In the event of an actual or probable bite from a Cape Cobra, execute the following first aid measures without delay.

Snake:

1. Make sure that the responsible snake or snakes have been appropriately and safely contained, and are out of danger of inflicting any additional bites.

Transportation:

1. Immediately call for transportation.

   Telephone:

Victim:

1. 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.

2. 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. S.K. Sutherland.)

3. 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.

4. DO NOT remove the splint or bandages until the victim has reached the hospital and is receiving Antivenom.

5. Have the South African Institute for Medical Research (S.A.I.M.R.) Polyvalent Antivenom ready for the emergency crew to take with the victim to the hospital. Give them the following:
   1. the available antivenom (at least 10-20 vials)
      
   2. the accompanying instruction (Protocol) packet
      
   3. the victim's medical packet (if available)

The bite of the Cape Cobra with envenomation can be rapidly fatal (as early as 30 minutes). Please read the attached Medical Management Protocol and respond appropriately. Intubation with ventilatory support may be required early.

1. First Aid:
   1. 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).

   2. Transport to a medical center emergency or trauma service.

2. Medical Management:
   1. 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.

   2. Observe for Signs and Symptoms of Envenomation.

   3. If signs or symptoms are present, perform the following:
      1. Administer Lactated Ringers Solution at 200 to 250 mls per hour.

      2. Draw samples and collect initial laboratory data.

      3. Withdraw the contents of 4 vials of South African Institute for Medical research (S.A.I.M.R.) Polyvalent Antivenom. Administer the antivenom I.V. piggyback at a rate of 1 vial (10 mls) per minute.

      4. Remove the splints and crepe bandage slowly over a period of 10 minutes. If symptoms progress rapidly, reapply the bandage, and administer an additional 4 vials. Again attempt to remove the bandage.

      5. Allergic or untoward reactions to the antivenom should be treated with Corticosteroids, Epinephrine, Benadryl, Atarax and/or Antihistamines as appropriate.

      6. Monitor Signs, Symptoms, and Laboratory data, and administer additional antivenom in 1 vial increments at a rate of 1 vial (10 mls) per 5 minutes as necessary to control the progression of symptoms.

      7. The required amount of antivenom will vary with the severity of envenomation. One should anticipate using (including the initial dose):

         4-8 vials total for a minor bite with envenomation.

         10-20 vials or more may be necessary for moderate or severe bites.

This person has received a bite and probable envenomation from a Cape Cobra (Naja nivea). This is a highly aggressive and nervous cobra which is distributed throughout the Cape Province adjacent areas of South Africa, Southwest Africa, and parts of Botswana. It is considered by most to be the most toxic and dangerous of the African Cobras; many human fatalities have been attributed to its bite. Envenomation constitutes a true medical emergency.

In this particular species, envenomation usually presents predominately with systemic neurologic manifestations and early respiratory paralysis. Drowsiness, neurological and neuromuscular symptoms may develop early; paralysis, ventilatory failure or death could ensue rapidly.

Please read and execute the following procedures without delay.

1. 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.

2. Make sure that at least 10 vials of South African Institute for Medical Research (S.A.I.M.R.) Polyvalent Antivenom are present with the patient. This antivenom contains the appropriate fractions necessary to neutralize the components of Cape Cobra venom.

3. 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
   
   Consultants
   
   References

Signs and Symptoms of Envenomation:

1. Neurological and Neuromuscular: These signs and symptoms may manifest early, but may be delayed in onset. Not necessarily any or all of these will develop, even with severe envenomation. Monitor for these carefully from the outset, they generally develop very quickly and dramatically.
   Respiratory paralysis or Dyspnea (may develop quickly)
   
   Excessive salivation
   
   Drowsiness
   
   Restlessness
   
   Sudden loss of consciousness
   
   Eyelid drooping (Ptosis)
   
   Ophthalmoplegia
   
   Palatal paralysis
   
   Glossopharyhgeal paralysis or Dysphagia
   
   Generalized convulsions
   
   Fasiculations
   
   Hyporeflexia or Areflexia
   
   Limb paralysis
   
   Stumbing gait (Ataxia)
   
   Head drooping (Cervical muscle paresis or paralysis)
   
   Incontinence
   
   Headache
   
   Local pain or Numbness around bite site (tends to be only mild)

2. General: These symptoms typically manifest within 15 minutes to 4 hours following the bite if envenomation occurred. However, in some cases they may represent the only indication of clinical envenomation.
   Shock
   
   Hypotension
   
   Abdominal Pain
   
   Nausea and Vomiting
   
   Regional lymphadenopathy and Lymphadenalgia
   
   Hyperpyrexia (Fever)
   
   Epistaxis
   
   Flushing of the face
   
   Warm skin
   
   Increased sweating
   
   Pallor

3. Nephrotoxicity: Acute Renal Failure has not yet been reported in cases of Cape Cobra bites in humans. Oliguria or Anuria with possible changes in urinary composition will herald the development of renal shutdown. Dialysis is advised.

