First time ever treatment for Snouted cobra bite

[Bushviper]

Yesterday a lady working for a game lodge was busy doing a demo and ended up getting bitten on the leg by a large adult snouted cobra. She was rushed to the local hospital by car and the ambulance met her half-way and rushed her into the hosp[ital. They realised they would not be able to handle a serious bite and transferred her to Pretoria. The first hospital could not accommodate and she ended up a surgical ICU in the city.

By last night her symptoms suddenly got worse and her eyelids were drooping and she was getting weaker. This only started about 7 hours after the bite which is very unusual. I went through late last night and checked on her but I felt she did not look too bad. This morning she could not open her eyes at all and was having trouble swallowing. This is usually a precursor to respiratory failure but her oxygen levels were still well within the normal range.

We decided not to give her antivenom because she is still young and in her career she might need antivenom for a life threatening or serious cytotoxic bite. Being in an ICU we knew they could monitor her progress and act within minutes if required. I had supplied them with enough antivenom and they had it in a fridge in the unit in the event that things went downhill suddenly.

This afternoon our very own Jenna Taylor and Wolfgang Wuster got into a discussion about possibly using neostigmine which basically kick starts the nerves that have been affected. After a few minutes I decided that we should try this for the snouted bite despite it never having been done before that any of us are aware of. WW mailed me the previous research in this regard and I went off to hospital.

I then managed to convince the doctors to have a look at this option and try it. They agreed with me that it was worth a try and this evening we gave the lady a mixture prescribed by Jenna. Within a minute her eyes were open and two minutes later she was swallowing easily. She could focus and looked 100% normal.

I know it could wear off and top ups will be required but I am just glad that in this case it worked. That means that in future in rural areas where they dont have antivenom they can use neostigmine and glycopyrrolate to counter these effects even if it just helps to get the patient to where he can be ventilated.

I am tired from very little sleep and worrying all day riding up and down to check on her but now I am going to go have a beer!

[vuduman]

Good stuff BV and Jenna for the expert advice.This is very interesting and relieving news.

[Rob Macmillan]

Well done BV on helping out there. To Jenna and WW, good going on the alternative treatment and with the success of it. It is brilliant news and this needs to be passed along to the medical fraternity in areas like Northern Kzn as well as Swaziland where bite stats are pretty high. Could this treatment possibly work on other neuro bites such as in mamba and cape cobra bites or is that venom composition to fast acting to prescribe neostigmine treatment? It would be great to know for those of us involved with snake call outs. Besides not being bitten, the next best thing would be to know that there is an alternative on hand besides being loaded with 10-20cc of antivenom and risking a future reaction to vevom exposure.

[SABOAMAN]

This morning in Beeld:

http://www.beeld.com/Suid-Afrika/Nuus/J ... k-20111020


’n Jong veldwagter van Mabula Lodge naby Bela-Bela (Warmbad) word in die waaksaal van die Harthospitaal in Pretoria behandel nadat sy deur ’n wipsnoet­kobra gepik is.

Me. Karin van Rooyen (20) is eergister deur die slang aan haar regterkuit gepik terwyl sy besig was om met die slange te werk.

Kollegas het met noodbehandeling begin en hospitaal toe gery.

Langs die pad is sy in ’n ambulans oorgelaai en na die hospitaal op Bela-Bela gebring van waar sy na Pretoria oorgeplaas is.

“Gewoonlik begin iemand wat deur ’n kobra gepik word binne ’n halfuur simptome wys.

“Karin het eers ná sewe uur simptome gewys en toe in ’n erge graad,” het mnr. Arno Naudé, voorsitter van die herpetologiese vereniging en deeltydse lektor in slangbyte aan die Universiteit van Pretoria se mediese skool, gister gesê.

“Haar ooglede bly toeval, sy het begin om haar sig te verloor, sy sukkel om te sluk en haal moeilik asem weens die liggaam se senuweestelsel wat aangetas is.”

Teen gisteraand het Van Rooyen nog geen teengif gekry nie en is daar beplan om ’n nuwe middel op haar te toets.

Dit stimuleer die senuweestelsel en word reeds gebruik op mense wat ná narkose sukkel om wakker te word.

“Mense wat meer as een keer slangteengif kry, kan allergies daarvoor raak en dan is dit van geen hulp vir hulle as hulle weer gepik word nie.

“In dié stadium is haar lewe nie in gevaar nie en gaan sy waarskynlik deur die nag op ’n ventilator geplaas word om haar asemhaling te vergemaklik,” het Naudé gesê.

