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Wed Jul 2 15:33:30 BST 2008

Tim,

Thanks for your patience. I'm old and slow. So if it doesn't shorten the
vent time, what is the autonomic dysfunction that it is important that it
helps with?

Rob

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Timothy Craig Hardcastle
Sent: Wednesday, July 02, 2008 8:05 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Monocled Cobra bite

Rob

The antivenin is to prevent the ongoing autonomic dysfunction related to
the venom and to decrease the incidence of prolonged symptoms - while
there is no "Level 1" evidence that it shortens ventilator time it does
in the reported case series benefit overall recovery.

Apart from Dr Blalock, who did both an M.Med Sci and a PhD on snake
bites, the other well respected local toxicologist who has written
extensively about these and spider bites is Dr G Muller, who published a
number of papers in the SAMJ during the late 80's and 90's. He is also
the co-author of the booklet "The diagnosis and treatment of
envenomation in South Africa" available from SA Institute for Medical
Research and originally published in 1996.

Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
Deputy director: Trauma Unit and Trauma ICU
Inkosi Albert Luthuli Central Hospital / UKZN
800 Bellair Road
Mayville, Durban

Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal

timothyhar at ialch.co.za 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert F. Smith
Sent: 02 July 2008 13:55
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Monocled Cobra bite

Tim,

So is the use of antivenin recommended because the effects usually take
so
long to wear off? Unlike Dr. Mattox's case? I was confused about that in
the
algorhythm.

Rob Smith

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Timothy Craig Hardcastle
Sent: Monday, June 30, 2008 2:16 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Monocled Cobra bite

Ken

Cobras are genus Naja. They are almost exclusively neurotoxic and can
cause
death from respiratory arrest within 45 - 120 minutes post bite.
They are endemic in South Africa and we see their bites with some
frequency.

In South Africa a polyvalent antivenin for Cobra, Mamba (Dendroaspis)
and
puff adder bites (Bitis) is available and the recommended dose is 80
- 120 ml IVI as soon as possible. You may repeat the dose once, being
prepared for allergic reaction.

Remember the patient is usually paralysed, but conscious, so sedatrion
is
required.

Slow recovery over several weeks is the usual course of the pathology
when
an adult snake is the assailant, but can be less severe with juveniles.
Extensive early physical therapy is advised.

I am not specifically aware of any issues other than these with the
monocled
cobra (what is its species name?)

Hope this helps.

Attached is a recent article with a syndromic approach to snake bites.

Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA) Principal
Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care Deputy
director:
Trauma Unit and Trauma ICU Inkosi Albert Luthuli Central Hospital / UKZN
800
Bellair Road Mayville, Durban

Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal

timothyhar at ialch.co.za 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of KMATTOX at aol.com
Sent: 30 June 2008 05:20
To: trauma-list at trauma.org
Cc: SURGINET at listserv.utoronto.ca; ccm-l at ccm-l.org
Subject: Monocled Cobra bite

For the endemic and usual kinds of poisonous snake bites in the United
States I have always proposed to be very sparingly in using  antivenin.
Today we
received a patient arriving less than 40  minutes after being bitten on
the 
finger by a monocled cobra.     He breeds and raises these snakes and
his
business is known to the authorities  and the game warden near his
house.      

Shortly after arrival his respiration just stopped and he was
intubated.   
He was sedated as if he had been given a muscle  relaxant.   His
BP,clotting 
studies were basically normal.    His TEG was normal.     He required no

pressors.    He had basically NO swelling or discoloration  at the site
of the bite 
as we usually see in US poisonous  snakes.     We called around the
country 
and the  consensus was that he should receive specific antivenin.    The

closest antivenin was 1/4 the way across Texas (None in Houston or
Galveston),  so it was flown here and he has received 6 vials of Naja
specific
antivenin.    
He is in the ICU and being supported with the  usual ICU care.   

The reason I am posting this is for several reasons:  

1.    Cobra bites are RARE in the United States
2.    I find that cobra breeders and sellers are fairly  common in the
United
States
3.    I found that the NEUROLOGIC paralysis was rapid  and sure, and the

hematological and coagulopathies effects of the antivenin  were not
seen.   
4.    Several of you on this web site have seen cobra  bites.     

I am seeking wisdom and advice as well as long range outcomes  and
effects.   
   I feel certain that we will  receive a large variety of opinion and 
advice.   We will receive and  welcome any and all and will weigh all
advice against 
his clinical  course.   

Thanks in advance.     

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Monocled Cobra bite