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Snake Envenomation, Cobra: Treatment & Medication
Updated: Dec 29, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
Prompt movement of the victim to a medical facility capable of rendering advanced care, including airway support and antivenom administration, is critical.
- Make every effort to specifically identify the envenoming species; this will aid further management and is vital in determining the proper antivenom to be administered.
- If the patient is bitten by a wild snake, the snake should be killed and brought to the admitting institution if it is possible to do so safely. Knowledge of the snake fauna of an area and habits of the various species may help in identification. Fairly accurate ELISA tests for identification of snake venoms in wound aspirate, serum, urine, and other body fluids have been developed but are not generally available in regions where cobras live.
- If the bite occurs in a research or zoo setting, the cage identification card should be brought to the hospital. If available, species-specific antivenom should be sent with the patient.
- If a captive cobra in a private collection inflicts the bite, identification may be more straightforward. Unfortunately, tremendous controversy exists among experts regarding taxonomy of cobra species and becomes amplified in the lay herpetoculturist community. A private collector who presents after being bitten by his or her captive "Thai cobra" may have been envenomed by any 1 of at least 3 different species, each with different clinical consequences. Thus, expect a variety of physiologic abnormalities and enlist professional help (eg, from a local zoo) to obtain prompt, accurate identification of the snake.
- In some regions of the world, clothing is wrapped around a bitten extremity proximal to the bite site. However, prolonged use of arterial tourniquets is unwise and has caused loss of limb function. A completely occlusive tourniquet is reasonable when a victim has been bitten by a highly toxic snake, such as a cobra, and is a short distance from medical care.
- An alternative first aid procedure is the Australian pressure immobilization technique (see Media files 10-14). This technique has been shown to be helpful in delaying systemic absorption of some elapid venoms, but its use in cobra bites remains controversial.
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 (10), around as much of the extremity as possible (see Media files 11-12). 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 (see Media files 13-14), 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.
- An elastic compress (eg, Ace wrap, clothing, crepe bandage) is wrapped rapidly around the bitten extremity, beginning distally and progressing proximally to encompass the entire limb. The compress is as tight as one used for immobilization of a severe ligamentous sprain. Then, the extremity is splinted and kept at heart level while the victim is carried from the scene. Research shows, however, that, in simulated snakebite scenarios, individuals usually underestimate the degree of tension required for the wrap to be effective, and, even with intensive training, are usually unable to apply the technique correctly.
- This technique should not be used in any situation in which the snake responsible for the bite is known to cause local necrosis, as local tissue damage may be increased with its use.
- Incisions are not helpful. Using a mechanical suction device is unlikely to return any significant amount of venom, and it could increase local tissue damage when a necrotizing venom is involved. Suction should, therefore, be avoided.
- Avoid cooling measures and ice application. They have been associated with increased necrotic complications.
- If venom is spit into the eyes, immediately and copiously irrigate them with any bland fluid, such as water, saline solution, or milk.
Emergency Department Care
- Assess the patient's airway and breathing. Aggressively manage any signs of impending respiratory failure with endotracheal intubation to prevent aspiration.
- Immediately institute cardiac and pulse oximetry monitoring and closely monitor the patient's vital signs.
- Start, at an appropriate rate, at least 1 large-bore line with normal saline or Ringer's lactate.
- Grading scales for judging the severity of viper venom poisoning rely heavily on local findings, which are variable in cobra bites; they should not be used. All persons who have been bitten by a cobra should be treated as if a severe envenomation has occurred.
- Antivenom is the only proven therapy for significant snakebites. About 20 laboratories in Africa, Asia, and Europe produce cobra antivenoms. Some are monovalent, but most are polyvalent against venoms of all the important snakes of a nation or region. However, the quality varies, and no international standards of purity or effectiveness exist. In the United States, no cobra antivenom has FDA approval. All are considered experimental drugs. Antivenoms are largely ineffective in preventing or ameliorating the necrosis caused by many cobra venoms.
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.
