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  5. Clinical entry: Hemachatus haemachatus

Clinic: Hemachatus haemachatus

Examine for venom effects

Local Effects

Bite site

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

Eyes

  • Intense local pain
  • Blepharospasm
  • Balpebral oedema
  • Leucorrhoea
  • Photophobia
  • Clouding of vision
  • Temporary blindness

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 effects - bite site1 Local effects - eyes2 Neurological effects3
Hemachatus haemachatus      

1Local Effects - bite site

  • Mild local swelling, ecchymosis in the area around the swelling (Rippey et al. 1976).

2Local Effects - eyes

  • Blepharospasm, chemosis, epiphora and conjunctivitis 5 minutes after venom ejection. The patient then fushed the eye for one hour with water.  The next day only sight redness, withwise normal (Chu et al. 2020). 

3Neurological effects

  • Diplopia, dyspnoea (Rippey et al. 1976).
  • Dysphagia, dysphonia, blurred vision, weakness of the arms and legs, dyspnoea (loss of consciousness) (FitzSimons 1962).

Other signs & symptoms

Drowsiness, nausea, vomiting, dizziness (Rippey et al. 1976).

Clinical management

See also Clinical Management: Central and Southern Africa

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

First Aid

Release of any type of tourniquet follow link above.

Local treatment

Bite site

Pain control
Tetanus prophylaxis
Standard wound care
WHO (2010a,b) 

Eyes

Diagnostic
Intense local pain, blepharospasm, palpebral oedema and leukorrhoea.
Slit-lamp or fluorescein examination: corneal erosions
Complications: Permanent opacities and blindness (secondary infection of corneal lesions). Destruction of the eye (panophthalmitis). Hypopyon and anterior uveitis (absorption of venom into the anterior chamber). Facial cranial nerve paralysis (local spread of venom) (Warrell 2023, Chu et al. 2010, WHO 2010a).

Treatment

“1) urgent decontamination by copious irrigation 
2) analgesia by vasoconstrictors with weak mydriatic activity (e.g. epinephrine) and limited topical administration of local anaesthetics (e.g. tetracaine)
3) exclusion of corneal abrasions by fluorescein staining with a slit lamp examination and application of prophylactic topical antibiotics
4) prevention of posterior synechiae, ciliary spasm and discomfort with topical cycloplegics and 5) antihistamines in case of allergic kerato-conjunctivitis.
5) Topical or intravenous antivenom and topical corticosteroids are contraindicated.” (Chu et al. 2010).

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 Hemachatus haemachatus - specific features

see

  • 'Species-specific envenoming pattern above'.

and

Key issues:

  • Descending paralysis, respiratory failure.
  • Eye involvement (spitting).

Specific treatment (antivenoms)

References

  • Chu ER, Weinstein SA, White J, Warrell DA.Venom ophthalmia caused by venoms of spitting elapid and other snakes: Report of ten cases with review of epidemiology, clinical features, pathophysiology and management. Toxicon. 2010 Sep 1;56(3):259-72. Epub 2010 Mar 21. PMID: 20331993.  doi.org/10.1016/j.toxicon.2010.02.023 
  • National Snakebite Management Guidelines Kingdom of Eswatini 2021 https://eswatiniantivenom.org/newsite/wp-content/uploads/2021/12/WHO-Snake-Bite-Treatment-Protocol-Manuscript-A4.pdf 
  • 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 (2010a) Guidelines for the prevention and clinical management of snakebite in Africa. https://www.who.int/publications/i/item/9789290231684
  • WHO (2010b) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139
  • WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured (2018)  https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured
  • 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 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

Hemachatus haemachatus

South Africa

  • Rippey et al. (1976)
    9 patients; bite 8/9, eye injury 1/9.
  • FitzSimons (1962)
    Report of a bite suffered by the author.

References

  • FitzSimons, V. (1962) Snakes of Southern Africa: Purnell & Sons, Capetown: 423
  • Rippey, J. J., E. Rippey, W. R. Branch (1976) A survey of snakebite in the Johannesburg area. S. Afr. Med. J.: 1872-1876