[Colinh]

Well done Arno you are as always a star and always willing to assist. You need a BIG medal for all that you have done. At least the dr this time was listening to you

[Blet]

Good outcome. The reality is that we know very little about the effects and composition of local snake venom. I attended a seminar on snake bite and its effects as monitored at The James Cook University, Australia. Afterwards a new study on coagulopathies in Snouted cobra and Puffadder bites as seen in dogs was discussed. Both species caused blood clotting concerns (in the case of Puffies, severely so right from the start and in Snouties only 24-48h after the bite)...no one knows why. None of the known clotting factors or the platelet counts where found to be abnormal. In the odd case, platelet counts where severely reduced, with no visible coagulopathy!
Lots to learn still..

[kinghero]

BV hope you enjoyed that beer weldone.

[froot]

What a lekker post. How is she doing now?

[WW]

Well done BV on helping out there. To Jenna and WW, good going on the alternative treatment and with the success of it. It is brilliant news and this needs to be passed along to the medical fraternity in areas like Northern Kzn as well as Swaziland where bite stats are pretty high. Could this treatment possibly work on other neuro bites such as in mamba and cape cobra bites or is that venom composition to fast acting to prescribe neostigmine treatment? It would be great to know for those of us involved with snake call outs. Besides not being bitten, the next best thing would be to know that there is an alternative on hand besides being loaded with 10-20cc of antivenom and risking a future reaction to vevom exposure.

Anticholinesterase drugs like neostigmine seem to work well for a number of elapids with predominantly postsynaptic neurotoxins, including many cobras (used successfully for various Asian species, including N. naja and N. philippinensis) as well as death adders (Acanthophis), and sometimes but not always on kraits (Bungarus{/i]), presumably depending on the balance of pre- and post-synaptic neurotoxins in the specimen involved.

In theory, these drugs ought to work on the neurotoxic effects of most members of the cobra group (prob. including king cobras, as well as [i]Pseudohaje, Walterinnesia, rinkhals and Aspidelaps), as well as other primarily postsynaptic venoms, such as especially Acanthophis, but also some coral snakes and perhaps some cases of krait bite. They are unlikely to help much for most Australasian elapids except Acanthophis, and of course they will do nothing whatsoever for any other effects of the venom, such as tissue destruction, coagulopathy, myotoxicity etc.

Interestingly, Roger Blaylock tried prostigmine on two Cape cobra patients, and it had little effect. The current snoutie case is especially interesting in this respect, since Naja annulifera is closely related to Naja nivea, yet clearly the latter has some toxins with a difference in its venom, so that patients don't respond to the anticholinesterases.

Mamba venoms have different modes of action, so I don't think we can expect them to have any effects there.

On the other hand, the fact that these drugs seem to work for Asian Naja and Acanthophis may be good news for keepers in S. Africa, where antivenom for these exotic species is presumably difficult to obtain. Ideally, antivenom should still be used, since without it the venom will remain in the circulation for days and potentially get up to other mischief, but the drugs can buy time and may just keep someone out of a ventilator, which has to be A Good Thing.

[Bushbaby]

Aparently the lady is doing very well. Just the droopy eyelids have persisted.

[mgiddings]

Good Job.

She should be glad she didnt recieve antivenom.

Interesting post to say the least

[Bushviper]

The girl is looking much better, the droopy eyelids has decreased to virtually normal levels and strangely enough the intense pain in the bitten limb has subsided. She is swallowing far more easily and is eating meals and drinking fluids. Her temperature is down although her white blood cell count is still severely elevated. The limb is still swollen as are the lymph glands in her groin and armpits.

I would rate this as a major success especially because even when the drugs worked out of her system (90 minutes or so by all calculation) her condition did not deteriorate by any significant amount.

I truly believe this can be a major tool in the arsenal of the African doctor treating non-spitting cobra bites. I have discussed the mamba toxins with Jenna and she has indicated that this may the exact wrong substance to be used in that scenario. I would still give Naja nivea a bash before paralysis becomes established in the patient. From what I saw this looks like it will still save lives if properly used.

[Wolf777]

Great post. Well done once again Bv and WW and Jenna. This could go a long way especially on this continent.

[ClintonT]

Fantastic efforts by all involved. I sincerely hope continued research is done on such treatments. Real life saving work.

[John Eckley]

I spoke to a friend, who is not a member here, and this is what he send me:
Report from prof Gouse Oberholzer is that those drugs have been used to treat cobra bites in indias for the past 15 years with mixed result! It is possible that the cases successfully treated may well have been mistaken identity and may well have been harmless or mildly venomous species! The tests done on african cobra s and mambas produced negetive results and pollyvalent antivenom was eventualy resorted to to ensure the victims survival! A recent case was successfully treated where the victim had a low body mass and even though serious symptoms were recorded the patients blood oxygene percentagess sugest that the. Bite may have been a low venom yield. The result is therefore inconclusive!