Clinic: Australian elapids

Examine for venom effects

Autopharmacological effects

• Nausea, vomiting
• Sweating
• Urticaria, angiooedema
• Arterial hypotension / hypovolaemic shock (transient, recurrent; immediate; delayed (CLS))
• Diarrhoea
• Bronchospasm 

Local Effects

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

Haematological effects 

• Clotting disturbances:
  • Bleeding from the fang marks and from injuries, in particular ones that are not located in the region in which venom application occurred.
  • Bleeding into the skin (ecchymosis, petechiae)
  • Gingival bleeding, bleeding from the nose, conjunctiva, haematemeis, bleeding per rectum, including melaena, haematuria, haemoptysis.
  • Oliguria, anuria (VICC / AKI)
• Bleeding and/or haemolytic anaemia:
  • Arterial hypotension (haemorrhagic shock)
  • Acute abdomen (intra-abdominal bleeding!)
  • Loin pain/renal bed sensitive to percussion (ischaemia, renal haemorrhage!)
  • Local neurological signs, meningism, coma (intracranial bleeding!)
  • Pale sclera
  • Oliguria, anuria (arterial hypotension / AKI)

Neurological effects

• Descending flaccid paralysis (rarely progresses to involve bulbar and respiratory muscles):
  • 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.  

Muscular effects

• Generalized rhabdomyolysis:
  • Muscles pain and tenderness, painful on passive stretching, muscle stiffness, trismus
  • Bulbar and respiratory muscle weakness.
  • Dark brown urine. 
  • Renal failure
  • Laboratory: Generalized rhabdomyolysis: defined by a serum creatine kinase level > 10,000 U/l
  • ECG: Signs of hyperkalaemia. 

Cardiac Effects

• Bradycardia, tachycardia, arrhythmias
• Arterial hypotension
• Heart failure
• ECG: Tachyarrhythmias, sinus bradycardia, ST-T wave changes, varying degrees of atrioventricular block, and evidence of hyperkalaemia.

Renal effects

• Acute kidney injury:
  • Loin pain (lower back pain)
  • Renal bed sensitive to percussion
  • Haematuria, haemoglobinuria, myoglobinuria
  • Oliguria (< 400 ml of urine / 24 h), anuria
  • Uraemia (nausea, acidotic breathing, hiccups, pleuritic chest pain, encephalopathy) 

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.

Grading of effects from Isbister et al. (2013), Isbister and Berling (2025), Johnston and Isbister (2021).

The overall picture of Australian elapid envenoming

“The most common systemic envenoming syndrome in the 835 envenomed patients was venom-induced consumption coagulopathy (611 cases, 73%), myotoxicity (142 cases, 17%), acute kidney injury (97 cases, 12%), and neurotoxicity (83 cases, 10%). Microangiopathic haemolytic anaemia occurred in 66 cases (7.9%). Less common but more severe complications included cardiac arrest in 25 cases (2.9%) and major haemorrhage in 13 (1.6%), both mainly after brown snake envenoming.” (Johnston et al. 2017a). The proportion of systemic envenoming syndromes in the 718 patients with accurate snake identification is shown in Box 2 of Johnston et al. (2017a).

See also Box 2 in Isbister et al. (2013).

Autopharmacological effects

¹There were 135 of 148 patients (91%) who developed myotoxicity with at least one non-specific systemic symptom or sign including nausea, vomiting, headache, abdominal pain, diaphoresis or diarrhoea (Johnston and Isbister 2021)

²Collapse after Australian snake envenoming almost always occurred within 60 minutes of the bite (on average 20 minutes), and was always accompanied by VICC; it most frequently followed brown snake bites.” (Isbister et al 2025, Johnston et al 2017).

It most often happens pre-hospital and immeditae life support is essential.

“Early collapse, cardiovascular collapse, or hypotensive collapse have been reported following bites by brown snakes, tiger snakes (Notechis scutatus), rough- scale snakes (Tropidechis carinatus), and taipans (Oxyuranus scutellatus). Collapse or, more frequently, hypotension have been reported following snakebite in other parts of the world, mainly after viper envenoming, but from a variety of different mechanisms.” (Isbister et al. 2025).
Definition of sudden collapse (Isbister et al. 2013): 

• “Collapse or syncope occurring within an hour of the bite
• Collapse is associated with hypotension and loss of consciousness
• Spontaneous recovery usually occurs within minutes
• Minority of patients (about 5%) have a cardiac arrest or seizure.”

