AIM To study the clinico-pathological spectrum of snake bite-induced acute kidney injury(AKI).METHODS A retrospective study of patients admitted at Indira Gandhi Medical College Hospital,Shimla with snake bite-induced...AIM To study the clinico-pathological spectrum of snake bite-induced acute kidney injury(AKI).METHODS A retrospective study of patients admitted at Indira Gandhi Medical College Hospital,Shimla with snake bite-induced AKI from July 2003 to June 2016.Medical records were evaluated for patient's information on demographic,clinical characteristics,complications and outcome.Outcomes of duration of hospital stay,requirement for intensive care unit support,treatment with dialysis,survival and mortality were analyzed.The survival and non survival groups were compared to see the difference in the demographic factors,clinical characteristics,laboratory results,and complications.In patients subjected to kidney biopsy,the findings of histopathological examination of the kidney biopsies were also analyzed.RESULTS One hundred and twenty-one patients were diagnosed with snake bite-induced AKI.Mean age was 42.2 ± 15.1 years and majority(58%) were women.Clinical details were available in 88 patients.The mean duration of arrival at hospital was 3.4 ± 3.7 d with a range of 1 to30 d.Eighty percent had oliguria and 55% had history of having passed red or brown colored urine.Coagulation defect was seen in 89% patients.The hematological and biochemical laboratory abnormalities were:Anemia(80.7%),leukocytosis(75%),thrombocytopenia(47.7%),hyperkalemia(25%),severe metabolic acidosis(39.8%),hepatic dysfunction(40.9%),hemolysis(85.2%) and rhabdomyolysis(68.2%).Main complications were:Gastrointestinal bleed(12.5%),seizure/encephalopathy(10.2%),hypertension,pneumonia/acute respiratory distress syndrome(ARDS) and disseminated intravascular coagulation(9.1% each),hypotension and multi organ failure(MOF)(4.5% each).Eighty-two percent patients required renal replacement therapy.One hundred and ten(90.9%) patient survived and 11(9.1%) patients died.As compared to the survival group,the white blood cell count(P = 0.023) and bilirubin levels(P = 0.006) were significant higher and albumin levels were significantly lower(0.005) in patients who died.The proportion of patients with pneumonia/ARDS(P = 0.001),seizure/encephalopathy(P = 0.005),MOF(P = 0.05) and need for intensive care unit support(0.001) was significantly higher and duration of hospital stay was significantly shorter(P = 0.012) in patients who died.Kidney biopsy was done in total of 22 patients.Predominant lesion on kidney biopsy was acute tubular necrosis(ATN) in 20(91%) cases.In 11 cases had severe ATN and in other nine(41%) cases kidney biopsy showed features of ATN associated with mild to moderate acute interstitial nephritis(AIN).One patient only had moderate AIN and one had patchy renal cortical necrosis(RCN).CONCLUSION AKI due to snake bite is severe and a high proportion requires renal replacement therapy.On renal histology ATN and AIN are common,RCN is rare.展开更多
BACKGROUND Venom-induced consumption coagulopathy(VICC)is characterized by coagulation dysfunction accompanied by decreased coagulation factor activity and fibrinogen(FBG)concentrations.We report a patient with VICC c...BACKGROUND Venom-induced consumption coagulopathy(VICC)is characterized by coagulation dysfunction accompanied by decreased coagulation factor activity and fibrinogen(FBG)concentrations.We report a patient with VICC caused by snake bite who manifested persistent FBG deficiency without abnormal coagulation factor activity.This information may be helpful in diagnosing and treating VICC.CASE SUMMARY A 49-year-old man who had been bitten by a snake 13 h previously was admitted to the Emergency Department of our hospital with visible swelling of a finger and a bleeding puncture site.The provisional diagnosis was VICC,this being made based on persistent bleeding from the puncture site and subcutaneous hemorrhage.Laboratory evidence of coagulation abnormalities,including fibrinolysis,and findings on thromboelastography confirmed VICC.He had persistent afibrinogenemia requiring intravenous infusions of cryoprecipitate and fresh frozen plasma,together with continuous large doses of human FBG.After this treatment,the patient’s right upper limb swelling improved significantly and his subcutaneous hemorrhage resolved.All of his abnormal laboratory findings returned to normal by day 25.During 6 months’of follow-up,the patient had no further hemorrhagic events.CONCLUSION Hemorrhagic snake venom can result in coagulation dysfunction characterized by persistent FBG deficiency without abnormal coagulation factor activity.展开更多
