IMMEDIATE FIRST AID
for bites by
In the event of an actual or probable bite from a King Cobra, execute the
following first aid measures without delay.
- Make sure that the responsible snake or snakes have been
appropriately and safely contained, and are out of danger of inflicting any
- Immediately call for transportation.
DO NOT cut or incise the bite site
- Keep the victim calm and reassured. Allow him or her to lie
flat and avoid as much movement as possible. If possible, allow the bitten
limb to rest at a level lower than the victim's heart.
- Immediately wrap a large crepe bandage snugly around the bitten limb
starting at the site of the bite and working proximally up the limb (the full
length if possible). The bandage should be as tight as one might bind a
sprained ankle. (See attached copy from "First Aid for Snakebite" by Dr.
- Secure the splint to the bandaged limb to keep the limb as rigid and
unmoving as possible. Avoid bending or moving the limb excessively while
applying the splint.
- DO NOT remove the splint or bandages until the victim has reached the
hospital and is receiving Antivenom.
- Have the TIGER SNAKE ANTIVENOM (Commonwealth Serum Laboratories) ready
for the emergency crew to take with the victim to the hospital. Give them the
- the available antivenom (at least 10 vials)
- the accompanying instruction (Protocol) packet
- the victim's medical packet (if available)
DO NOT apply ice to the bite site
Summary for Human Bite
The bite of the King Cobra with envenomation can be rapidly fatal (as early
as 30 minutes). Please read the attached Medical Management Protocol and
- First Aid:
- Bandage and Immobilize the bitten limb with crepe bandages and splint
as described in the Immediate First Aid section. Rest this extremity below the
level of the patient's heart (if practical).
- Transport to a medical center emergency or trauma service.
- Medical Management:
- Call your local Poison Control Center or the San Diego Regional Poison
Control Center (800 876-4766). They should locate a consultant to help you
treat this patient.
- Observe for Signs and Symptoms of Envenomation.
- If signs or symptoms are present, perform the following:
- Administer Lactated Ringers Solution at 200 to 250 mls per
- Draw samples and collect initial laboratory data.
- Dilute the contents of 2 vials (6000 units) of Commonwealth Serum
Laboratories Tiger Snake Antivenom 1:10 in Lactated Ringers Solution.
Adminster the antivenom I.V. piggyback over 30 minutes at a rate of 200 units
Note: Tiger Snake Antivenom is the prefered antivenom of choice in
treating King Cobra bites. It has a high neutralizing
- Remove the splints and crepe bandage slowly over a period of 10
minutes. If symptoms progress rapidly, reapply the bandage, and administer an
additional 2 vials. Again attempt to remove the bandage.
- Allergic or untoward reactions to the antivenom should be treated with
Corticosteroids, Epinephrine, Benadryl, Atarax and/or Antihistamines as
- Monitor Signs, Symptoms, and Laboratory data, and administer additional
antivenom in 1 vial (3000 units) increments at a rate of 100 units per minute
as necessary to control the progession of symptoms.
- The required amount of antivenom will vary with the severity of
envenomation. One should anticipate using (including the initial
4-6 vials total for a minor bite with envenomation.
8-20 vials total may be necessary for moderate or severe bites.
for bites by
This person has received a bite and probable envenomation from a King Cobra
(Ophiophagus hannah). This is a very venomous and dangerous snake which is
widely distributed in India, China, Malaysia, Indonesia, Southeast Asia, and as
far as the Philippines. The King Cobra is the largest venomous snake in the
world, and can inject an extremely large quantity of venom in one bite.
Envenomation signifies a true medical emergency. In this particular species,
envenomation usually presents predominately with systemic neurologic
manifestations. Drowsiness, neurological and neuromuscular symptoms may
develop early; paralysis, ventilatory failure or death often ensue
Please read and execute the following procedures without delay.
- A crepe bandage and splint have been applied as immediate first aid
adjuncts to retard the absorption of the venom. DO NOT remove until the
patient has arrived at the hospital and is receiving the antivenom.