Kakumanu et al. (2019) investigated the differences between rapid cardiovascular collapse and prolonged hypotension induced by snake venom. They concluded that the effects of venom on the cardiovascular system manifest in at least two ways: rapid cardiovascular collapse with sudden onset (possibly mediated by depletable endogenous mediators) and prolonged hypotension with slower onset (possibly mainly mediated by vasodilation).

³Local effect

“Local effects are uncommon in Australian snakebite and are minimal for bites by brown snakes, which cause most major cases of systemic envenoming in Australia. How ever, some local pain, swelling and bruising may occur. Less commonly, prominent regional swelling is observed after bites by snakes that cause myotoxicity, including black and tiger snakes.” (Isbister et al. 2013)
More significant local signs can occur in bites from black snakes, tiger snakes and rough-scaled snakes. Rarely, necrosis develops, most common with red-bellied balck snakes (Isbister and Berling 2025).
“Local bite site effects occurred in 19 of 148 patients (13%) who developed myotoxicity and included 13 patients with substantial swelling or necrosis.
Figure 1. (a) Localised bite site necrosis occurring secondary to rough-scaled snake (Tropedechis carinatus) bite. (b) Localised swelling occurring secondary to red bellied black snake (Pseudechis porphyriacus) bite” (Johnston and Isbister 2021, Weinstein et al. 2018).

Hematological effects

⁴Bleeding 

Gingival bleeding, epistaxis, haematemesis, haematuria, etc., haemorrhagic schock (Isbister et al 2013). 
Australian elapids inducing VICC
Bite site, IV cannula site, minor haemorrhage, gum bleeding are common, e.g. in Brown snake envenoming (Allen et al. 2012).

Major haemorrhage is rare, however, severe and mostly observed in brown snake envenoming (Allen et al. 2012, Johnston et al. 2017a).
Intracranial haemorrhages associated with venom induced consumption coagulopathy rarely occurs (Berling et al. 2015).
Australian elapids inducing anticoagulant coagulopathy
Black snakes, including mulga snakes, cause anticoagulant coagulopathy but it is not clinically important (Isbister et al. 2013).

⁵Coagulopathy
Type of haemostatic defect
Definition of VICC and partial VICC (Isbister et al. 2013)

“Venom-induced consumption coagulopathy (VICC): Activation of the clotting pathway by prothrombin activator toxins and consumption of clotting factors (fibrinogen, factor V and factor VIII) lead to a consumptive coagulopathy.

• INR is high or unrecordable and aPTT is prolonged.
• Fibrinogen level is low or undetectable and D-dimer level is very high.

Complete or severe VICC is defined as:

• Undetectable fibrinogen level, INR >3.0 (most often unrecordable), abnormal aPTT (outside the laboratory’s reference interval), and very high D-dimer level (100–1000´assay cut-off)

Partial VICC (less severe changes) is defined as:

• Low but detectable fibrinogen level (< 1.5 g/L) and INR <3.0”

Definition of anticoagulant coagulopathy (Isbister et al. 2013)
“Provides a good marker of envenoming by all black snakes, including mulga snakes, but is not clinically important

• aPTT is moderately abnormal (1.5–2.5´laboratory’s reference interval), with or without mild elevation of INR (>1.3)
• D-dimer and fibrinogen levels are generally normal (D-dimer < 1.5g/L [or >2.0g/L in some laboratories])”

Pseudechis spp. (P. australis, P. porphyricus, other black snakes)
Anticoagulant type (Berling and Isbister 2015, Isbister 2010)

Pseudonaja spp, Notechis scutatus, Tropidechis carinatus, Holocephalus spp, Oxyuranus scutellatus
Venom-induced consumption coagulopathy (VICC)* (Berling and Isbister 2015, Isbister 2010)

