestive enzymes which start to digest the pray
from the inside when they are bitten. These venoms contain both
hematogenous and nerve agents. The % of nerve vs hematogenous varies
from species to species. The pit vipers (our most common venomous snake
in the US) is mostly hematogenous hence the swelling and discoloration.
The snakes which have mostly nerve venom such as the coral snake in the
US and even more the Cobra and its relatives even the so called spitting
snake used to blind his prey. The venom is actually sprayed from a
special fang with holes in the front rather than the tip.

I agree with you that most envenomations in the US are from the pit
vipers and do not necessarily need the antivenom and its associated
problems. Although the newer forms of the antivenom are not made from
horses and do not have the serum sickness associated with their use.
The physician can judge amount of envenomation and strength of the venom
based on swelling and discoloration. This is a result of the type of
venom (hematogenous destruction). Since the snakes without a predominate
amount hematogenous venom do not produce swelling and the first
indication of problems is the neurologic changes.

Finlay Russell, MD, PhD in Arizona has been, to many of us, for the last
50 years or so, the guru for venomous snakes and other animals (spiders
included). I will be happy to share with you (offline) his contacts if
you wish

Norman

Norman McSwain Jr, MD FACS
Trauma Director Charity Hospital
Professor of Surgery
Tulane University School of Medicine
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of KMATTOX at aol.com
Sent: Sunday, June 29, 2008 10:20 PM
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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