- Make sure that at least 10 vials of Tiger Snake Antivenom are present
with the patient. This antivenom is strongly paraspecific, and contains the
appropriate fractions necessary to neutralize the components of King Cobra
- If the patient has been envenomated, the treatment is 4 to 15 vials of
intravenous antivenom. Envenomation is diagnosed by the presence of
characteristic signs and symptoms. Necessary information follows and is
organized in sections:
- Signs and Symptoms of Envenomation
- Medical Management
- General Considerations
- Special Considerations
Signs and Symptoms of Envenomation:
- Neurological and Neuromuscular: These signs and symptoms if they are
to occur will usually manifest earliest (possibly within 15 to 30 minutes
following the bite). Not all of these will necessarily develop, even with
- Eyelid drooping (Ptosis)
- Respiratory paralysis or Dyspnea (often severe apnea with early
- Palatal paralysis
- Glossopharyngeal paralysis
- Limb paralysis
- Head drooping (Cervical muscle paresis or paralysis)
- Hyporeflexia (generalized)
- Sudden loss of consciousness
- Stumbling gait (Ataxia)
- General: These symptoms typically manifest within one to four hours
following the bite if envenomation occurred. Pain will usually begin
immediately after the bite.
- Hypotension with irregular Peripheral Pulses
- Generalized Shock
- Flushing of the face
- Warm skin
- Pain around bite site
- Nausea and Vomiting
- Abdominal Pain
- Urticaria and Fever
- Cardiotoxicity: Direct clinical cardiotoxic effects have not yet been
reported in King Cobra envenomations. These have been recorded in some cobra
and other elapid envenomations. Clinical monitoring of cardiac function and
rhythm would be advised.
- Renal: Nephrotoxic effects have likewise not been reported with the
King Cobra, but have been seen in Mamba, Tiger Snake, Taipan and other elapid
envenomations. Oliguria or Anuria with possible changes in urinary composition
will herald the development of renal shutdown. Dialysis is advised.
- Local Symptoms: In some cases of King Cobra bite, local tissue
destruction and necrosis may be extensive. Swelling may extend proximally on
the bitten extremity with bleb formation. Gangrene requiring amputation can
occur. Local tissue damage may include:
- Localized dusky discoloration of skin
- Serosanguineous vesiculation
- Secondary bacterial infection (Proteus vulgaris was cultured in one
- Necrosis with tissue sloughing (can be extensive, but will likely remain
localized to the bite site)
- Local edema
- Swelling (may extend proximally)
- Fang Marks: Fang marks may be present as one or more well defined
punctures, as a series of small lacerations or scratches, or there may not be
any noticeable or obvious markings where the bite occurred. The absence of
fang marks does not preclude the possibility of a bite (especially if a
juvenile snake is involved). In general, the fang marks from a King Cobra are
large, well defined and spaced apart with slight bleeding from the marks.
Multiple bites inflicted by a single snake or by more than one snake are also
possible, and should be noted if present (See Special Considerations below).
The presence of fang marks does not always imply that the injection or
deposition of venom into the bite wound (envenomation) actually occurred. In
some cases, the snake may voluntarily elect not to inject venom with the strike
resulting in a dry bite.
- Admit patient to an emergency or trauma service and call the consultant
identified by the Poison Control Center.
- Begin a peripheral intravenous infusion (16 gauge catheter) of Lactated
Ringers Solution at a rate of 250 cc/hour.
- Draw blood from the contralateral arm, and collect urine for the
following laboratory tests. Mark STAT.
- Type and Cross Match TWO units of Whole blood.
- CBC with differential and platelets.
- Coagulation Parameters:
- Prothrombin Time (PT)
- Partial Thromboplastin Time (PTT)
- Fibrinogen levels
- Fibrin Degradation Products
- Serum Electrolytes, BUN/Creatinine, Calcium, Phosphorus.
- Lactate Dehydrogenase (with Isoenzyme analysis). Isoenzyme analysis may
indicate multiple targets of the venom components which may dictate further
- Urinalysis (Macroscopic and Microscopic Analysis). Must include
- Urine Electrolytes and Creatinine
- Free Protein
- Electrocardiogram (Place the patient on continuous monitoring). Rapid
heart rate to be expected.
- Continuous Urine Output Monitoring (Indwelling Foley Catheter if
unconscious). Watch for possible oliguria or anuria.
- Additional Tests as needed or indicated by patient's hospital
- It may be necessary or practical to repeat some of the above serum and
urine tests periodically over the hospital course to monitor the effects of
antivenom therapy or to detect late changes in parametric values.