*“The most common coagulopathy associated with snake envenoming worldwide is venom-induced consumption coagulopathy (VICC), which results from activation of the coagulation pathway by snake toxins including thrombin-like enzymes, prothrombin activators, and factor X activators. VICC has often been likened to disseminated intravascular coagulation (DIC) because of the elevated D-dimer, prolonged prothrombin time, and low fibrinogen. However, VICC is not characterized by other important features of DIC, such as evidence of systemic microthrombi and end-organ failure. In addition, the time course of VICC differs with rapid onset and resolution, and the mechanism of initiation of coagulation activation differs because thrombin generation in DIC is mediated by the tissue factor/factor VIIa pathway. In a proportion of patients with VICC, a clinical syndrome consistent with thrombotic microangiopathy has been reported and is characterized by acute renal failure, thrombocytopenia, and microangiopathic hemolytic anemia. This thrombotic microangiopathy appears to only occur in conjunction with VICC but in several different snakes worldwide including vipers and elapids. Consistent with thrombotic microangiopathy, it progresses despite the resolution of the coagulopathy, suggesting a distinct but related process. The existence of the overlapping clinical syndromes of VICC and thrombotic microangiopathy in snake envenoming is the likely reason for the mistaken idea that snakebite causes DIC.” (Isbister 2010).

⁶Thrombotic microangiopathy (TMA)
“TMA include disseminated intravascular coagulation, microangiopathic haemolytic anaemia diagnosed by finding schistocytes in peripheral blood films, thrombocytopenia, and acute kidney injury associated with arteriolar and capillary microthrombi.” (Warrell and Williams 2023).
Definition of Thrombotic microangiopathy (Isbister et al. 2013)
“Presence of fragmented red blood cells on blood film (microangiopathic haemolytic anaemia), thrombocytopenia and a rising creatinine level (>120mmol/L), which may lead to acute renal failure requiring dialysis.”
Thrombotic microangiopathy occurs in about 15% of Australian snake envenoming cases and only from snakes that cause VICC and develops within 24 hours of the bite.
Patients with VICC: blood film with 24 hours of the bite (schistocytes > 1% is diagnostic of microangiopathic haemolytic anaemia); serial creatinine.
There is limited evidence that antivenom prevents TMA.
See Noutsos et al. (2020, 2022a,b) and footnote 5 above (Isbister 2010).

⁷Neurological effects

Definition of neurotoxicity  (Isbister et al. 2013)
A descending flaccid paralysis that classically first involves the eye muscles (ptosis, diplopia and blurred vision), followed by bulbar muscles, respiratory muscle paralysis and limb paralysis.
It occurs mainly in death adder and taipan and also Pseudechis papuanus envenoming and is mostly caused by presynaptic phospholipase A₂.
Antivenom given within 3 to 4 hours after the bite can prevent neurotoxicity. Once generaized paralysis has devloped, recovery may take up to weeks (Johnston et al.2017b, Lalloo et al. 1995).

⁸Muscular effects 

Definition of myotoxicity (Isbister et al. 2013)

• Local or generalised myalgia and/or muscle tenderness
• CK level is usually normal (within the laboratory’s reference interval) on admission and rapidly rises over 24–48 hours (peak ranges from 1000U/L in mild cases to >100000U/L in severe cases)
• Potassium level may also be elevated (>5.0mmol/L) in severe cases, and renal impairment may develop”

The onset of abnormal CK values is, however, delayed (median time to recording the first abnormal CK activity level 11 hours; 34 hours to the peak level) conpared to clinical signs of muscle injury (Johnston and Isbister 2021).
Non-envenomned patients may present with elevated CK values, e.g. due to physical activity. Early presentation of elevated CK which decrease again points towards other causes since myotoxicity-associated elevated CK activity comes in much laeter (see above) and continues to increase.
The delayed increase of CK limits the usefulness of CK to trigger antivenom application since myotoxicity seems to be prevented if antivenom is given 3 hours after the bite in mulga snake envenoming and 6 hours after the bite in red-bellied black snake evnenoming (Johnston et al. 2013; Isbister et al. 2024).
Snake species most commonly associated with myotoxicity are Notechis spp. (30%), Pseudechis porphyriacus (20%) and Pseudechis australis (13%) (Johnston and Isbister 2021).

