What is the management of a cobra (Elapidae family) snakebite?

Management of Cobra Snakebite

For cobra (Elapidae) envenomation, immediately activate emergency services, apply pressure immobilization bandaging (40-70 mm Hg upper extremity, 55-70 mm Hg lower extremity) to the entire bitten limb, immobilize the extremity, and transport rapidly to a medical facility for antivenom administration—the definitive life-saving treatment that must be given intravenously as quickly as possible before respiratory paralysis develops. 1, 2, 3

Immediate Field Management

Critical First Actions

• Activate emergency medical services immediately upon suspecting cobra envenomation, as this is a true medical emergency with rapid progression to respiratory failure 2, 3, 4
• Apply pressure immobilization bandaging with specific pressures: 40-70 mm Hg for upper extremity bites and 55-70 mm Hg for lower extremity bites, wrapping the entire length of the bitten limb to slow lymphatic spread of neurotoxic venom 1, 3
• Remove all rings, watches, and constricting objects from the affected extremity immediately to prevent ischemic injury as swelling progresses 2, 3
• Immobilize the bitten extremity and minimize victim movement to reduce systemic venom absorption through the lymphatic system 2, 3

Critical Distinction for Cobra Bites

Pressure immobilization is specifically recommended for cobra (Elapidae) envenomation because these snakes produce primarily neurotoxic venom rather than the cytotoxic venom of North American pit vipers 2, 3. This technique slows venom dissemination by reducing lymph flow and can delay the onset of life-threatening neurotoxic symptoms 3, 5.

Harmful Practices to Absolutely Avoid

• Do NOT apply suction devices (with or without incision)—they remove virtually no venom, provide no clinical benefit, and may worsen tissue injury 1, 2, 3
• Do NOT apply ice to the bite wound—it has no proven benefit and may cause additional tissue injury 2, 3
• Do NOT use electric shock—it is completely ineffective and potentially harmful 2, 3
• Do NOT apply arterial tourniquets—while pressure immobilization is recommended, arterial tourniquets can worsen local tissue injury 2, 3

Hospital Management

Antivenom Administration

• Antivenom is the cornerstone and only definitive treatment for cobra envenomation and must be administered intravenously as quickly as possible to halt the envenomation process 2, 6, 4, 7
• Initial dose: 10 vials of antivenom administered intravenously after appropriate hypersensitivity testing 6
• Timing is critical: Antivenom is most effective when given within 4 hours of the bite, and early administration can prevent progression to respiratory paralysis 4, 8
• Have epinephrine readily available (0.3-0.5 mg IM in adults, 0.01 mg/kg up to 0.3 mg in children) for potential anaphylactic reactions to antivenom 6

Respiratory Support

• Ensure airway management and ventilatory support readiness before antivenom administration, as cobra neurotoxins paralyze striated muscles, especially respiratory muscles 6, 3, 4
• Intubation and mechanical ventilation may be necessary if dyspnea or respiratory insufficiency develops 4, 7
• Respiratory paralysis can occur within hours and is preceded by neurological symptoms including local paresthesia, paresis, and cranial nerve involvement 4

Critical Pitfalls and Caveats

Tourniquet Removal Hazard

If a tourniquet was applied in the field (not recommended practice), remove it very gradually under controlled hospital conditions with antivenom and ventilatory support immediately available 5. Sudden tourniquet release can cause precipitous worsening of symptoms, including complete respiratory paralysis requiring immediate artificial ventilation 5.

Common Errors to Avoid

• Delaying transport to attempt ineffective field treatments—rapid transport to definitive care is paramount 2, 3
• Failing to recognize the neurotoxic nature of cobra venom and not preparing for respiratory support 4, 7
• Excessive victim movement which accelerates venom absorption through lymphatic channels 2, 3
• Underestimating the speed of progression—cobra syndrome can advance to respiratory paralysis within hours 4

Clinical Monitoring

Monitor for progressive neurological symptoms including:

• Local paresthesia at the bite site progressing proximally 4
• Cranial nerve involvement (ptosis, diplopia, dysphagia) 4
• Respiratory muscle weakness leading to dyspnea 4, 7
• Complete respiratory paralysis if untreated 4, 7, 5