Medication Summary
Evidence supports the trial 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. [25, 26] These temporizing drugs should not, however, delay securing the airway of a victim who is developing respiratory distress or inability to handle secretions.
As with any form of bite, update the tetanus status as necessary. Antibiotic prophylaxis is not necessary.
Antihistamines
Class Summary
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)
Diphenhydramine can be administered parenterally. It is often the H1 blocker of choice in treating or preventing anaphylactoid reactions. It is also effective orally in treating itching associated with serum sickness. If an acute allergic reaction subsequently occurs, further administration may be required.
Cimetidine (Tagamet)
Cimetidine is an H2 antagonist coadministered with an H1 antagonist if there is no response to the H1 antagonist alone; it treats itching and flushing in anaphylaxis, pruritus, urticaria, and contact dermatitis.
Cardiovascular agents
Class Summary
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 and antivenom.
Epinephrine (Epi-Pen)
With its combined alpha- and beta-adrenergic effects, Epinephrine is the drug of choice for the treatment of an acute anaphylactoid reaction because it halts and reverses the major abnormalities associated with such reactions (eg, hypotension, laryngospasm, bronchospasm, edema, urticaria); it must be available immediately for administration if such a reaction to antivenom occurs.
Dopamine (Intropin)
Dopamine may be required to support blood pressure in the face of hypotension caused by an anaphylactic/anaphylactoid reaction (unresponsive to fluids, epinephrine) or by direct snake venom effects (unresponsive to fluids, antivenom).
Norepinephrine (Levophed)
Norepinephrine may be used as an alternative to dopamine to support blood pressure in the face of hypotension caused by an anaphylactic/anaphylactoid reaction that is unresponsive to fluids and epinephrine.
Corticosteroids
Class Summary
Used in management of both acute and delayed allergic phenomena following antivenom administration. Corticosteroids, however, 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.
Prednisone (Deltasone, Orasone, Sterapred)
Prednisone is useful orally in managing mild-to-moderate serum sickness treated on an outpatient basis.
Cholinesterase inhibitors
Class Summary
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)
Edrophonium is a short-acting anticholinesterase agent; it may provide significant improvement in muscle strength (eg, ability to open eyes) within 2 minutes and its effect peaks in 5 minutes. Weakness rapidly returns, however, and can be subsequently treated with a longer-acting agent, such as neostigmine.
Neostigmine (Prostigmin)
Neostigmine is a longer-acting cholinesterase inhibitor that can be used if a trial of edrophonium is effective; it inhibits the destruction of acetylcholine by acetylcholinesterase, which facilitates the transmission of impulses across the myoneural junction.
Immune globulins
Class Summary
Consists of administration of immunoglobulin pooled from serum of immunized subjects.
Tetanus immune globulin (TIG)
Tetanus immune globulin is 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.
Toxoids
Class Summary
Toxoids are used to induce active immunity against the respective antigens.
Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Adacel, Boostrix)
This is a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine. It promotes active immunity to diphtheria, tetanus, and pertussis by inducing the production of specific neutralizing antibodies and antitoxins. It is indicated for active booster immunization for tetanus, diphtheria, and pertussis prevention for persons aged 10-64 years (Adacel approved for 11-64 y, Boostrix approved for 10-18 y). It is the preferred vaccine for adolescents scheduled for booster.
Tetanus toxoid adsorbed or fluid
The immunizing agent of choice for most adults and children older than 7 years is tetanus and diphtheria toxoids. It is 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, it may be administered into the deltoid or midlateral thigh muscles. In infants, the preferred site of administration is the mid thigh laterally.
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Naja naja (Indian Cobra). Photo by Robert Norris, MD.
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Naja atra (Chinese cobra). Photo by Sherman Minton, MD.
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Naja kaouthia (Monocellate cobra). Photo by Sherman Minton, MD.
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Naja nivea (Cape cobra). Photo by Sherman Minton, MD.
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Necrosis from a cobra bite. Photo by Sherman Minton, MD.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