⁹Cardial effects

See footnote 2 (Isbister et al. 2013, 2025)

¹⁰Renal effects

Direct venom nephrotoxicity, renal ischaemia secondary to shock, disseminated intravascular coagulation with thrombotic microangiopathy (TMA), haemoglobinuria, myoglobinuria, and hyperkalaemia contribute to acute tubular necrosis.” (Warrell and Williams 2023).
In Australian elapid envenoming, AKI mostly occurs in the context of thrombotic microangiopathy and rhadomyolysis (Johnston et al. 2017a, Isbister and Berling 2025).
Rhabdomyolysis associated with myotoxicity of Notechis spp. (30%), Pseudechis porphyriacus (20%) and Pseudechis australis (13%) leads to AKI (Johnston and Isbister 2021). 

General references
Berling and Isbister (2015), Isbister (2010), Noutsos et al. (2020, 2022a), Warrell (2023), Warrell and Williams (2023) 

Publications reporting broadly on Australian elapid envenoming and treatment

Currie (2000), Currie (2004), Johnston et al. (2017a), Berling et al (2015), Isbister et al (2025), Johnston and Isbister (2021), Noutsos et al (2022b), Sutherland and Tibballs (2001), White (1995).

Species-specific publications 
see ‘References’ at the end of the file.

Clinical management

See also Clinical Management: australia and the pacific islands

First Aid

If a tourniquet has been applied, it should not be removed until

• systemic envenoming has been excluded: absence of non-specific systemic symptoms and normal results of laboratory investigations (Ireland et al. 2010, Isbister and Berling 2025)
  or

• after compeltion of antivenom administration for patients with systemic envenoming (Isbister et al. 2025).

• adverse outcomes have been observed in patinets with tight pressure bandages left in place for many hours (Little 2023).
• all patients must be observed after removal of the bandage.

Local treatment

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

• Comprehensive ABCDE approach

• ICRC Basic Emergency Care: approach to the acutely ill and injured (SAMPLE  and ABCDE approach: first module)

Obey Australian ElapidS - specific features

see 

• 'Species-specific envenoming pattern' above

and

• Guidance and guidelines – Australian elapids specific
  • Guidelines for the Management of Snakebites, WHO Regional Office CE Asia (Australasian Elapids)
  • Chiew et al. (2021)
  • Isbister and Berling (2025)
  • Snakebite. In: Therapeutic Guidelines, Melbourne 2020
  • Isbister et al. (2013)

Key issues

Exclusion of systemic envenoming 

Laboratory parameters (INR, aPTT and CK) and neurological reassessments identify severe envenoming in almost all patients within 12 hours of the bite (Ireland et al. 2010, Isbister and Berling 2025).

Rapid cardiovascular collapse and prolonged hypotension

See footnotes 1 and 2 above

Respiratory failure

Lifesaving in neurotoxic Australian elapid envenoming (as supportive treatment and when antivenoms are not available or fail):
Airway management
Breathing: Oxygen ⇨ assisted ventilation ⇨ mechanical ventilation

Venom-induced consumptive coagulopathy (VICC) and thrombotic microangiopathy (TMA)

See footnotes 4, 5 and 6 above.

Rhabdomyolysis, hyperkalaemia and hypercalcaemia

See footnote 10 above.

Specific treatment (antivenoms)

• WHO Snakebite Information and Data Platform

• CSL Seqirus

• Guidance and guidelines – Australian elapids specific

  • Guidelines for the Management of Snakebites, WHO Regional Office CE Asia (Australasian elapids)

  • Chiew et al. (2021) 

  • Isbister et al. (2013) 

  • Isbister (2022) 

  • Isbister (2024) 

  • Isbister and Berling (2025)