- If the envenomating species has been determined, a resource, such as the Antivenom Index (published and maintained by the American Association of Zoological Parks and Aquariums and the American Association of Poison Control Centers), can be accessed by calling a regional poison control center or the Arizona Poison and Drug Information Center (from outside Arizona, 520-626-6016; from Arizona only, 800-362-0101). This document lists the preferred antivenoms available for most medically important venomous snakes around the world and has information about where these sera can be obtained in the United States (usually zoos or serpentariums). Once the antivenom is located, the physician may need assistance from the police or military to facilitate its rapid transport.
- If possible, the antivenom should have antibodies against venom of the cobra species that inflicted the bite. However, shared venom antigens among cobra species exist, and heterologous antivenoms may be effective. Venoms of the African spitting cobras are among the most difficult to neutralize by nonspecific antivenoms. Notechis (Australian tiger snake) antivenom proved effective in animal experiments against 9 of 11 cobra venoms, exceptions being ringhals and Chinese cobra venoms. Apparent effectiveness of tiger snake antivenom in clinically treating cobra bites has been shown in a few cases.
- If the patient arrives with some device applied in an attempt to limit spread of the venom, such as a tourniquet, constriction band, or pressure device, quickly assess the patient to determine if any evidence of systemic toxicity is present.
- Assess the presence of distal pulses below the ligature. If symptoms are present and antivenom is available, start the antivenom before removing the tourniquet device. If symptoms are absent and antivenom is available, remove the device and observe the patient closely for symptoms or signs of toxicity. If signs of envenoming occur, administer antivenom promptly.
- If the tourniquet is totally occluding arterial flow, apply a more loosely fitting device, such as a proximal constriction band, as tightly as one would for a phlebotomy. A pressure immobilization device may also be used (see Prehospital Care). A more loosely fitting device is appropriate to prevent the release of an acidotic, hyperkalemic blood into the central circulation as the tourniquet is released.
- When applicable, initiate and continue irrigation of the eyes with saline. Applying several drops of a topical ophthalmic anesthetic agent may reduce pain and aid in irrigation. The topical use of 1:1000 epinephrine solution is reported to relieve pain promptly. A fluorescein-aided slit lamp examination helps to find evidence of corneal damage. A brief course of topical ophthalmic antibiotics may be prescribed.
Consultations
- Toxicologist or expert in snake envenomation
- Regional poison control center
- A local zoo or museum may be able to assist in species identification and may have appropriate antivenom in stock.
- An ophthalmologist should evaluate any patient who has suffered eye exposure to spitting cobra venom.
- General surgeon or plastic surgeon for follow-up care of necrotic wounds
Medication
The definitive therapy for cobra envenomation is antivenom administration, which should be started as soon as possible if evidence of systemic envenoming is present. If specific antivenom is not rapidly available, the patient must be supported using conservative measures alone. Measures include securing the airway and supporting respirations as necessary. Hypotension should be treated initially with intravenous fluids (initially crystalloids but if blood pressure/tissue perfusion fails to improve, then albumin). If hypotension persists after the intravascular volume is replete, vasopressor agents may be necessary.
Evidence supports the use of cholinesterase-inhibiting drugs, such as edrophonium or neostigmine, as a temporizing measure in a situation of severe cobra venom poisoning with significant neurologic abnormalities until antivenom can be obtained.
Administer antivenom according to the manufacturer's instructions.
As with any form of bite, update the tetanus status as necessary. Antibiotic prophylaxis is not necessary.
Antivenom
Imparts passive immunity to the victim against the venom components of the snake(s) for which it is manufactured. The heterologous antibodies bind with venom antigens and block their deleterious effects.
Antivenom (variable, see below)
Several different cobra antivenoms are produced by various countries. They are of variable purity and efficacy. The most appropriate agent for the species involved should be determined and obtained. Given venom variability, antivenom produced in the country of origin of the offending species is preferred. An intradermal skin test for potential acute sensitivity is often recommended before administration. Such skin tests (outlined in the manufacturer's package inserts) are, however, unreliable predictors of anaphylaxis/anaphylactoid reactions. Before administration, intravascular volume should be expanded using crystalloids such as normal saline or Ringer's lactate unless some contraindication (eg, congestive heart failure) is present. Pretreatment with antihistamines (H1 and H2 blockers) can be considered, though their efficacy at preventing adverse reactions to antivenom is unproven. Epinephrine should be immediately available for treatment of an anaphylactoid response to the heterologous serum.
