Cobra Envenomation Clinical Presentation

  • Author: Robert L Norris, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 19, 2011
 

History

The onset of symptoms and signs following a cobra bite can be extremely variable.

  • Immediate, local pain (almost always present)
  • Soft tissue swelling (may be progressive)
  • Neurologic findings, which may begin early and be rapidly progressive (in anecdotal cases, victims have suffered respiratory arrest in a matter of minutes) or may be delayed in onset as long as 24 hours
  • Alteration of mental status (eg, drowsiness, occasionally with euphoria)
  • Complaints related to cranial nerve dysfunction, such as ptosis (often one of the earliest neurotoxic findings), ophthalmoplegia, dysphagia, and dysphasia
  • Profuse salivation, nausea, vomiting, and abdominal pain
  • Paresis of neck and jaw muscles and generalized muscular weakness followed by flaccid paralysis
  • Shortness of breath, respiratory failure (muscular paresis and accumulated secretions)
  • Chest pain or tightness
  • Eye pain, tearing, blurred vision (with eye exposure to venom from spitting cobras)
Next

Physical

Impending respiratory failure

  • Respiratory distress or weakness
  • Cyanosis

Neurologic dysfunction

  • Altered mental status
  • Ptosis (may be the earliest sign of systemic toxicity)
  • Generalized weakness or paralysis

Cardiovascular collapse

  • Hypotension
  • Tachycardia or bradycardia

Other

Soft tissue edema may be noted.

Signs of necrosis usually appear within 48 hours of the bite. The area around the fang punctures darkens.

See the image below.

Necrosis from a Naja atra (Chinese cobra) bite. ThNecrosis from a Naja atra (Chinese cobra) bite. This resulted in a severe deformity. The patient had few systemic signs or symptoms. Photo by Sherman Minton, MD.

Blistering may follow.

Necrosis is usually confined to the skin and subcutaneous tissue but may be quite extensive. See the image below.

Necrosis from a cobra bite. Photo by Sherman MintoNecrosis from a cobra bite. Photo by Sherman Minton, MD.

A putrid smell is characteristic.

Acute inflammation of the eye follows venom-spitting exposure and is characterized by ocular congestion, edema of the conjunctiva and cornea, and a whitish discharge.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Robert L Norris, MD  Professor, Department of Surgery, Chief, Division of Emergency Medicine, Stanford University Medical Center

Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, California Medical Association, International Society of Toxinology, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

James Li, MD  Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

David Eitel, MD, MBA  Associate Professor, Department of Emergency Medicine, York Hospital; Physician Advisor for Case Management, Wellspan Health System, York

David Eitel, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, American Society of Pediatric Nephrology, Society for Academic Emergency Medicine, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Russell FE. Snake venom poisoning in the United States. Annu Rev Med. 1980;31:247-59. [Medline].

  2. Bush SP, Hegewald KG, Green SM, et al. Effects of a negative pressure venom extraction device (Extractor) on local tissue injury after artificial rattlesnake envenomation in a porcine model. Wilderness Environ Med. 2000;11(3):180-8. [Medline].

  3. Gold BS. Neostigmine for the treatment of neurotoxicity following envenomation by the Asiatic cobra. Ann Emerg Med. Jul 1996;28(1):87-9. [Medline].

  4. John J, Gane BD, Plakkal N, Aghoram R, Sampath S. Snake bite mimicking brain death. Cases J. 2008;1(1):16. [Medline].

  5. Khandelwal G, Katz KD, Brooks DE, Gonzalez SM, Ulishney CD. Naja Kaouthia: two cases of Asiatic cobra envenomations. J Emerg Med. Feb 2007;32(2):171-4. [Medline]. [Full Text].

  6. Lifshitz M, Maimon N, Livnat S. Walterinnesia aegyptia envenomation in a 22-year-old female: a case report. Toxicon. Mar 2003;41(4):535-7. [Medline].

