First time ever treatment for Snouted cobra bite

This section will help you get first aid treatment protocols incase of an envenomation. This includes indigenous and exotic reptiles. Please do not use this forum for photo sharing, etc.

Re: First time ever treatment for Snouted cobra bite

Postby Shamrock » Sat Oct 22, 2011 8:00 pm

Well if the Indians have been using it for 15 years (even with mixed results) I'll definately give it a bash before I consider antivenom!
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Re: First time ever treatment for Snouted cobra bite

Postby WW » Sat Oct 22, 2011 8:12 pm

John Eckley wrote: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!


There are certainly multiple accounts of highly successful use in carefully designed prospective studies in the Philippines (Watt et al., 1989 - Naja philippinensis), and well-documented cases for Acanthophis in New Guinea and Australia. No question of misidentified snakes there.

Nobody is arguing that it would be a panacea, but it may buy time in some cases, or even keep someone out of a respirator - which must be A Good Thing.

Reference:
WATT G, MEADE BD, THEAKSTON RDG, et al. Comparison of Tensilon and antivenom for the treatment of cobra-bite paralysis. Trans R Soc Trop Med Hyg; 83:570-573, 1989.
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Re: First time ever treatment for Snouted cobra bite

Postby Blet » Sat Oct 22, 2011 10:33 pm

Bottom line is...loads of study possibilities still here. The reality is that, even though WE may find snake envenomations interesting and of importance, it remains of relatively minor importance in SA compared to most medical emergencies. The fact that you can ID the group/genus of snake involved in a bite and administer very specific treatment and antivenom from a small blood or urine sample in Australia, makes quite a big difference. We've got 2 antivenom options of wich Bommslang hardly ever gets administered. Studies around synthetic 'antivenom' as apposed to horse or sheep serum based products are also encouraging...but these newer options are extremely expensive. In the SA situation even local products are mighty expensive. From a veterinary perspective, I see mostly Cape Cobra bites and these average around R15000-20000 per simple case...and I've lost patients 4d after regaining the ability to breath spontaneously. Interestingly, the last study on Puffadder bites, suggest no antivenom treatment at all...that's likely to change due to new studies on coagulopathies and I must admit seeing more than a few acute deaths from confirmed Puffy bites within 90min of the actual event...this is in and around Cape Town and I do believe there is a variation in effect and virulence depending on dose, age/size of patient, age/size of snake and locality. I count myself lucky if I get the oppertunity to treat a Cape Cobra bite in a dog...most patients do not make it to the clinic! Cape cobras and Mambas will alway remain a gigantic issue...If I ever got into a Cape cobra bite situation, I would insist on antivenom the minute neorological signs creep in. These animals are not to be underestimated! A final point...almost all Cape cobra bites in dogs (if the patient survives!) cause local tissue necrosis. I manage these as opn wounds and they heal uneventfully over a matter of 2-3w, but I found this interesting in such an obviously neurotoxic species!
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Re: First time ever treatment for Snouted cobra bite

Postby Bushviper » Sun Oct 23, 2011 6:23 pm

John Eckley wrote: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!


I actually previously owned the snake that bit her so I am pretty sure after having caught in excess of 100 snouted cobras in the last year and three in the last week that I know what a snouted cobra looks like. Unless he knows of some non venomous species which is brown and yellow banded, makes a hood and grows to 1.5 metres in length I would be really interested.

The test on Mambas would not work because they are excitory neurotoxins (dendrotoxins) and you would expect a doctor to know that. The only other local cases I could find were from Cape cobra who's venom works on the other side of the neuromuscular junction and even antivenom has been proven to be ineffective if administered after total paralysis has set in. Obviously the cocktail of neostigmine and glycopyrrolate would not be effective. This has been discussed by Dart and many others and is common knowledge that it cannot be used to reverse the effects once total paralysis has set in. They used atropine in those cases in any case and not this mixture.

In this case the dose of venom might possibly have not been lethal but the reversal did speed recovery and thus reduce hospital time. Usually after ptosis and dysphagia the next symptom is respiratory distress. That is what I have found in the possibly 30 or so bites where I have been present. It just proves that this does work in snouted cobra envenomation.