Adult
As per the manufacturer's recommendations, generally, 100-200 mL (more may be required); dilute in 500-1000 mL of normal saline, and begin IV at a slow rate with the physician in immediate attendance to intervene immediately if a reaction occurs; if no reaction, increase rate in order to administer full starting dose in 1-2 h; if acute reaction occurs, halt and treat patient prn with epinephrine, antihistamines, and steroids; antivenom usually may be restarted at slower rate (possibly more dilute); if reaction persists or is severe, may need to rely solely on sound supportive care
Pediatric
Administer as in adults, though may reduce volume of diluent
None reported
Documented hypersensitivity (may give in severe envenomation, despite hypersensitivity)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
While use in pregnancy has not been well studied, it is generally felt that the benefits outweigh the risks.
Heterologous serums carry inherent risks of anaphylactoid reactions, and agents for emergency treatment of anaphylaxis should be immediately available; limited shelf life; emergency situation, antivenom outdated up to 5 y may be used if not visibly turbid
Antihistamines
Antihistamines (H1 and H2 blockers) may blunt or prevent an acute allergic reaction when given before the administration of antivenom. If an anaphylactic/anaphylactoid reaction occurs despite pretreatment, further antihistamine dosing may be required. These agents are useful in managing pruritus in cases of delayed serum sickness, which may appear days to weeks following antivenom treatment.
Diphenhydramine (Benadryl)
Administered parenterally. Often the H1 blocker of choice in treating or preventing anaphylactoid reactions. Also effective PO in treating itching associated with serum sickness. If acute allergic reaction subsequently occurs, further administration may be required.
Adult
Pretreatment before antivenom: 1 mg/kg IV; not to exceed 100 mg
Serum sickness: 1 mg/kg PO q6h prn itching; not to exceed 400 mg/d
Pediatric
Pretreatment before antivenom: 1 mg/kg IV; not to exceed 100 mg
Serum sickness: 1 mg/kg PO q6h prn itching; not to exceed 300 mg/d
Potentiates effect of CNS depressants; because of alcohol content, do not give syrup dose form to patient taking medications that can cause disulfiramlike reactions
Documented hypersensitivity; MAOIs
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction
Cimetidine (Tagamet)
H2 antagonist coadministered with H1 antagonist if no response to H1 antagonist alone; treats itching and flushing in anaphylaxis, pruritus, urticaria, and contact dermatitis.
Adult
300 mg IV q6h prn
Pediatric
5-10 mg/kg IV q6h prn; not to exceed 300 mg/dose
Can increase blood levels of theophylline, phenytoin, quinidine, propranolol, metronidazole, warfarin, tricyclic antidepressants, and lidocaine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Elderly persons may experience confusional states; may cause impotence and gynecomastia in young males; may increase levels of many drugs; adjust dose or discontinue treatment if changes in renal function occur
Cardiovascular agents
Useful in treating acute allergic reactions that may occur with antivenom administration and in supporting the blood pressure and tissue perfusion of hypotensive patients with shock unresponsive to IV fluids alone.
Epinephrine (Epi-Pen)
With its combined alpha- and beta-adrenergic effects, is the DOC for treatment of an acute anaphylactoid reaction because it halts and reverses the major abnormalities associated with such reactions (eg, hypotension, laryngospasm, bronchospasm, edema, urticaria); must be available immediately for administration if such a reaction to antivenom occurs.