- OBSERVE PATIENT CLOSELY for signs and symptoms of envenomation which
usually manifest between 15 minutes and two hours following the bite.
- If NONE of the signs or symptoms have been noted after TWO hours, there
is the possibility that the patient received a dry bite (no venom
- VERY SLOWLY begin to remove the bandages and splint watching carefully
for any changes in the patient's status. If any changes occur, assume the
patient has been envenomed and prepare to give antivenom immediately (as
- If signs and symptoms still fail to manifest, continue CLOSE observation
of the patient for an additional 24 hours.
- IF ANY SIGN OR SYMPTOM becomes apparent or has been noted during the
course of treatment, begin Antivenom Therapy as follows:
- Dilute the contents of TWO vials of Tiger Snake Antivenom (6000 units)
in Lactated Ringers Solution (Hartmann's Solution) to a total volume of 120
- Administer the diluted Antivenom intravenously over a period of 30
minutes at a rate of 4 mls per minute (i.e., 2 vials per 30 minutes or 200
units per minute).
- Should any signs of ALLERGY/ANAPHYLAXIS (e.g., coughing, dyspnea,
urticaria, itching, increased oral secretions, etc.) develop, immediately
discontinue the administration of antivenom, and treat symptoms with
Epinephrine, Steroids and Antihistamines. As soon as the patient is
stabilized, continue the antivenom infusion at a slower rate.
- After 15 minutes of antivenom administration, the splint and the
bandages may be removed. This should be done VERY SLOWLY over a period of FIVE
minutes to prevent a bolus release of venom. If the patient's condition
worsens, reapply the crepe bandage, wait 10 minutes and release the bandage
again slowly over 10 minutes while antivenom administration is
- Antivenom Therapy is the mainstay of treatment for King Cobra
envenomation. Many of the symptoms are ameliorated or entirely eliminated by
the antivenom alone. Other symptoms will require additional modalities of
therapy to correct.
- Neurological Symptoms (especially respiratory obstruction or failure)
tend to predominate the clinical picture in cases of King Cobra envenomation,
and are usually the most immediate cause of dangerous problems. Often, these
are improved by the antivenom. If breathing becomes impaired, provide
respiratory assistance. Secretions may become copious, necessitating
suctioning or even intubation.
- Hematological symptoms may present as a Disseminated Intravascular
Coagulopathy, and are treated as are other DICs. This, however, has not yet
been reported with King Cobra envenomation.
- Renal symptoms may complicate the situation, and if severe (i.e., Acute
Renal Failure) may necessitate Peritoneal Dialysis.
- If severe muscle or respiratory paralysis develops and persists,
administer 0.6 mg of Atropine IV. Follow by giving 0.5 mg of Neostigmine IV
every 30 minutes for a maximum of FIVE doses.
- If the bite site develops signs suggestive of infection, Cultures and
Sensitivities should be obtained prior to starting appropriate Antibiotic
- It is important to keep venom neutralization current and continuous.
The best method to accomplish this is to keep a close watch on the patient's
status. If the present condition does not improve, or should it worsen for any
reason, additional antivenom should be administered. Give all additional
antivenom in 1 vial (3000 unit) doses. Dilute one vial in Lactated Ringers
Solution to a total volume of 60 mls and deliver I.V piggyback over 30 minutes
at a rate of 2 mls per minute (i.e., 1 vial per 30 minutes or 100 units per
minute). One should anticipate using (including the Initial dose):
4-6 vials total for a minor bite with envenomation.
8-20 vials total may be necessary for moderate or severe bites.
- It is advisable to perform periodic serum and urine analyses during
therapy (as outlined above).
- It is always best to keep the patient in an Intensive Care setting
until free of major symptoms for 24 hours. The patient should be observed in
the hospital for at least 24 hours after symptoms are stabilized.
- It is important that the patient be placed at rest, kept warm, and avoid
- The onset of dangerous Neurotoxic symptoms can be rapid and
subtle. In addition, they are more rapidly reversed in their early stages than
when fully developed. It may be necessary to wake the patient and perform a
brief neurologic check every hour or so to assure that breathing and other
vital functions are not impaired. Carefully note the progress of any paralysis
which may be present.