The history of research and preparation of prescriptions for snake bites in Fujian Province was reviewed, and the process of incorporating snake doctors into the system and the gradual establishment of snake bite trea...The history of research and preparation of prescriptions for snake bites in Fujian Province was reviewed, and the process of incorporating snake doctors into the system and the gradual establishment of snake bite treatment system in Fujian were explored. The composition of several main snake bite preparations in Fujian was preliminarily compared and analyzed to provide reference for the research and development of similar new preparations at present.展开更多
Objective:To describe the epidemiology of snake bite in the region and attempt to compare proven Russell’s viper with hump-nosed viper bites.Methods:All snake bite admissions to the Toxicology Unit of Teaching Hospit...Objective:To describe the epidemiology of snake bite in the region and attempt to compare proven Russell’s viper with hump-nosed viper bites.Methods:All snake bite admissions to the Toxicology Unit of Teaching Hospital Peradeniya over three year from 2006 were included. Results:Of the 776 snakebites,665(86%) were unidentified and non-envenomed.Humpnosed viper and Russell’s viper accounted for 55(7%) and 40(5%) bites respectively,of them, incriminated snakes were found in 36(65%) and 19(48%) cases.The cobra bites-5,krait bites-0. The median ages:Russell’s viper bites-41(range 16-66),hump-nosed viper bites-42(range 15- 75).The gender incidence,time of bite(】58%daytime) were similar.In hump-nosed viper bite; upper limb involved in 13(36%),happened at home garden in 22(61%),none in paddy fields.In Russell’s viper bite;6(33%) occurred in paddy fields.Dry bites were similar at 5%.In humpnosed viper bite:local effects 94%,coagulopathy 3%,acute renal failure 3%and one patient died.In Russell’s viper bite;local effects 84%,coagulopathy 53%,neurotoxicity 21%.Abdominal pain occurred only in Russell’s viper bites 10(53%).Conclusions:Overwhelming numbers of unidentified,non-envenomed snakebites are common in the central hills.Some distinctive differences were observed between Russell’s viper and hump-nosed viper bites.展开更多
Snake bites are one among the under reported clinical emergencies from tropical countries.There are variations in clinical presentation of snake bites and its toxic features differ with the species and type of bite.Th...Snake bites are one among the under reported clinical emergencies from tropical countries.There are variations in clinical presentation of snake bites and its toxic features differ with the species and type of bite.There are lots of controversies in the treatment guidelines which often makes it difficult to manage.We report the case of a severe hemotoxic snake bite who presented to the outpatient service of our hospital with a trivial fool injury.Even though snakebites are familiar clinical situations for an emergency physician from tropics,we report this case as mast are under reported.We also intend to emphasize the excellent outcome of appropriately diagnosed and treated cases of snake bite.展开更多
Objective: To explore the treatment measure of rhabdomyolysis caused by snake bites, and provide guidance for further prevention and control of snake bites. Methods: To retrospectively analyze the 841 cases of serpent...Objective: To explore the treatment measure of rhabdomyolysis caused by snake bites, and provide guidance for further prevention and control of snake bites. Methods: To retrospectively analyze the 841 cases of serpentine bites in our hospital from January 2006 to July 2017;127 cases of patients with rhabdomyolysis syndrome were screened out, and their clinical manifestations, laboratory results, related treatment and prognosis were analyzed. Results: 127 cases patients were rhabdomyolysis out of 841 cases, 28 cases patients developed acute renal failure;treatment measures included local wound treatment, application of tetanus antitoxin, anti-snake venom serum, anti-infection, fluid “hydration” and diuretic, alkaline urine and hybrid renal replacement therapy. 112 cases were cured, improved conditions in 9 cases, 3 cases of death, 3 cases uncured. The improvement rate of is 95.26% after treatment. Conclusion: The rhabdomyolysis had a high incidence in snake bite patients, severe cases often developed acute renal failure. Serum myopsin and related biochemical blood tests could be used to diagnose rhabdomyolysis quickly. Combined treatment methods are the main measure to increase the cured rate and decrease the death rate.展开更多