He is welcome to his opinion although I do reject his comments without him having studied the case. If the patient did not have any venom (non venomous bite) in her system the result should have been a massively increased tachycardia and possibly a total collapse of the respiratory system. Neither of these took place. There were enough symptoms to show she had been envenomated.

Possibly the prof could do with some reading matter try :

Severe neurotoxic envenoming by the Malayan krait Bungarus candidus: response to antivenom and anticholinesterase By Warrel et al.

Comparison of Tensilor and antivenom for the treatment of cobra-bite paralysis by George Watt et al,

Successful treatment of presumed death-adder neurotoxicity using anticholinesterases by Mark Little and Peter Pereira

Resolution of neurotoxicity with anticholinesterase therapy in death-adder envenomation. Currie B, Fitzmaurice M, Oakley J.

The use of anticholinesterase therapy, Dr Kenneth D Winkel et al

Anticholinesterases as antidotes to envenomation of rats by the death adder (Acanthophis antarcticus). Flachsenberger W, Mirtschin P

POSITIVE RESPONSE TO EDROPHONIUM IN DEATH ADDER (ACANTHOPHIS ANTARCTICUS) ENVENOMATION by B. J. HUDSON

Neurotoxic snake bite with respiratory failure by Prithwis Bhattacharya, Arpan Chakraborty\

Neostigmine in the treatment of snake accidents caused by Micrurus frontalis: Report of two cases. Oswaldo Vital Brazil

MANAGEMENT OF COBRA SNAKE BITE : MANZOOR AHMED FARIDI

A Contextual Approach to Managing Snake Bite in Pakistan: Snake Bite Treatment with Particular Reference to Neurotoxicity and the Ideal Hospital Snake Bite Kit by Naeem A Quraishi et al.

Anticholinesterase Treatment for Patients With Paralytic Strabismus Following a Viper Bite, Jung Ho Lee, MD, Sung Min Ahn, MD and Bo Young Jung, MD

Bites by coral snakes (Micrurus spp.) in Campinas, State of São Paulo, Southeastern Brazil ( Acidentes por serpentes corais (Micrurus spp.) em Campinas, Estado de São Paulo, sudeste do Brasil) by Fábio Bucaretchi et al.

These are from recognised medical journals and show rather positive results. These should be enough to keep him amused for a while.
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Re: First time ever treatment for Snouted cobra bite

Postby yoson10 » Tue Nov 01, 2011 4:54 am

Bushviper wrote:
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.



Interesting...Do the symptoms usually start earlier than this or later?

I don't really know anything about African cobras but I do know a bit about Asian cobras so I am interested to see how they compare to each other.

Bushviper wrote:
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!



The snouted cobra doesn't have a cytotoxic component to its venom? Are most African cobras( excluding the spitters) not cytotoxic?

Just wondering because some Asia cobras(not spitters) can be neurotoxic and also very very cytotoxic...with some of the worst cytotoxicity I have ever seen being from Asian non spitting cobras....Just wondering if you get cytotoxicity with the snouted and other non spitting African cobras.
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Re: First time ever treatment for Snouted cobra bite

Postby Bushviper » Tue Nov 01, 2011 1:17 pm

Yoson we get some necrotic complications from the snouted cobras as well as the forest cobras.

Usually we see symptoms within 30 minutes although I have seen some within minutes of a serious bite.
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Re: First time ever treatment for Snouted cobra bite

Postby yoson10 » Wed Nov 02, 2011 3:32 am

Bushviper wrote:
Usually we see symptoms within 30 minutes although I have seen some within minutes of a serious bite.