  7. Lim BL. Venomous land snakes of Malaysia. In: Chou LM, Gopalkrishnakone P, eds. Snakes of Medical Importance - Asia-Pacific Region. National of University of Singapore;1990:387-417.

  8. Looareesuwan S, Viravan C, Warrell DA. Factors contributing to fatal snake bite in the rural tropics: analysis of 46 cases in Thailand. Trans R Soc Trop Med Hyg. 1988;82(6):930-4. [Medline].

  9. Low BW, Corfield BWR. Acetylcholine receptor alpha-toxin binding site - theoretical and model studies. Asia Proc J Pharmacol. 1987;2:115-27.

  10. Minton SA. Bites by non-native venomous snakes in the United States. Wilderness Environ Med. 1996;4:297-303.

  11. Minton SA Jr. Paraspecific protection by elapid and sea snake antivenins. Toxicon. Jul 1967;5(1):47-55. [Medline].

  12. Norris RL, Ngo J, Nolan K. Physicians and lay people are unable to apply pressure immobilization properly in a simulated snakebite scenario. Wilderness Environ Med. 2005;16(1):16-21. [Medline].

  13. Pithayanukul P, Leanpolchareanchai J, Bavovada R. Inhibitory effect of tea polyphenols on local tissue damage induced by snake venoms. Phytother Res. Jan 2010;24 Suppl 1:S56-62. [Medline].

  14. Reid HA. Bites by foreign venomous snakes in Britain. Br Med J. Jun 17 1978;1(6127):1598-1600. [Medline].

  15. Reid HA. Cobra bites. Br Med J. 1964;2:540-545.

  16. Reid HA, Thean PC, Martin WJ. Epidemiology of snake bite in north Malaya. Br Med J. 1963;1:992-997.

  17. Sawai Y, Tseng CS. Snakebites on Taiwan. Snake. 1969;1:9-18.

  18. Stahel E. Epidemiological aspects of snake bites on a Liberian rubber plantation. Acta Trop. Dec 1980;37(4):367-74. [Medline].

  19. Tin-Myint, Rai-Mra, Maung-Chit, et al. Bites by the king cobra (Ophiophagus hannah) in Myanmar: successful treatment of severe neurotoxic envenoming. Q J Med. Sep 1991;80(293):751-62. [Medline].

  20. Veto T, Price R, Silsby JF, Carter JA. Treatment of the first known case of king cobra envenomation in the United Kingdom, complicated by severe anaphylaxis. Anaesthesia. Jan 2007;62(1):75-8. [Full Text].

  21. Viravan C, Looareesuwan S, Kosakarn W, et al. A national hospital-based survey of snakes responsible for bites in Thailand. Trans R Soc Trop Med Hyg. Jan-Feb 1992;86(1):100-6. [Medline].

  22. Visser J, Chapman DS. Snakes and Snake-bite. 1978:1-152.

  23. Walsh DS, Looareesuwan S, Wilairatana P, et al. Randomized dose-ranging study of the safety and efficacy of WR 238605 (Tafenoquine) in the prevention of relapse of Plasmodium vivax malaria in Thailand. J Infect Dis. Oct 1999;180(4):1282-7. [Medline].

  24. Warrell DA. Clinical toxicology of snakebite in Africa and the Middle East and Asia. In: Clinical Toxicology of Animal Venoms and Poisons. CRC Press;1995:433-594.

  25. Warrell DA, Ormerod LD. Snake venom ophthalmia and blindness caused by the spitting cobra (Naja nigricollis) in Nigeria. Am J Trop Med Hyg. May 1976;25(3):525-9. [Medline].

  26. Watt G, Padre L, Tuazon L, et al. Bites by the Philippine cobra (Naja naja philippinensis): prominent neurotoxicity with minimal local signs. Am J Trop Med Hyg. Sep 1988;39(3):306-11. [Medline].