Snakebite has become a serious public health problem with high mortality and disability rates.Ultrasound can provide imaging basis for diagnosis and treatment of snakebites and relative complications.The application p...Snakebite has become a serious public health problem with high mortality and disability rates.Ultrasound can provide imaging basis for diagnosis and treatment of snakebites and relative complications.The application progresses of ultrasound in snakebites and complications were reviewed in this article.展开更多
Insert Snakebite is a global public health issue, and in majority of cases it is undermined. Tropical and subtropical countries are most effected, Bangladesh being one of them. There is scarcity of countries’ epidemi...Insert Snakebite is a global public health issue, and in majority of cases it is undermined. Tropical and subtropical countries are most effected, Bangladesh being one of them. There is scarcity of countries’ epidemiological situation in relation to snakebite poisoning. This study has looked at the epidemiological status of snakebite poisoning from national representative survey findings. Methods: A nationwide cross-sectional survey was conducted in 12 randomly selected districts of Bangladesh in 2003. A total of 171,366 households were surveyed and information was collected from 819,429 populations by face to face interview. Multi-stage cluster sampling methods were used in this survey and covered urban, rural and slum populations. Results: Annually an estimated 15,372 (10.98/100,000) individuals were bitten by snakes and of them 1709 (1.22/100,000) died every year. Males were found to be most vulnerable with a risk of 1.51 times higher than female. Rural populations were also 10.54 times higher at risk than the populations living in the urban areas. Among the victims 94% were from the poor socio economic conditions. Around 43.9% of the incidences occurred during evening to midnight. Home was found the most common area for snake bite (33.6%), and the Leg was found to be the most common site for biting (63.1%). A total of 96.6% victims sought treatment, of them 61% sought immediate treatment from traditional healing methods. Conclusions: Present incidence of snakebite in Bangladesh has clearly shown that there is emerging public health needs for intervention that can reduce the mortality and burden of the disease in the country.展开更多
Background: Snakebite envenomation in pregnancy is uncommon. It can lead to a poor outcome in both the mother and the fetus. We describe our approach to envenomation in pregnancy based on the currently available evide...Background: Snakebite envenomation in pregnancy is uncommon. It can lead to a poor outcome in both the mother and the fetus. We describe our approach to envenomation in pregnancy based on the currently available evidence. Case: We reported two case of snakebite in the third trimester of pregnancy having caused placental abruption with expelling a fresh still born baby and a live baby. In both cases, consumption coagulopathy occurred. managed by polyvalent anti-snake and blood transfusion. Their investigations became normal and they were discharged of hospitalization. Conclusion: Snakebite envenomation in pregnant is a maternal and fetal emergency. Treatment must be quick and well adapted.展开更多
OBJECTIVE: To evaluate the effects of Jidesheng anti-venom used externally for skin and soft-tissue necrosis from Chinese cobra bite.METHODS: A retrospective review was performed according to the clinical data recorde...OBJECTIVE: To evaluate the effects of Jidesheng anti-venom used externally for skin and soft-tissue necrosis from Chinese cobra bite.METHODS: A retrospective review was performed according to the clinical data recorded from January 2002 to December 2012. A total of 126 patients(116 females and 10 males) with skin and soft-tissue necrosis due to Chinese cobra bite were divided into two groups. The control group was treated externally with 40% glyceride magnesium sulfate(n=52), and the treatment group was given Jidesheng anti-venom externally(n=74). The data collected included maximum local necrotic area of skin and soft tissues, de-tumescence time, healing time,and