  • Snakebite. In: Therapeutic Guidelines, Melbourne 2020
    

References

• Allen GE, Brown SG, Buckley NA, O'Leary MA, Page CB, Currie BJ, White J, Isbister GK; ASP Investigators. Clinical effects and antivenom dosing in brown snake (Pseudonaja spp.) envenoming--Australian snakebite project (ASP-14). PLoS One. 2012;7(12):e53188. Epub 2012 Dec 28. PMID: 23300888; PMCID: PMC3532501. https://doi.org/10.1371/journal.pone.0053188
• Berling I, Isbister GK. Hematologic effects and complications of snake envenoming. Transfus Med Rev. 2015 Apr;29(2):82-9. Epub 2014 Dec 18. PMID: 25556574. https://doi.org/10.1016/j.tmrv.2014.09.005
• Berling I, Brown SG, Miteff F, Levi C, Isbister GK. Intracranial haemorrhages associated with venom induced consumption coagulopathy in Australian snakebites (ASP-21). Toxicon. 2015 Aug;102:8-13. doi: 10.1016/j.toxicon.2015.05.012. Epub 2015 May 21. PMID: 26003794. https://doi.org/10.1016/j.toxicon.2015.05.012
• Chiew AL, Buckley NA, Graudins A, Munir VL. Review article:Up (to) date for Australian Toxicology and Toxinology guidelines.Emerg Med Australas. 2021 Feb;33(1):6-8. Epub 2020 Oct 29. PMID: 33124195. https://doi.org/10.1111/1742-6723.13663
• Currie BJ. Snakebite in tropical Australia, Papua New Guinea and Irian Jaya. Emerg Med 2000; 12: 285-294. https://doi.org/10.5694/j.1326-5377.2004.tb06526.x
• Currie BJ. Snakebite in tropical Australia: a prospective study in the "Top End" of the Northern Territory. Med J Aust. 2004 Dec 6-20;181(11-12):693-7. PMID: 15588215. https://doi.org/10.1046/j.1442-2026.2000.00150.x
• Ireland G, Brown SG, Buckley NA, Stormer J, Currie BJ, White J, Spain D, Isbister GK; Australian Snakebite Project Investigators. Changes in serial laboratory test results in snakebite patients: when can we safely exclude envenoming? Med J Aust. 2010 Sep 6;193(5):285-90. doi: 10.5694/j.1326-5377.2010.tb03909.x. PMID: 20819048. https://doi.org/10.5694/j.1326-5377.2010.tb03909.x
• Isbister GK. Snakebite doesn't cause disseminated intravascular coagulation: coagulopathy and thrombotic microangiopathy in snake envenoming. Semin Thromb Hemost. 2010 Jun;36(4):444-51. Epub 2010 Jul 7. PMID: 20614396. https://doi.org/10.1055/s-0030-1254053
• Isbister GK. Antivenom availability, delays and use in Australia. Toxicon X. 2022 Dec 8;17:100145. PMID: 36523639; PMCID: PMC9747507. https://doi.org/10.1016/j.toxcx.2022.100145
• Isbister GK. The critical time period for administering antivenom: golden hours and missed opportunities. Clin Toxicol (Phila). 2024 May;62(5):277-279. Epub 2024 May 28. PMID: 38804828. https://doi.org/10.1080/15563650.2024.2352026
• Isbister GK and Berling I. Snake envenoming. Approach to suspected snakebite and delivering effective antivenom. MedicineToday 2025; 26(1-2): 22-3. https://medicinetoday.com.au/system/files/pdf/MT2025-1-2-022-ISBISTER.pdf 
• Isbister GK, Brown SG, Page CB, McCoubrie DL, Greene SL, Buckley NA. Snakebite in Australia: a practical approach to diagnosis and treatment. Med J Aust. 2013 Dec 16;199(11):763-8. PMID: 24329653. https://doi.org/10.5694/mja12.11172
• Isbister GK, Jenkins S, Downes MA, Fakes K, Buckley NA. A randomized controlled trial and prospective cohort investigating antivenom for red-bellied black snake envenomation. Clin Toxicol (Phila) 2024; 62: 343-351.
• Isbister GK, Isoardi KZ, Chiew AL, Jenkins S, Buckley NA.Early cardiovascular collapse after envenoming by snakes in Australia, 2005-2020: an observational study (ASP-31). Med J Aust. 2025 Apr 7;222(6):313-317. doi: 10.5694/mja2.52622. Epub 2025 Mar 9. PMID: 40058771; PMCID: PMC11972595. https://doi.org/10.5694/mja2.52622
• Johnston CI, Isbister GK. Australian snakebite myotoxicity (ASP-23). Clin Toxicol (Phila). 2021 Jul;59(7):611-618.Epub 2020 Nov 6. PMID: 33156703. https://doi.org/10.1080/15563650.2020.1836377
• Johnston CI, Brown SG, O'Leary MA, Currie BJ, Greenberg R, Taylor M, Barnes C, White J, Isbister GK; ASP investigators. Mulga snake (Pseudechis australis) envenoming: a spectrum of myotoxicity, anticoagulant coagulopathy, haemolysis and the role of early antivenom therapy - Australian Snakebite Project (ASP-19). Clin Toxicol (Phila). 2013 Jun;51(5):417-24. Epub 2013 Apr 15. PMID: 23586640. https://doi.org/10.3109/15563650.2013.787535
• Johnston CI, Ryan NM, Page CB, Buckley NA, Brown SG, O'Leary MA, Isbister GK. The Australian Snakebite Project, 2005-2015 (ASP-20). Med J Aust. 2017a Aug 7;207(3):119-125. PMID: 28764620. https://doi.org/10.5694/mja17.00094
• Johnston CI, Ryan NM, O'Leary MA, Brown SG, Isbister GK. Australian taipan (Oxyuranus spp.) envenoming: clinical effects and potential benefits of early antivenom therapy - Australian Snakebite Project (ASP-25). Clin Toxicol (Phila). 2017b Feb;55(2):115-122. Epub 2016 Nov 30. PMID: 27903075. https://doi.org/10.1080/15563650.2016.1250903
• Kakumanu R, Kemp-Harper BK, Silva A, Kuruppu S, Isbister GK, Hodgson WC. An in vivo examination of the differences between rapid cardiovascular collapse and prolonged hypotension induced by snake venom. Sci Rep. 2019 Dec 27;9(1):20231. PMID: 31882843; PMCID: PMC6934742. https://doi.org/10.1038/s41598-019-56643-0
• Lalloo DG, Trevett AJ, Korinhona A, Nwokolo N, Laurenson IF, Paul M, Black J, Naraqi S, Mavo B, Saweri A, et al. Snake bites by the Papuan taipan (Oxyuranus scutellatus canni): paralysis, hemostatic and electrocardiographic abnormalities, and effects of antivenom. Am J Trop Med Hyg. 1995 Jun;52(6):525-31. PMID: 7611559. https://doi.org/10.4269/ajtmh.1995.52.525
• Noutsos T, Currie BJ, Lek RA, Isbister GK. Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis.PLoS Negl Trop Dis. 2020 Dec 8;14(12):e0008936. PMID: 33290400; PMCID: PMC7748274. https://doi.org/10.1371/journal.pntd.0008936
• Noutsos T, Currie BJ, Wijewickrama ES, Isbister GK.Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice. Toxins (Basel). 2022a Jan 14;14(1):57. PMID: 35051033; PMCID: PMC8778654. https://doi.org/10.3390/toxins14010057

