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  5. Clinical entry: Ophiophagus sp.

Clinic: Ophiophagus sp.

Examine for venom effects

Local Effects

  • Pain
  • Tender local (spreading) swelling
  • Blistering
  • Lymphangiopathy and lymphadenopathy
  • Necrotic skin

Neurological effects

  • Descending flaccid paralysis
    • Ptosis (not to be mixed up with tiredness / drowsiness; test: lid retraction with upward gaze).
    • Double vision (external ophthalmoplegia)
    • Difficulties to swallow (dysphagia) (bulbar paralysis) > inhalation of vomitus!
    • Difficulties to lift the head when lying on the back (‘broken neck syndrome’)
    • Cyanosis, shallow breathing, respiratory arrest (respiratory paralysis); respiratory arrest may be precipitated by obstruction of the upper airway by the paralysed tongue or inhaled vomitus. 
    • Weakness or loss of voluntary movement; movements of digits may still be possible, allowing the patient to communicate.
    • Loss of consciousness and generalized convulsions caused by hypoxaemia in patients who have respiratory paralysis.  

Species-specific envenoming pattern

The assessment of the envenoming pattern is based on the data from publication in which the identification of the snakes is clearly specified and in accordance with accepted criteria.

  

Local effects1

 Neurological
effects2

Ophiophagus sp.

Local effects
1Bite site

Local swelling, extensive in 1 patient with 47% increase in the circumference of the arm; necrosis, surgical debridement necessary (e.g., Tin-Myint et al. 1991).

2Neurological effects

Dysarthria, ptosis, flaccid paralysis of the skeletal musculature, respiratory failure. The patient appeared to be unconscious, but had actually maintained consciousness: was able to indicate 'yes' and 'no' by moving a finger (e.g., Tin-Myint et al. 1991).

Other effects

“Intractable hypotension can occur in patients envenomed by Asian cobras and king cobras, despite adequate respiratory support.” (Warrell 2023) 

Clinical management

See also (depending on the origin of the culprit)

Clinical Management: Indian Subcontinent and Southeast Asia

Clinical Management: Far East

for advice on post-First Aid measures, diagnosis (clinical, laboratory) and treatment (supportive, antivenom).

First Aid

Release of any type of tourniquet follow links above.

Local treatment

Bite site

Pain control
Tetanus prophylaxis
Standard wound care
Necroses: debridement; split-thickness skin grafting
Systemic antibiotics: standard indications
WHO (2010, 2016) 

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

Follow SAMPLE & ABCDE ApproAch

Obey  Ophiophagus sp. - specific features

see 

  • 'Species-specific envenoming pattern' above

and

Key issues

Respiratory failure

Lifesaving in neurotoxic Asian cobra envenoming (as supportive treatment and when antivenoms are not available or fail):

Airway management
Breathing: Oxygen ⇨ assisted ventilation ⇨ mechanical ventilation

Arterial hypotension
Arterial hypotension (systolic blood pressure fluctuating between 50 and 90 mmHg) over a period of many hours (possible venom-induced vasodilatation or hypovolaemia due to sequestration of fluid in the swollen extremity) (Tin-Myint et al. 1991).
“Intractable hypotension can occur in patients envenomed by Asian cobras and king cobras, despite adequate respiratory support.” (Warrell 2023)

Specific treatment (antivenoms)

References 

  • Tin-Myint, Rai-Mra, Maung-Chit, Tun-Pe, Warrell DA. Bites by the king cobra (Ophiophagus hannah) in Myanmar: successful treatment of severe neurotoxic envenoming. Q J Med. 1991 Sep;80(293):751-62. PMID: 1754675.
  • Warrell DA. Venomous and poisonous animals. In: Farrar J, Garcia PJ, Hotez T, Junghanss T, Kang G, Laloo D (eds.). Manson’s tropical diseases. 24th ed. Elsevier; 2023.
  • WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured  https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2 
  • WHO ABCDE Approach https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
  • WHO (2010) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139
  • WHO (2016) Guidelines for the management of snakebites. 2nd edition. https://www.who.int/publications/i/item/9789290225300
  • WHO Snakebite Information and Data Platform https://www.who.int/teams/control-of-neglected-tropical-diseases/snakebite-envenoming/snakebite-information-and-data-platform

Species-specific evidence

Ophiophagus sp.

China

Guangxi Zhuang Autonomous Region

Ophiophagus hannah
Sawai et al. (1992)

  • 12 Ophiophagus hannah bites; identification: 10/12 bites occurred in snake catchers, who can certainly be assumed to have correctly identified the snake that caused the bite (Ophiophagus hannah). 

Yunnan
Ophiophagus hannah
  • Zhao et al. (2025) 
    1  case; identification: morphological.


Malaysia

Ophiophagus bungarus
  • Tan et al. (2022)
    4 cases and review of the literature
  • Muthusamy and Gopalakrishnakone (1990)
    1 case; identification: description by patient and a companion, recognition from photos.

Myanmar

Ophiophagus hannah

  • Tin-Myint et al. (1991)
    3 cases; identification: morphological; review of the literature on Ophiophagus hannah.
  •  Tun-Pe te al. (1995)
    2 cases; identification: morphological.  Boosted venom IgG response in the patient with previous bites and recent traditional immunization.

Philippines

Ophiophagus bungarus (?)

  • Arrieta et al. (2024)
    1 patient; identification: from a photo by a herpetologist.