- Respiratory obstruction and failure are the greatest immediate
concern. Should the patient develop difficulties in breathing or airway
impairment, respiratory support will be required. If the tongue, jaw or
pharynx become paralyzed, insert an oral airway. Make sure adequate suction
equipment is available and operative.
- Fluid management is very important in snake bite cases.
Intravenous administration is always the most appropriate route. Blood
replacement SHOULD NOT be stared until the circulating venom anticoagulants
have been fully neutralized.
- If any signs of Oropharyngeal paralysis or impaired
swallowing exist, give NOTHING BY MOUTH, and keep patient on his side
with head down. Watch for airway compromise and aspiration.
- Morphine is CONTRAINDICATED because of its tendency to suppress
respiration. Alcohol should also be avoided. Diazepam (Valium) may be given,
but not in large quantities.
- In cases in which Circulatory Shock remains uncorrected by
antivenom therapy, Plasma volume expanders and/or vasopressor agents may be
given with appropriate considerations.
- Tetanus prophylaxis should be current.
- Antibiotics are NOT recommended prophylactically.
- Multiple Bites:
- It is possible for a King Cobra to deliver more than one bite in a
single attack. If there is evidence that such an attack occurred (i.e.,
history or multiple bite sites), twice (2X) the INITIAL dose of antivenom
should be given: FOUR vials (12000 units) diluted in Lactated Ringers
Solution to a total volume of 240 mls, and delivered over 30 minutes at a rate
of 8 mls per minute (i.e., 4 vials per 30 minutes or 400 units per
- Severe Envenomation:
- If the patient shows severe signs of envenomation, particularly if early
after the bite, increase the INITIAL dose of antivenom 2X or 3X. Dilute this
volume 1:10 in Lactated Ringers Solution, and deliver over 30 minutes. If the
patient is in extreme fluid load, antivenom may be delivered at more
concentrated volumes until the patient is in appropriate fluid
- Testing for Equine Protein Sensitivity:
- It is NOT ADVISABLE to utilize subcutaneous or intradermal testing for
sensitivity to equine products in that such testing may be unreliable, and may
unnecessarily delay antivenom therapy which must be used if any signs of King
Cobra envenomation are present.
- If there is reason to believe that the patient may be sensitive to
equine protein products (e.g., previous snake bite treated with antivenom in
which a sensitivity reaction was noted, multiple previous snake bites):
- Administer 1 gram of Solumedrol I.V. push.
- Wait 15 minutes.
- Administer the antivenom at a rate as tolerated by the patient, and
beginning at a rate of 3 mls/ minute (i.e., 150 units/min).
- Monitor Pulse and Blood Pressure carefully. Be prepared to treat for
Anaphylaxis with Epinephrine and other vasoactive medications.
- Clinical Experience with Ophiophagus hannah:
- The King Cobra is indeed the largest of the world's venomous snakes
approaching and perhaps surpassing lengths of 18 feet. Although its venom,
drop for drop, is less toxic than those of many of the smaller cobras and other
elapids, the volume of venom the King Cobra is capable of producing and
delivering in a single bite is enormous. Thus, any aggravated attack with
clinical evidence of envenomation may rapidly result in a life-threatening
emergency. In nature, the King Cobra feeds almost exclusively on other snakes
including the Common Cobra (Naja naja ssp.).
- Although very widely distributed over southern Asia, the King Cobra is
not often encountered in nature by humans, and is rarely a cause of snake bite
accidents. The few confirmed attacks by King Cobras in nature have often
resulted in rapid death. In other cases, dry bites or mild envenomation have
- Few clinical cases have actually been recorded. In general, a rapidly
progressing neurotoxic syndrome develops which includes early respiratory
paralysis and loss of consciousness. Delay in administration or insufficient
dosages of antivenom may allow such neurological symptoms to manifest which
may be very difficult to reverse once established. Large amounts of antivenom
have been required to reverse the progression of symptoms in some cases, and
recovery may be slow.
The following references are recommended for further indepth reading. This
material includes case histories, guidelines and recent findings in elapid
literature. These should be read only after treatment has begun, and the
patient is in stable status.
- COMMONWEALTH SERUM LABORATORIES: Treatment of Snake Bite in Australia
and Papua New Guinea using Antivenom (Package Insert with Antivenom). CSL,
- GANTHAVORN, S.: A Case of King Cobra Bite. Toxicon, 9:293, 1971.
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