• Noutsos T, Currie BJ, Isoardi KZ, Brown SGA, Isbister GK. Snakebite-associated thrombotic microangiopathy: an Australian prospective cohort study [ASP30]. Clin Toxicol (Phila). 2022b Feb;60(2):205-213. doi: 10.1080/15563650.2021.1948559. Epub 2021 Jul 30. PMID: 34328386.https://doi.org/10.1080/15563650.2021.1948559

• Sutherland and Tibballs. Australian animal toxins: the creatures, their toxins, and care of the poisoned patient. Second ed. South Melbourne: Oxford University Press; 2001.

• Snakebite. In: Toxicology and Toxinology. Therapeutic Guidelines. 3rd ed. Melbourne: Therapeutic Guidelines Ltd; 2020 
• 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.
• Warrell DA, Williams DJ. Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet. 2023 Apr 22;401(10385):1382-1398. PMID: 36931290. https://doi.org/10.1016/s0140-6736(23)00002-8

• Weinstein, Scott A., Mirtschin, Peter J., Tristram, Hamish, Lawton, Luke, and White, Julian (2018) Local morbidity from red- bellied black snake (Pseudechis porphyriacus, Elapidae) envenoming: two cases and a brief review of management. Toxicon, 142. pp. 34-41. https://doi.org/10.1016/j.toxicon.2017.12.047