Thailand

Ophiophagus hannah

  • Ganthavorn (1971)
    1 case; identification: morphological. 

Captive snake

USA
  • Wetzel and Christy (1989)
    1 case; identification: morphological.

Signs & symptoms

Local effects
Local pain and swelling (Ganthavorn 1971, Muthusamy and Gopalakrishnakone 1990, Wetzel and Christy 1989), local blistering (Ganthavorn 1971, Muthusamy and Gopalakrishnakone 1990), superficial necrosis (Ganthavorn 1971, Muthusamy and Gopalakrishnakone 1990).
Local swelling 2/3, extensive in 1 patient with 47% increase in the circumference of the arm; necrosis 1/3, surgical debridement necessary (Tin-Myint et al. 1991).
Local swelling 10/12, necrosis 3/12 (Sawai et al. 1992).

Neurological effects
Preparalytic phase: 30 min (ptosis), 70 min (dysphagia, respiratory paralysis) (Ganthavorn 1971); 60 min (ptosis) (Muthusamy and Gopalakrishnakone 1990).
Blurred vision (Wetzel and Christy 1989, Muthusamy and Gopalakrishnakone 1990), ptosis (Ganthavorn 1971, Muthisamy and Gopalakrishnakone 1990), dysphagia (Ganthavorn 1971, Muthusamy and Gopalakrishnakone 1990), generalised muscle weakness (Ganthavorn 1971, Wetzel and Christy 1989, Muthusamy and Gopalakrishnakone 1990), paralysis of the respiratory musculature with respiratory failure (Ganthavorn 1971).
Dysarthria, ptosis, flaccid paralysis of the skeletal musculature, respiratory failure. The patient appeared to be unconscious, but had actually maintained consciousness: was able to indicate 'yes' and 'no' by moving a finger (1/3) (Tin-Myint et al. 1991).
Signs of paralysis 8/12 (Sawai et al. 1992).

Other signs & symptoms
Vomiting (approx. 1 h after the bite).
Arterial hypotension (systolic blood pressure fluctuating between 50 and 90 mmHg) over a period of many hours (possible venom-induced vasodilatation or hypovolaemia due to sequestration of fluid in the swollen extremity) (Tin-Myint et al. 1991).
Euphoria, hallucinations, headache (Wetzel and Christy 1989).

Case fatality rate
7/12; time interval between the bite and death 1.5–10 h (Sawai et al. 1992).
Fatal case (Arrieta et al. 2024).

Morbidity
Necroses 3/12 (Sawai et al. 1992).

Treatment (symptomatic)

Successful artificial respiration; restoration of spontaneous respiration after 19 h (Ganthavorn 1971); after 64.5 h (Tin-Myint et al. 1991).

References

  • Arrieta R, Aoki Y, Tan MA, Sarsalijo MS, Sarmiento MJ, Paghubasan J, Tiglao PJ, Yoshimura K, Sakai A, Agosto LC. A fatal snakebite envenomation due to King cobra (Ophiophagus hannah) in the Eastern Visayas, Philippines. Toxicon. 2024 Jun;244:107751.  Epub 2024 May 8. PMID: 38723869. https://doi.org/10.1016/j.toxicon.2024.107751
  • Ganthavorn S. A case of king cobra bite. Toxicon. 1971 Jul;9(3):293-4. PMID: 5092397. https://doi.org/10.1016/0041-0101(71)90084-5           
  • Muthusamy, E., P. Gopalakrishnakone (1990) A king cobra bite, case report. Snake 22: 60-62                          
  • Sawai, Y., Y. Kawamura, M. Toriba, T. Kobayashi, N. P. Wang, C. B. Li, B. Y. Li, Z. Y. Li, H. P. Li, S. X. Tang (1992) An epidemiological study on the snakebites in Guangxi Zhuang Autonomous Region, China in 1990. Snake 24: 1-15
  • Tan CH, Bourges A, Tan KY. King Cobra and snakebite envenomation: on the natural history, human-snake relationship and medical importance of Ophiophagus hannah. J Venom Anim Toxins Incl Trop Dis. 2022 Jan 5;27:e20210051. PMID: 35069710; PMCID: PMC8733962. https://doi.org/10.1590/1678-9199-JVATITD-2021-0051
  • Tin-Myint, Rai-Mra, Maung-Chit, Tun-Pe, Warrell DA. Bites by the king cobra (Ophiophagus hannah) in Myanmar: successful treatment of severe neurotoxic envenoming. Q J Med. 1991 Sep;80(293):751-62. PMID: 1754675.
  • Tun-Pe, Aye-Aye-Myint, D. A. Warrell, Tin-Myint (1995) King cobra (Ophiophagus hannah) bites in Myanmar: Venom antigen levels and development of venom antibodies. Toxicon 33 (3): 379-382
  • Wetzel WW, Christy NP. A king cobra bite in New York City. Toxicon. 1989;27(3):393-5.  PMID: 2728028. https://doi.org/10.1016/0041-0101(89)90186-4                   
  • Zhao H, Han B, Ao C, Bao D, Dai R. Envenoming by King Cobra (Ophiophagus hannah s str) with Cardiopulmonary Arrest in Yunnan, China. Wilderness Environ Med. 2025 Dec;36(4):559-563. Epub 2025 Jun 3. PMID: 40458835. https://doi.org/10.1177/10806032251345769