Adult
Moderate hypotension: 0.01 mL/kg of 1:1000 (1 mg/mL) IM; repeat prn q10-20min; not to exceed 0.5 mL
Severe hypotension: Cautiously 2 mcg/min IV initially (eg, 1 mg of epinephrine in 500 mL isotonic saline, starting at 1 mL/min); titrate to effect
Pediatric
Moderate hypotension: 0.01 mL/kg of 1:1000 (1 mg/mL) IM; may repeat prn q10-20min; not to exceed 0.3 mL
Severe hypotension: Cautiously 0.05 mcg/kg/min IV initially (eg, 1 mg of epinephrine in 500 mL isotonic saline, starting at 0.025 mL/kg/min); titrate to effect
Decreased effectiveness in the presence of beta- and alpha-blocking agents; increased toxicity of halogenated inhalational anesthetics
Documented hypersensitivity; cardiac dysrhythmias; angle-closure glaucoma; do not use during labor (may delay second stage of labor)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in elderly persons, prostatic hypertrophy, hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac dysrhythmias
Dopamine (Intropin)
May be required to support BP in face of hypotension caused by anaphylactic/anaphylactoid reaction (unresponsive to fluids, epinephrine) or by direct snake venom effects (unresponsive to fluids, antivenom).
Adult
5-20 mcg/kg/min IV; titrate to effect
Pediatric
Administer as in adults
Phenytoin, alpha- and beta-adrenergic blockers, general anesthesia, and MAOIs increase and prolong effects
Documented hypersensitivity; pheochromocytoma; ventricular fibrillation
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor closely urine flow, cardiac output, pulmonary wedge pressure, and blood pressure during the infusion; prior to infusion, correct hypovolemia with either whole blood or plasma, as indicated; monitoring central venous pressure or left ventricular filling pressure may be helpful in detecting and treating hypovolemia
Norepinephrine (Levophed)
May be used as an alternative to dopamine to support BP in face of hypotension caused by anaphylactic/anaphylactoid reaction that is unresponsive to fluids and epinephrine.
Adult
0.5-1 mcg/min IV; titrate to effect
Pediatric
0.1 mcg/kg/min IV; titrate to effect
MAOIs and tricyclic antidepressants may interact to produce excessive hypertension; phenothiazines may inhibit the pressor effects of norepinephrine
Documented hypersensitivity; peripheral or mesenteric vascular thrombosis because ischemia may be increased and the area of the infarct extended
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Correct blood-volume depletion, if possible, before norepinephrine therapy; extravasation may cause severe tissue necrosis and, thus, should be administered into a large vein; caution in occlusive vascular disease
Corticosteroids
Essential for management of both acute and delayed allergic phenomena following antivenom administration. Corticosteroids have no primary role in the management of snake venom poisoning.
Methylprednisolone (Solu-Medrol, Depo-Medrol)
Steroids ameliorate the delayed effects of anaphylactoid reactions and may limit biphasic anaphylaxis. In severe cases of serum sickness, parenteral steroids may be beneficial to reduce the inflammatory effects of this immune-complex mediated disease.
Adult
125 mg IV q6-8h
Pediatric
1-2 mg/kg IV q6-8h
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; phenobarbital, phenytoin and rifampin may decrease levels (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
Prednisone (Deltasone, Orasone, Sterapred)
Useful PO in managing mild-to-moderate serum sickness treated on an outpatient basis.
Adult
1 mg/kg PO qd until symptoms resolve; taper over 1-2 wk
Pediatric
1-2 mg/kg PO qd until symptoms resolve; taper over 1-2 wk
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral diseases; peptic ulcer disease; hepatic dysfunction; connective tissue, fungal, or tubercular skin infections
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Cholinesterase inhibitors
May be effective in temporarily reversing muscle weakness until antivenom can be obtained. Their use might obviate intubation, but airway protection should not be delayed if there is any doubt of the patient's respiratory status or ability to protect the airway.
Edrophonium (Enlon, Reversol)
Short-acting anticholinesterase agent; may provide significant improvement in muscle strength (eg, ability to open eyes) within 2 min and its effect peaks in 5 min. Weakness rapidly returns, however, and can be subsequently treated with a longer-acting agent, such as neostigmine.