skin-grafting rate.RESULTS: There were no significant differences in gender, age, and disease condition between the control and treatment groups(P>0.05). No statistically significant difference was found in de-tumescence time between the two groups(P>0.05). The maximum local necrotic area of skin and soft tissues was(19.9 ± 7.3) cm2in the treatment group,while it was(23.3±6.4) cm2in the control group.The healing time of the treatment group was shorter than that of the control group [(32.1 ± 3.7) vs(34.4±4.5) days)] The skin-grafting rate in the treatment group was lower than that of the control group(10.81% vs 25.00%). There were statistically significant differences in maximum local necrotic area of skin and soft tissues, healing time, and skin-grafting rate between the control and treatment groups(all P<0.05).CONCLUSION: External application of Jidesheng anti-venom may help to promote wound healing and reduce the skin-grafting rate in cases of skin and soft-tissue necrosis due to Chinese cobra bite.展开更多
目的:探讨负压封闭引流技术(VSD)治疗毒蛇咬伤的有效性及安全性。方法:计算机检索Cochrane Library、PubMed、Embase、Web of Science、中国知网、万方、维普、中国生物医学文献等数据库,收集VSD治疗毒蛇咬伤的随机对照试验,对符合纳入...目的:探讨负压封闭引流技术(VSD)治疗毒蛇咬伤的有效性及安全性。方法:计算机检索Cochrane Library、PubMed、Embase、Web of Science、中国知网、万方、维普、中国生物医学文献等数据库,收集VSD治疗毒蛇咬伤的随机对照试验,对符合纳入标准的临床研究进行资料提取,采用Cochrane系统评价员手册5.0版进行质量评价,采用RevMan 5.3和STATA 16软件进行Meta分析。结果:共纳入20项原始研究,合计1774例患者。Meta分析结果显示,VSD治疗毒蛇咬伤总有效率显著高于常规切开引流(RR=1.18,95%CI:1.11,1.26),患者住院时间(MD=-6.52,95%CI:-6.95,-6.08)、患肢肿胀消退时间(MD=-3.57,95%CI:-4.27,-2.87)、植皮/二期缝合时间(MD=-4.35,95%CI:-4.74,-3.97)、创面感染发生率(RR=0.24,95%CI:0.15,0.37)及皮肤坏死发生率(RR=0.30,95%CI:0.21,0.43)均显著降低(均P<0.05)。结论:负压封闭引流技术治疗毒蛇咬伤的安全性及疗效均较好。展开更多
文摘AIM To study the clinico-pathological spectrum of snake bite-induced acute kidney injury(AKI).METHODS A retrospective study of patients admitted at Indira Gandhi Medical College Hospital,Shimla with snake bite-induced AKI from July 2003 to June 2016.Medical records were evaluated for patient's information on demographic,clinical characteristics,complications and outcome.Outcomes of duration of hospital stay,requirement for intensive care unit support,treatment with dialysis,survival and mortality were analyzed.The survival and non survival groups were compared to see the difference in the demographic factors,clinical characteristics,laboratory results,and complications.In patients subjected to kidney biopsy,the findings of histopathological examination of the kidney biopsies were also analyzed.RESULTS One hundred and twenty-one patients were diagnosed with snake bite-induced AKI.Mean age was 42.2 ± 15.1 years and majority(58%) were women.Clinical details were available in 88 patients.The mean duration of arrival at hospital was 3.4 ± 3.7 d with a range of 1 to30 d.Eighty percent had oliguria and 55% had history of having passed red or brown colored urine.Coagulation defect was seen in 89% patients.The hematological and biochemical laboratory abnormalities were:Anemia(80.7%),leukocytosis(75%),thrombocytopenia(47.7%),hyperkalemia(25%),severe metabolic acidosis(39.8%),hepatic dysfunction(40.9%),hemolysis(85.2%) and rhabdomyolysis(68.2%).Main complications were:Gastrointestinal bleed(12.5%),seizure/encephalopathy(10.2%),hypertension,pneumonia/acute respiratory distress syndrome(ARDS) and disseminated intravascular coagulation(9.1% each),hypotension and multi organ failure(MOF)(4.5% each).Eighty-two percent patients required renal replacement therapy.One hundred and ten(90.9%) patient survived and 11(9.1%) patients died.As compared to the survival group,the white blood cell count(P = 0.023) and bilirubin levels(P = 0.006) were significant higher and albumin levels were significantly lower(0.005) in patients who died.The proportion of patients with pneumonia/ARDS(P = 0.001),seizure/encephalopathy(P = 0.005),MOF(P = 0.05) and need for intensive care unit support(0.001) was significantly higher and duration of hospital stay was significantly shorter(P = 0.012) in patients who died.Kidney biopsy was done in total of 22 patients.Predominant lesion on kidney biopsy was acute tubular necrosis(ATN) in 20(91%) cases.In 11 cases had severe ATN and in other nine(41%) cases kidney biopsy showed features of ATN associated with mild to moderate acute interstitial nephritis(AIN).One patient only had moderate AIN and one had patchy renal cortical necrosis(RCN).CONCLUSION AKI due to snake bite is severe and a high proportion requires renal replacement therapy.On renal histology ATN and AIN are common,RCN is rare.