Yeah that's what I have seen/read about in Asian cobras...They symptoms are usually very fast appearing..I have heard about people have their diaphragms paralyzed within 10 minutes.
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Re: First time ever treatment for Snouted cobra bite

Postby yoson10 » Wed Nov 02, 2011 3:54 am

Blet wrote:Bottom line is...loads of study possibilities still here. The reality is that, even though WE may find snake envenomations interesting and of importance, it remains of relatively minor importance in SA compared to most medical emergencies. The fact that you can ID the group/genus of snake involved in a bite and administer very specific treatment and antivenom from a small blood or urine sample in Australia, makes quite a big difference. We've got 2 antivenom options of wich Bommslang hardly ever gets administered. Studies around synthetic 'antivenom' as apposed to horse or sheep serum based products are also encouraging...but these newer options are extremely expensive. In the SA situation even local products are mighty expensive. From a veterinary perspective, I see mostly Cape Cobra bites and these average around R15000-20000 per simple case...and I've lost patients 4d after regaining the ability to breath spontaneously. Interestingly, the last study on Puffadder bites, suggest no antivenom treatment at all...that's likely to change due to new studies on coagulopathies and I must admit seeing more than a few acute deaths from confirmed Puffy bites within 90min of the actual event...this is in and around Cape Town and I do believe there is a variation in effect and virulence depending on dose, age/size of patient, age/size of snake and locality. I count myself lucky if I get the oppertunity to treat a Cape Cobra bite in a dog...most patients do not make it to the clinic! Cape cobras and Mambas will alway remain a gigantic issue...If I ever got into a Cape cobra bite situation, I would insist on antivenom the minute neorological signs creep in. These animals are not to be underestimated! A final point...almost all Cape cobra bites in dogs (if the patient survives!) cause local tissue necrosis. I manage these as opn wounds and they heal uneventfully over a matter of 2-3w, but I found this interesting in such an obviously neurotoxic species!



Yeah most of the Indian cobra bites in dogs that I have seen have resulted in the dogs death in about 30 minutes..Especially when bitten in the face which is pretty much a death sentence. Dogs seem to do better with viper bites and most of the ones bitten by saw scaled vipers survived.

Their is definitely a variation in effect/virulence in different localities...and it can be a great difference. Who knows what causes it.. but their is definitely regional differences in snake venom for the same snake in different locations.

The cape cobra is one of the most venomous cobras in the world so I'm guessing a dog doesn't stand much of a chance of surviving a bite




And from my personal experience Anticholinesterase drugs like neostigmine don't work to well for most Krait bites...especially when the paralysis is already setting in. I've heard it works better for postsynaptic neurotoxins but it isn't very effective for many Krait bites...I only have experience with Common Kraits.

Here are some Krait bite studies

viewtopic.php?f=4&t=22370
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Re: First time ever treatment for Snouted cobra bite

Postby Jen » Fri Nov 18, 2011 3:41 pm

Hi all. Sorry for the belated post! This isn’t meant for those of you in the medical field, but I’d like to explain how these drugs basically work. Below is a diagram of the normal neuromuscular junction:

Image

When a nerve impulse arrives, acetylcholine is released from the nerve and binds to a receptor on the muscle. This ultimately results in a muscle contraction.

Acetylcholine is broken down by an enzyme called acetylcholinesterase. Once it is broken down, the receptor is free for more acetylcholine to bind and therefore the muscle can contract again.
SOME snake venoms behave in a similar way to neuromuscular blocking drugs (which I use on a daily basis in my work as an anaesthetist) Once they reach the neuromuscular junction, they also bind to the same receptors. They are huge and bind for long periods of time – by doing this they block of the receptor to acetylcholine & so no muscle contraction can occur. Essentially the patient is paralysed.

One way of overcoming this is to give a drug called neostigmine. It blocks acetylcholinesterase – the enzyme responsible for breaking down normal acetylcholine. By doing this, the body’s acetylcholine builds up more & more until eventually there is so much and it can push the drug (or venom) off the receptor – allowing it to be free so that normal muscle contraction can occur.

For snake envenomation to be managed successfully with neostigmine, the venom has to behave exactly like a neuromuscular blocker used in anaesthesia:
1) It should bind to the acetylcholine receptor on the muscle (mamba venom doesn’t bind in the correct place & so neostigmine won’t work)
2) It should not bind permanently to the receptor (otherwise the acetylcholine that builds up will be unable to push the venom off the receptor) Cape cobra venom seems to bind to the receptor too tightly – this is why it doesn’t work

Importantly, neostigmine is not a replacement for antivenom. I foresee it rather as an option when there is no antivenom available or when a patient has had previous anaphylaxis with antivenom.