  27. Watt G, Theakston RD, Hayes CG, et al. Positive response to edrophonium in patients with neurotoxic envenoming by cobras (Naja naja philippinensis). A placebo-controlled study. N Engl J Med. Dec 4 1986;315(23):1444-8. [Medline].

  28. Westhoff G, Tzschatzsch K, Bleckmann H. The spitting behavior of two species of spitting cobras. J Comp Physiol A Neuroethol Sens Neural Behav Physiol. Oct 2005;191(10):873-81. [Medline].

  29. Wongtongkam N, Wilde H, Sitthi-Amorn C. A study of Thai cobra (Naja kaouthia) bites in Thailand. Mil Med. Apr 2005;170(4):336-41. [Medline].

 
Previous
Next
 
Naja naja (Indian Cobra). Photo by Robert Norris, MD.
Naja atra (Chinese cobra). Photo by Sherman Minton, MD.
Naja kaouthia (Monocellate cobra). Photo by Sherman Minton, MD.
Naja nivea (Cape cobra). Photo by Sherman Minton, MD.
Necrosis from a cobra bite. Photo by Sherman Minton, MD.
Necrosis from a Naja atra (Chinese cobra) bite. This resulted in a severe deformity. The patient had few systemic signs or symptoms. Photo by Sherman Minton, MD.
Table of antivenom choices for cobra bites. As antivenom manufacturers come and go in the market, choices in this list may or may not be available. Consultation with regional poison control centers, which have access to the Antivenin Index, may help identify and locate an appropriate product for use.
Cobra antivenoms and their manufacturers (part 1). As antivenom manufacturers come and go in the market, choices in this list may or may not be available. Consultation with regional poison control centers, which have access to the Antivenin Index, may help identify and locate an appropriate product for use.
Cobra antivenoms and their manufacturers (part 2). As antivenom manufacturers come and go in the market, choices in this list may or may not be available. Consultation with regional poison control centers, which have access to the Antivenin Index, may help identify and locate an appropriate product for use.
The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms, but its use in cobra bites remains controversial. A broad pressure bandage is immediately wrapped, beginning distally (illustration 1 of 5), around as much of the extremity as possible (illustrations 2 and 3). No effort should be spent removing clothing prior to bandage application. The bandage is wrapped snugly, as for a severely sprained ligament. A splint (or sling when applied to the upper extremity) is then placed (illustrations 4 and 5), and the victim is carried from the scene. The victim should expend no effort in getting to definitive care. Pressure immobilization should remain in place until the victim has reached medical care. The doctor will decide when to remove the bandages. If venom has been injected, it will move into the bloodstream quickly once the bandages are removed. The doctor should leave the bandages and splint in position until appropriate antivenom is available. Used with permission from Commonwealth Serum Laboratories.
The Australian pressure immobilization technique, illustration 2 of 5. A broad pressure bandage is immediately wrapped, beginning distally (as shown above), around as much of the extremity as possible. No effort should be spent removing clothing prior to bandage application. The bandage is wrapped snugly, as for a severely sprained ligament. Used with permission from Commonwealth Serum Laboratories.
The Australian pressure immobilization technique, illustration 3 of 5. A broad pressure bandage is immediately wrapped, beginning distally (as shown above), around as much of the extremity as possible. No effort should be spent removing clothing prior to bandage application. The bandage is wrapped snugly, as for a severely sprained ligament. Used with permission from Commonwealth Serum Laboratories.
The Australian pressure immobilization technique, illustration 4 of 5. A splint (or sling when applied to the upper extremity) is then placed and the victim is carried from the scene. The victim should expend no effort in getting to definitive care. Pressure immobilization should remain in place until the victim has reached medical care. Used with permission from Commonwealth Serum Laboratories.
The Australian pressure immobilization technique, illustration 5 of 5. A splint (or sling when applied to the upper extremity) is then placed and the victim is carried from the scene. The victim should expend no effort in getting to definitive care. Pressure immobilization should remain in place until the victim has reached medical care. Used with permission from Commonwealth Serum Laboratories.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.