文摘BACKGROUND Venom-induced consumption coagulopathy(VICC)is characterized by coagulation dysfunction accompanied by decreased coagulation factor activity and fibrinogen(FBG)concentrations.We report a patient with VICC caused by snake bite who manifested persistent FBG deficiency without abnormal coagulation factor activity.This information may be helpful in diagnosing and treating VICC.CASE SUMMARY A 49-year-old man who had been bitten by a snake 13 h previously was admitted to the Emergency Department of our hospital with visible swelling of a finger and a bleeding puncture site.The provisional diagnosis was VICC,this being made based on persistent bleeding from the puncture site and subcutaneous hemorrhage.Laboratory evidence of coagulation abnormalities,including fibrinolysis,and findings on thromboelastography confirmed VICC.He had persistent afibrinogenemia requiring intravenous infusions of cryoprecipitate and fresh frozen plasma,together with continuous large doses of human FBG.After this treatment,the patient’s right upper limb swelling improved significantly and his subcutaneous hemorrhage resolved.All of his abnormal laboratory findings returned to normal by day 25.During 6 months’of follow-up,the patient had no further hemorrhagic events.CONCLUSION Hemorrhagic snake venom can result in coagulation dysfunction characterized by persistent FBG deficiency without abnormal coagulation factor activity.
文摘The history of research and preparation of prescriptions for snake bites in Fujian Province was reviewed, and the process of incorporating snake doctors into the system and the gradual establishment of snake bite treatment system in Fujian were explored. The composition of several main snake bite preparations in Fujian was preliminarily compared and analyzed to provide reference for the research and development of similar new preparations at present.
文摘Objective:To describe the epidemiology of snake bite in the region and attempt to compare proven Russell’s viper with hump-nosed viper bites.Methods:All snake bite admissions to the Toxicology Unit of Teaching Hospital Peradeniya over three year from 2006 were included. Results:Of the 776 snakebites,665(86%) were unidentified and non-envenomed.Humpnosed viper and Russell’s viper accounted for 55(7%) and 40(5%) bites respectively,of them, incriminated snakes were found in 36(65%) and 19(48%) cases.The cobra bites-5,krait bites-0. The median ages:Russell’s viper bites-41(range 16-66),hump-nosed viper bites-42(range 15- 75).The gender incidence,time of bite(】58%daytime) were similar.In hump-nosed viper bite; upper limb involved in 13(36%),happened at home garden in 22(61%),none in paddy fields.In Russell’s viper bite;6(33%) occurred in paddy fields.Dry bites were similar at 5%.In humpnosed viper bite:local effects 94%,coagulopathy 3%,acute renal failure 3%and one patient died.In Russell’s viper bite;local effects 84%,coagulopathy 53%,neurotoxicity 21%.Abdominal pain occurred only in Russell’s viper bites 10(53%).Conclusions:Overwhelming numbers of unidentified,non-envenomed snakebites are common in the central hills.Some distinctive differences were observed between Russell’s viper and hump-nosed viper bites.
文摘Snake bites are one among the under reported clinical emergencies from tropical countries.There are variations in clinical presentation of snake bites and its toxic features differ with the species and type of bite.There are lots of controversies in the treatment guidelines which often makes it difficult to manage.We report the case of a severe hemotoxic snake bite who presented to the outpatient service of our hospital with a trivial fool injury.Even though snakebites are familiar clinical situations for an emergency physician from tropics,we report this case as mast are under reported.We also intend to emphasize the excellent outcome of appropriately diagnosed and treated cases of snake bite.
文摘Objective: To explore the treatment measure of rhabdomyolysis caused by snake bites, and provide guidance for further prevention and control of snake bites. Methods: To retrospectively analyze the 841 cases of serpentine bites in our hospital from January 2006 to July 2017;127 cases of patients with rhabdomyolysis syndrome were screened out, and their clinical manifestations, laboratory results, related treatment and prognosis were analyzed. Results: 127 cases patients were rhabdomyolysis out of 841 cases, 28 cases patients developed acute renal failure;treatment measures included local wound treatment, application of tetanus antitoxin, anti-snake venom serum, anti-infection, fluid “hydration” and diuretic, alkaline urine and hybrid renal replacement therapy. 112 cases were cured, improved conditions in 9 cases, 3 cases of death, 3 cases uncured. The improvement rate of is 95.26% after treatment. Conclusion: The rhabdomyolysis had a high incidence in snake bite patients, severe cases often developed acute renal failure. Serum myopsin and related biochemical blood tests could be used to diagnose rhabdomyolysis quickly. Combined treatment methods are the main measure to increase the cured rate and decrease the death rate.