I hope this helps those of you who were asking questions!
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Re: First time ever treatment for Snouted cobra bite

Postby Warren Klein » Fri Nov 18, 2011 6:13 pm

Importantly, neostigmine is not a replacement for antivenom. I foresee it rather as an option when there is no antivenom available or when a patient has had previous anaphylaxis with antivenom.
A very good point to make. Thanks for the explaination Jen.
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Re: First time ever treatment for Snouted cobra bite

Postby Dendroaspis_bastian » Fri Dec 30, 2011 3:53 am

yoson10 wrote:
Bushviper wrote:
Usually we see symptoms within 30 minutes although I have seen some within minutes of a serious bite.


Yeah that's what I have seen/read about in Asian cobras...They symptoms are usually very fast appearing..I have heard about people have their diaphragms paralyzed within 10 minutes.


Are you serious? Show me an actual case of this happening? It certainly isn't the case with Naja naja or Naja kaouthia - as their venoms are both of very high molecular weight, meaning for an elapid, the venom is slow to act. The case is seen across just about all asiatic cobras - - Naja sputatrix and Naja philippinensis carry high molecular weight venom proteins.

I think N. nivea has the lowest molecular weight venom proteins of any cobra, making its venom the most rapid-acting of any cobras.

Kraits and australian brown snakes, though more venomous than any cobra, also have very high molecular weight venoms (which is why death may be prolonged for hours, even days in the case of some krait species).

alpha-neurotoxins and beta-neurotoxins are of high molecular weight (much lower weight than most viperid venoms, but still high weight for proteins).

Dendrotoxins are the toxins with the lowest molecular weight (low mass proteins and peptides), making mamba species' venom the most rapid acting. Cases of fully grown adult humans dying within 20 minutes of black mamba bites have been documented, never has there been such documentation for any cobra. Not even for O. hannah.
I can assure you that you will never ever be able to materialize a case where any asiatic cobra "paralyzing diaphragms in 10 minutes". That's just BS. As a holder of a degree in clinical laboratory science, I just laugh when I see that considering the fact that all the proteins (the lethal part of venoms) I've worked with from most alpha-neurotoxins (both long and short proteins) are of high molecular mass.
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Re: First time ever treatment for Snouted cobra bite

Postby WW » Fri Dec 30, 2011 12:30 pm

Dendroaspis_bastian wrote:
yoson10 wrote:
Bushviper wrote:
Usually we see symptoms within 30 minutes although I have seen some within minutes of a serious bite.


Yeah that's what I have seen/read about in Asian cobras...They symptoms are usually very fast appearing..I have heard about people have their diaphragms paralyzed within 10 minutes.


Are you serious? Show me an actual case of this happening? It certainly isn't the case with Naja naja or Naja kaouthia - as their venoms are both of very high molecular weight, meaning for an elapid, the venom is slow to act. The case is seen across just about all asiatic cobras - - Naja sputatrix and Naja philippinensis carry high molecular weight venom proteins.


For actual cases, see http://www.ncbi.nlm.nih.gov/pubmed/3177741

I think N. nivea has the lowest molecular weight venom proteins of any cobra, making its venom the most rapid-acting of any cobras.


All cobra neurotoxicity is due to three finger toxins, and they all have pretty similar molecular weights, at least in terms of the magnitude of differences that will make any difference in clinical cases.


Kraits and australian brown snakes, though more venomous than any cobra, also have very high molecular weight venoms (which is why death may be prolonged for hours, even days in the case of some krait species).



Brown snakes (Pseudonaja are notorious for causing very sudden early collapse and sometimes death (within 15-30 mins of the bite), although this has little to do with neurotoxins.

Kraits venoms are more slow-acting (as are taipan venoms) because much of their mode of action is presynaptic, which has a longer latency period than postsynaptic neurotoxicity.