4. Cardiotoxicity: Direct toxic effects on the myocardium or conducting system have not yet been reported in Cape Cobra envenomation. However, effects on the nervous or vascular systems may manifest as cardiac complications. Monitoring of cardiac function and rhythm is advised.

5. Local Symptoms: Swelling around the area of the bite site should be expected especially of involved digits. Local necrosis with tissue slough may also be possible.

6. 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). The Cape Cobra is easily agitated, and is invariably aggressive toward its enemy. Any sudden movements by the target will result in a series of rapid strikes. Thus, multiple bites inflicted by a single snake or by more than one snake are clearly 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.

Medical Management:

1. Admit patient to an emergency or trauma service and call the consultant identified by the Poison Control Center.

2. Begin a peripheral intravenous infusion (16 gauge catheter) of Lactated Ringers Solution at a rate of 250 cc/hour.

3. Draw blood from the contralateral arm, and collect urine for the following laboratory tests. Mark STAT.
   1. Type and Cross Match TWO units of Whole Blood.

   2. CBC with differential and platelets.

   3. Coagulation Parameters:
      1. Prothrombin Time (PT)
         
      2. Partial Thromboplastin Time (PTT)
         
      3. Fibrinogen levels
         
      4. Fibrin Degradation Products

   4. Serum electrolytes, BUN/Creatinine, Calcium, Phosphorous.

   5. Lactate Dehydrogenase (with Isoenzyme analysis). Isoenzyme analysis may indicate multiple targets of the venom components which may dictate further management.

   6. Urinalysis (Macroscopic and Microscopic Analysis). Must include analysis for:
      1. Hemoglobin
         
      2. Urine Electrolytes and Creatinine
         
      3. Free Protein

   7. Electrocardiogram (Place the patient on continuous monitoring). Rapid heart rate.

   8. Continuous Urine Output Monitoring (Indwelling Foley Catheter if unconscious). Watch for possible oliguria or anuria.

   9. Additional tests as needed or indicated by patient's hospital course.

   10. 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 previously normal or slightly abnormal.

4. OBSERVE PATIENT CLOSELY for signs and symptoms of envenomation which usually manifest between 15 minutes and two hours after the bite occurred.
   1. 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 injected).
      1. 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 directed below).

   2. If signs and symptoms still fail to manifest, continue CLOSE observation of the patient for an additional 12 to 24 hours.

5. IF ANY SIGN OR SYMPTOM becomes apparent or has been noted during the course of treatment, begin Antivenom Therapy as follows:
   1. Each vial of S.A.I.M.R. Polyvalent Antivenom is packaged as a pepsin-digested purified liquid form, and is ready for immediate use.

   2. Secure Four vials (40 mls) immediately, and withdraw the contents into a single syringe.

   3. Prepare a second syringe with 500 mg of Solumedrol; place on standby.

   4. Administer the undiluted Antivenom by direct intravenous injection in an established I.V. slowly over a period of 2 minutes.

   5. 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. After the patient is stabilized, continue injecting the remaining initial dose of antivenom without further delay.

   6. After the first four vials (40 mls) of antivenom has been administered, 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:
      1. Reapply the crepe bandage.

      2. Prepare an additional three vials of antivenom immediately as directed above.

      3. Deliver this dose by direct intravenous injection slowly over 4 minutes.

      4. Release the bandage again slowly over 10 minutes.

      5. The patient should have received a total of 8 vials (80 mls) of antivenom at this point.

6. Antivenom Therapy is the mainstay of treatment for African 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. Local symptoms may take several days to weeks to completely resolve; their progression, however, may be controlled with antivenom therapy.
   1. Neurological Symptoms (especially respiratory obstruction or failure) will tend to predominate the clinical picture in cases of African cobra envenomation, and are usually the most immediate cause of dangerous problems. Once established, these may be difficult to improve with the antivenom; early diagnosis and administration of antivenom is critical. If breathing becomes impaired, intubate the patient, and provide respiratory assistance. Secretions may become copious, necessitating suctioning.

   2. Hematological symptoms may present as a Disseminated Intravascular Coagulopathy, and are treated as are other DICs. Some clinical cases of Cape Cobra envenomation have shown mild transient prolongation of coagulation parameters and elevation of fibrin degradation products; other cases have exhibited no signs of coagulopathy.

   3. Renal symptoms have not yet been reported in Cape Cobra envenomation, but may complicate the situation, and if severe (i.e., Acute Renal Failure) may necessitate Peritoneal Dialysis.

   4. If severe muscular or respiratory difficulties develop and persist, 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. However, previous case reports have shown that Prostigmine was UNABLE to aid in the reversal of established respiratory paralysis.