• White J. Clinical toxicology of snakebite in Australia and New Guinea. In: Meier J, White J, editors. Handbook of clinical toxicology of animal venoms and poisons. New York: CRC Press, 1995: 595-618.
• 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-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 Snakebite Information and Data Platform. https://www.who.int/teams/control-of-neglected-tropical-diseases/snakebite-envenoming/snakebite-information-and-data-platform
• 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. 2^nd edition (Australasian elapids)  https://www.who.int/publications/i/item/9789290225300

Species-specific evidence

Acanthophis sp. (Death adder)

• Johnston CI, O'Leary MA, Brown SG, Currie BJ, Halkidis L, Whitaker R, Close B, Isbister GK; ASP Investigators. Death adder envenoming causes neurotoxicity not reversed by antivenom--Australian Snakebite Project (ASP-16). PLoS Negl Trop Dis. 2012;6(9):e1841. Epub 2012 Sep 27. PMID: 23029595; PMCID: PMC3459885. https://doi.org/10.1371/journal.pntd.0001841

Hoplocephalus sp.

• Isbister GK, White J, Currie BJ, O'Leary MA, Brown SG; ASP Investigators. Clinical effects and treatment of envenoming by Hoplocephalus spp. snakes in Australia: Australian Snakebite Project (ASP-12). Toxicon. 2011 Dec 1;58(8):634-40. Epub 2011 Sep 28. PMID: 21967812. https://doi.org/10.1016/j.toxicon.2011.09.013

Notechis scutatus ssp. (Tiger snake)

• Isbister GK, O'Leary MA, Elliott M, Brown SG. Tiger snake (Notechis spp) envenoming: Australian Snakebite Project (ASP-13). Med J Aust. 2012 Aug 6;197(3):173-7. PMID: 22860796. https://doi.org/10.5694/mja11.11300

Oxyuranus sp.(Taipans)

• Connolly S, Trevett AJ, Nwokolo NC, Lalloo DG, Naraqi S, Mantle D, Schofield IS, Fawcett PR, Harris JB, Warrell DA. Neuromuscular effects of Papuan Taipan snake venom. Ann Neurol. 1995 Dec;38(6):916-20. PMID: 8526464. https://doi.org/10.1002/ana.410380612
• Heap R, Kennedy A, Davies W, Tasoulis T, Isbister GK. Taipan envenoming … south of the border. Anaesth Intensive Care. 2024 Sep;52(5):335-337. Epub 2024 Sep 5. PMID: 39233566. https://doi.org/10.1177/0310057x241247852
• Johnston CI, Ryan NM, O'Leary MA, Brown SG, Isbister GK. Australian taipan (Oxyuranus spp.) envenoming: clinical effects and potential benefits of early antivenom therapy - Australian Snakebite Project (ASP-25). Clin Toxicol (Phila). 2017b Feb;55(2):115-122. Epub 2016 Nov 30. PMID: 27903075. https://doi.org/10.1080/15563650.2016.1250903
• Lalloo DG, Trevett AJ, Korinhona A, Nwokolo N, Laurenson IF, Paul M, Black J, Naraqi S, Mavo B, Saweri A, et al. Snake bites by the Papuan taipan (Oxyuranus scutellatus canni): paralysis, hemostatic and electrocardiographic abnormalities, and effects of antivenom. Am J Trop Med Hyg. 1995 Jun;52(6):525-31. PMID: 7611559. https://doi.org/10.4269/ajtmh.1995.52.525
• Lalloo DG, Trevett AJ, Owens D, Minei J, Naraqi S, Saweri A, Hutton RA, Theakston RD, Warrell DA. Coagulopathy following bites by the Papuan taipan (Oxyuranus scutellatus canni). Blood Coagul Fibrinolysis. 1995 Feb;6(1):65-72. PMID: 7540879. https://doi.org/10.1097/00001721-199502000-00011
• Trevett AJ, Lalloo DG, Nwokolo NC, Naraqi S, Kevau IH, Theakston RD, Warrell DA. Electrophysiological findings in patients envenomed following the bite of a Papuan taipan (Oxyuranus scutellatus canni). Trans R Soc Trop Med Hyg. 1995 Jul-Aug;89(4):415-7.PMID: 7570884. https://doi.org/10.1016/0035-9203(95)90035-7
• Weinstein SA, Everest E, Purdell-Lewis J, Harrison M, Tavender F, Alfred S, Marrack L, Davenport-Klunder C, Wearn N, White J. Neurotoxicity with persistent unilateral ophthalmoplegia from envenoming by a wild inland taipan (Oxyuranus microlepidotus, Elapidae) in remote outback South Australia.Toxicon. 2017 Oct;137:15-18. Epub 2017 Jul 8. PMID: 28694006. https://doi.org/10.1016/j.toxicon.2017.07.006