Adult
10 mg slow IV push after pretreatment with atropine (0.6 mg IV)
Pediatric
<35 kg: 5 mg slow IV push after pretreatment with atropine (0.02 mg/kg up to 0.6 mg [minimum 0.1 mg] IV)
>35 kg: 10 mg slow IV push after pretreatment with atropine (0.6 mg IV)
Atropine, nondepolarizing muscle relaxants, procainamide, and quinidine may decrease effects of edrophonium; succinylcholine, digoxin, IV acetazolamide, neostigmine, and physostigmine may increase effects
Documented hypersensitivity; GI or GU obstruction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in bronchial asthma and those receiving a cardiac glycoside; may cause cholinergic crisis, which may be fatal; IV atropine should be readily available for treatment of cholinergic reactions
Neostigmine (Prostigmin)
Longer-acting cholinesterase inhibitor that can be used if a trial of edrophonium is effective; inhibits the destruction of acetylcholine by acetylcholinesterase, which facilitates the transmission of impulses across the myoneural junction.
Adult
0.5 mg slow IV push or SC q20min (pretreat with atropine)
Pediatric
Not established
Atropine antagonizes muscarinic effects of neostigmine; effects of neuromuscular agents are increased
Documented hypersensitivity; GI or GU obstruction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in epilepsy, asthma, bradycardia, hyperthyroidism, cardiac arrhythmias, or peptic ulcer; anticholinesterase insensitivity can develop for brief or prolonged periods
Immune globulins
Consists of administration of immunoglobulin pooled from serum of immunized subjects.
Tetanus immune globulin (Hyper-Tet)
Used for passive immunization of any person with a wound that might be contaminated with tetanus spores when the person has not previously completed a primary tetanus immunization series.
Adult
Prophylaxis: 250-500 Units IM in different anatomical site than tetanus toxoid administration
Clinical tetanus: 3000-10,000 Units IM
Pediatric
Prophylaxis: 250 Units IM in different anatomical site than tetanus toxoid administration
Clinical tetanus: Administer as in adults
None reported
Since antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live virus vaccination
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Persons with isolated immunoglobulin A (IgA) deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing since intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing the medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not admix with other medications since usually incompatible
Toxoids
Used to induce active immunity against the respective antigens.
Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Adacel, Boostrix)
Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine. Promotes active immunity to diphtheria, tetanus, and pertussis by inducing production of specific neutralizing antibodies and antitoxins. Indicated for active booster immunization for tetanus, diphtheria, and pertussis prevention for persons aged 10-64 y (Adacel approved for 11-64 y, Boostrix approved for 10-18 y). Preferred vaccine for adolescents scheduled for booster.
Adult
One-time alternative to Td in adults when pertussis component is also indicated: 0.5 mL IM once as a single dose into deltoid muscle; at least 5 y should elapse since last dose of tetanus-, diphtheria-, and/or pertussis-containing vaccine; booster with Td recommended q10y
>65 years: Not indicated
Pediatric
<10 years: Not indicated
>10 years: Administer as in adults; preferred vaccine for adolescents scheduled for booster
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization because of a poor immune response
Documented hypersensitivity; encephalopathy within 7 d following pertussis-containing vaccine; progressive neurologic disorder, uncontrolled epilepsy, or progressive encephalopathy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Routine immunization of symptomatic and asymptomatic persons infected with HIV is recommended; may cause transient redness, swelling, or pain at injection site; infrequently causes fever; administer only if benefit outweighs risk to individuals with bleeding disorders (eg, hemophilia, thrombocytopenia) or those who are on anticoagulant therapy; caution if fever, shock, persistent crying, Guillain-Barré syndrome, or seizures occurred following previous DTP or DTaP vaccine (consider administering Td instead)
Tetanus toxoid
The immunizing agent of choice for most adults and children >7 y is tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is the mid-thigh laterally.
Adult
Suggested dosing:
Primary immunization: 0.5 mL IM, give 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y
Pediatric
Administer as in adults
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin test antigens; avoid concurrent use of medication with systemic chloramphenicol since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)
Documented hypersensitivity; a history of any type of neurological symptoms or signs following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat actual tetanus infections, or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin) diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended
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Further Reading
Keywords
snakebite, snake bite, cobra bite, snake venom, treatment, symptoms, cobra envenomations, snake envenomations, Naja, Naja philippinensis, Philippine cobra, Ophiophagus hannah, king cobra, Hemachatus haemachatus, ringhals, Walterinnesia aegyptia, desert black snake, Boulengerina, water cobra Pseudohaje, tree cobra