I can assure you that you will never ever be able to materialize a case where any asiatic cobra "paralyzing diaphragms in 10 minutes". That's just BS. As a holder of a degree in clinical laboratory science, I just laugh when I see that considering the fact that all the proteins (the lethal part of venoms) I've worked with from most alpha-neurotoxins (both long and short proteins) are of high molecular mass.


I'm sure Drs. Watt and colleagues, the authors of the paper linked to above, will be delighted to have their obviously mistaken clinical observations (aka "just BS") corrected by your lab experience.
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Re: First time ever treatment for Snouted cobra bite

Postby Bushviper » Fri Dec 30, 2011 1:35 pm

Thanks WW. It is so pleasant when a world renowned authority can quote serious research published in peer reviewed journals when making a point.
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Re: First time ever treatment for Snouted cobra bite

Postby Dendroaspis_bastian » Fri Dec 30, 2011 6:36 pm

Nothing you said contradicts what I said. First, the Philippine cobra is considered to be the most venomous of all the Naja species. You materialized 3 cases in which paralysis set in in 30 minutes (cases could've been IV or very close to blood vessels, or not) - not 10 minutes though. If he had claimed 30 minutes, I wouldn't have objected - but 10 minutes? Most often, it takes almost 20 minutes for symptoms to begin to manifest. That's one thing. Yoson10, keeps insisting that Naja naja is this extremely venomous snake that can kill people in 15 minutes, which is total BS. As I said in my first post on this board, which I believe was deleted. It was in the topic of "asiatic snakes vs african snakes" or something along those lines. I mentioned that it is the smaller, island bound cobra species that are the more venomous and often more dangerous - N. sputatrix, N. philippinensis, N. atra (it is island bound in Taiwan). The Indian cobra, monocled cobra, and even the king cobra (though not a true cobra) are in fact less venomous than the species I first mentioned.

I'm not contradicting Drs. Watt and his colleagues, I am telling yoson10 that paralysis will not set in in 10 minutes. Maybe its possible in a case of a severe black mamba envenomation, but not any Asiatic cobras. Dendrotoxins are the far more rapid-acting than alpha-neurotoxins, beta-neurotoxins, and cardiotoxins.
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Re: First time ever treatment for Snouted cobra bite

Postby @ndy » Fri Dec 30, 2011 6:59 pm

Dendroaspis_bastian wrote:Nothing you said contradicts what I said. First, the Philippine cobra is considered to be the most venomous of all the Naja species. You materialized 3 cases in which paralysis set in in 30 minutes (cases could've been IV or very close to blood vessels, or not) - not 10 minutes though. If he had claimed 30 minutes, I wouldn't have objected - but 10 minutes? Most often, it takes almost 20 minutes for symptoms to begin to manifest. That's one thing. Yoson10, keeps insisting that Naja naja is this extremely venomous snake that can kill people in 15 minutes, which is total BS. As I said in my first post on this board, which I believe was deleted. It was in the topic of "asiatic snakes vs african snakes" or something along those lines. I mentioned that it is the smaller, island bound cobra species that are the more venomous and often more dangerous - N. sputatrix, N. philippinensis, N. atra (it is island bound in Taiwan). The Indian cobra, monocled cobra, and even the king cobra (though not a true cobra) are in fact less venomous than the species I first mentioned.

I'm not contradicting Drs. Watt and his colleagues, I am telling yoson10 that paralysis will not set in in 10 minutes. Maybe its possible in a case of a severe black mamba envenomation, but not any Asiatic cobras. Dendrotoxins are the far more rapid-acting than alpha-neurotoxins, beta-neurotoxins, and cardiotoxins.


Dendroaspis_bastian do you even have any field experience? are you saying that your "LAB" experience is FACT? You are busy stepping on the toes of persons that have LOTS and LOTS of field experience with a lot of the species that is mentioned here. I don't know you at all and I don't know what your experience with these species is but the Pic that I am see is "Denroaspis_bastian = Know it all Lab geek"

I am no expert on venomous snakes, hell I don't even keep Venomous snakes, but there are a couple of persons on this forum that I will CALL if I get bitten for advise/assistance and the no 1 person would be Arno "Bushviper"
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