7. 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. The antivenom should ideally be diluted (1:10) in Lactated Ringers Solution, and always given by intravenous infusion at a rate of ONE vial per 10 minutes. Give all additional antivenom in unit (one vial) doses. One should anticipate using (including the initial dose):

   4-6 vials total for a minor bite with envenomation

   8-20 vials or more may be necessary for moderate or severe bites

8. It is advisable to perform periodic serum and urine analyses during therapy (as outlined above).

9. 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.

General Considerations:

1. It is important that the patient be placed at rest, kept warm, and avoid unnecessary movement.

2. 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.

3. Respiratory obstruction and failure are the greatest immediate concerns. 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.

4. Fluid management is very important in snake bite cases. The patient should be well hydrated, and a brisk urine output maintained. Blood replacement SHOULD NOT be started until the circulating venom anticoagulants have been fully neutralized.

5. 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.

6. Morphine is CONTRAINDICATED because of its tendency to suppress respirations. Alcohol should also be avoided.

7. In cases in which Circulatory Shock remains uncorrected by antivenom therapy, Plasma volume expanders and/or vasopressor agents may be given with appropriate considerations.

8. Tetanus prophylaxis should be current.

Special Considerations:

1. Multiple Bites:
   1. It is possible for a Cape Cobra to deliver more than one bite in a single attack, and thus may inject a larger volume of venom. If there is evidence that such an attack occurred (i.e., history or multiple bite sites), the INITIAL dose of antivenom should be 8 vials (80 mls) given by direct intravenous injection. Give the antivenom slowly over four minutes. WATCH CLOSELY for signs of allergic response; correct reaction (as described below). Give all subsequent doses in ONE vial increments at 1 vial per 10 minutes as necessitated by the presence of continued signs and symptoms.

2. Severe Envenomation:
   1. If the patient shows severe signs of envenomation, particularly if early after the bite, up to 12 vials (120 mls) can be given as an INITIAL dose. Give the antivenom by direct intravenous injection in two divided six vial (60 mls) boluses. Correct any adverse or allergic reactions with Corticosteroids, Antihistamines, and/or Epinephrine as indicated.

3. Testing for Equine Protein Sensitivity:
   1. 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 Cape Cobra envenomation are present.

   2. 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):

   3. If there is reason to believe that the patient may be sensitive to equine protein products, the following may be performed:
      1. Administer 1 gram of Solumedrol I.V. push.

      2. Wait 10 minutes.
      3. Administer the antivenom by direct intravenous infusion at a rate of 1 vial (10 mls) per 5 minutes.

      4. Monitor Pulse and Blood Pressure carefully. Be prepared to treat for Anaphylaxis with Epinephrine and other vasoactive medications.

4. Clinical Experience with Naja nivea:
   1. Due to its highly toxic venom, its unrelenting aggressive demeanor, and its propensity to live near human habitats, the Cape Cobra is clearly one of the most dangerous snakes in Africa, and should be considered in the same magnitude of emergency as bites by the Black Mamba (Dendroaspis polylepis polylepis). It frequently bites when handled or molested; clinical envenomation is often fatal.

   2. Clinical experience with Naja nivea has demonstrated that respiratory paralysis can be rapid in onset, and difficult to reverse once established even with large amounts of antivenom. Since both Prostigmine and antivenom fail to reverse fully established paralysis, it is suggested that the toxin becomes fixed presumably to a presynaptic target, is unavailable to bind with the antivenom, and that reversal occurs only after metabolic degradation has taken place. Thus, artificial ventilatory support can be life-saving and may be absolutely essential. Long-term intubation and ventilation as long as 7-8 days or more has been necessary in several cases. Early administration of antivenom before the onset of respiratory impairment may allow for sufficient binding of the neurotoxic components, and avoid the need for mechanical ventilation. Large amounts of antivenom (e.g., 15-20 vials total) may be required for treatment of severe envenomation.

   3. Provided that the diagnosis of clinical envenomation is made as early as possible, antivenom therapy is instituted early, and ventilatory support is provided, the patient should do well.

References:

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.

1. SOUTH AFRICAN INSTITUTE FOR MEDICAL RESEARCH: Anti-Snakebite Serum. (Package Insert with Antivenom), 1980.

2. BLAYLOCK, R.S., LICHTMAN, A.R., POTGIETER, P.D.: Clinical Manifestations of Cape Cobra (Naja nivea) Bites. S. Afr. J. Med., 68:342, 1985.

   -Recommended reading, although not specifically concerning Cape Cobra-

3. WARRELL, D.A., GREENWOOD, B.M., DAVIDSON, N.M., OMEROD, L.D., PRENTICE, C.R.M.: Necrosis, haemorrhage and Complement Depletion Following Bites by the Spitting Cobra (Naja nigricollis). Quart. J. Med., n.s., 45(177:1, 1976.

4. STROVER, H.M.: Observations on Two Cases of Snake-bite by Naja nigricollis ss mossambica. Cent. Afr. J. Med., 19(1):12, 1973.