Pseudechis sp. (Black snakes)

Pseudechis porphyriacus (Red-bellied black snake)

• Churchman A, O'Leary MA, Buckley NA, Page CB, Tankel A, Gavaghan C, Holdgate A, Brown SG, Isbister GK. Clinical effects of red-bellied black snake (Pseudechis porphyriacus) envenoming and correlation with venom concentrations: Australian Snakebite Project (ASP-11). Med J Aust. 2010 Dec 6-20;193(11-12):696-700. PMID: 21143062. https://doi.org/10.5694/j.1326-5377.2010.tb04108.x
• Sanhajariya S, Duffull SB, Isbister GK. Investigating myotoxicity following Australian red-bellied black snake (Pseudechis porphyriacus) envenomation. PLoS One. 2021 Sep 10;16(9):e0256653. PMID: 34506531; PMCID: PMC8432874. https://doi.org/10.1371/journal.pone.0256653
• Weinstein SA, Mirtschin PJ, Tristram H, Lawton L, White J. Local morbidity from red-bellied black snake (Pseudechis porphyriacus, Elapidae) envenoming: Two cases and a brief review of management. Toxicon. 2018 Feb;142:34-41. Epub 2017 Dec 19. PMID: 29269114. https://doi.org/10.1016/j.toxicon.2017.12.047

Pseudechis australis (Mulga snake / King Brown snake)

• Johnston CI, Brown SG, O'Leary MA, Currie BJ, Greenberg R, Taylor M, Barnes C, White J, Isbister GK; ASP investigators. Mulga snake (Pseudechis australis) envenoming: a spectrum of myotoxicity, anticoagulant coagulopathy, haemolysis and the role of early antivenom therapy - Australian Snakebite Project (ASP-19). Clin Toxicol (Phila). 2013 Jun;51(5):417-24. Epub 2013 Apr 15. PMID: 23586640. https://doi.org/10.3109/15563650.2013.787535
• Razavi S, Weinstein SA, Bates DJ, Alfred S, White J. The Australian mulga snake (Pseudechis australis: Elapidae): report of a large case series of bites and review of current knowledge. Toxicon. 2014 Jul;85:17-26. Epub 2014 Apr 13. PMID: 24726467. https://doi.org/10.1016/j.toxicon.2014.04.003

Pseudechis papuanus

• Lalloo D, Trevett A, Black J, Mapao J, Naraqi S, Owens D, Hutton R, Theakston RD, Warrell DA. Neurotoxicity and haemostatic disturbances in patients envenomed by the Papuan black snake (Pseudechis papuanus).Toxicon. 1994 Aug;32(8):927-36. PMID: 7985197. https://doi.org/10.1016/0041-0101(94)90371-9

Pseudonaja sp. (Brown snakes)

• Allen GE, Brown SG, Buckley NA, O'Leary MA, Page CB, Currie BJ, White J, Isbister GK; ASP Investigators. Clinical effects and antivenom dosing in brown snake (Pseudonaja spp.) envenoming--Australian snakebite project (ASP-14). PLoS One. 2012;7(12):e53188. Epub 2012 Dec 28. PMID: 23300888; PMCID: PMC3532501. https://doi.org/10.1371/journal.pone.0053188

Tropidechis carinatus (Rough-scaled snake)

• Gan M, O'Leary MA, Brown SG, Jacoby T, Spain D, Tankel A, Gavaghan C, Garrett P, Isbister GK. Envenoming by the rough-scaled snake (Tropidechis carinatus): a series of confirmed cases. Med J Aust. 2009 Aug 3;191(3):183-6. PMID: 19645653. https://doi.org/10.5694/j.1326-5377.2009.tb02736.x