文摘Snakebite has become a serious public health problem with high mortality and disability rates.Ultrasound can provide imaging basis for diagnosis and treatment of snakebites and relative complications.The application progresses of ultrasound in snakebites and complications were reviewed in this article.
文摘Insert Snakebite is a global public health issue, and in majority of cases it is undermined. Tropical and subtropical countries are most effected, Bangladesh being one of them. There is scarcity of countries’ epidemiological situation in relation to snakebite poisoning. This study has looked at the epidemiological status of snakebite poisoning from national representative survey findings. Methods: A nationwide cross-sectional survey was conducted in 12 randomly selected districts of Bangladesh in 2003. A total of 171,366 households were surveyed and information was collected from 819,429 populations by face to face interview. Multi-stage cluster sampling methods were used in this survey and covered urban, rural and slum populations. Results: Annually an estimated 15,372 (10.98/100,000) individuals were bitten by snakes and of them 1709 (1.22/100,000) died every year. Males were found to be most vulnerable with a risk of 1.51 times higher than female. Rural populations were also 10.54 times higher at risk than the populations living in the urban areas. Among the victims 94% were from the poor socio economic conditions. Around 43.9% of the incidences occurred during evening to midnight. Home was found the most common area for snake bite (33.6%), and the Leg was found to be the most common site for biting (63.1%). A total of 96.6% victims sought treatment, of them 61% sought immediate treatment from traditional healing methods. Conclusions: Present incidence of snakebite in Bangladesh has clearly shown that there is emerging public health needs for intervention that can reduce the mortality and burden of the disease in the country.
文摘Background: Snakebite envenomation in pregnancy is uncommon. It can lead to a poor outcome in both the mother and the fetus. We describe our approach to envenomation in pregnancy based on the currently available evidence. Case: We reported two case of snakebite in the third trimester of pregnancy having caused placental abruption with expelling a fresh still born baby and a live baby. In both cases, consumption coagulopathy occurred. managed by polyvalent anti-snake and blood transfusion. Their investigations became normal and they were discharged of hospitalization. Conclusion: Snakebite envenomation in pregnant is a maternal and fetal emergency. Treatment must be quick and well adapted.
基金Supported by Guangxi Natural Science Foundation (No.2012GXNSFAA276011 and No.2013GXNSFBA019163)Youth Science Foundation of Guangxi Medical University (No.GXMUYSF201216)
文摘OBJECTIVE: To evaluate the effects of Jidesheng anti-venom used externally for skin and soft-tissue necrosis from Chinese cobra bite.METHODS: A retrospective review was performed according to the clinical data recorded from January 2002 to December 2012. A total of 126 patients(116 females and 10 males) with skin and soft-tissue necrosis due to Chinese cobra bite were divided into two groups. The control group was treated externally with 40% glyceride magnesium sulfate(n=52), and the treatment group was given Jidesheng anti-venom externally(n=74). The data collected included maximum local necrotic area of skin and soft tissues, de-tumescence time, healing time,and skin-grafting rate.RESULTS: There were no significant differences in gender, age, and disease condition between the control and treatment groups(P>0.05). No statistically significant difference was found in de-tumescence time between the two groups(P>0.05). The maximum local necrotic area of skin and soft tissues was(19.9 ± 7.3) cm2in the treatment group,while it was(23.3±6.4) cm2in the control group.The healing time of the treatment group was shorter than that of the control group [(32.1 ± 3.7) vs(34.4±4.5) days)] The skin-grafting rate in the treatment group was lower than that of the control group(10.81% vs 25.00%). There were statistically significant differences in maximum local necrotic area of skin and soft tissues, healing time, and skin-grafting rate between the control and treatment groups(all P<0.05).CONCLUSION: External application of Jidesheng anti-venom may help to promote wound healing and reduce the skin-grafting rate in cases of skin and soft-tissue necrosis due to Chinese cobra bite.
