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  5. Clinical entry: Deinagkistrodon acutus

Clinic: Deinagkistrodon acutus

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 (bleeding, haemolysis!)
    • Oliguria, anuria (arterial hypotension / AKI!)

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.

  

Autopharma-
cological 
effects1
 

 Local
effects2		 Haematological effects
Bleeding3  Coagulopathy4
Deinagkistrodon acutus        

1Autopharmacological effects

  • Nausea, vomiting, abdominal pain.

2Local effects

  • Local pain and swelling (extensive),
  • necrosis   (extensive)


3Haematological effects

  • Gastrointestinal bleeding, including gingival bleeding and epistaxis. 

4Type of haemostatic defect
Direct fibrinogen-coagulating ("thrombin-like") activity and reactive (secondary) fibrinolysis, thromoytopenia.

Morbidity

Necroses, some with extensive loss of soft tissue and impairment of function, amputation.

Case fatality

Risks: Haemorrhage and wound complications.

Clinical management

See also (depending on the origin of the culprit)

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 link above.

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care
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 Deinagkistrodon acutus - specific features

see 

  • 'Species-specific envenoming pattern' above

Key issues

see footnotes above

Specific treatment (antivenoms)

References

  • WHO-ICRC Basic Emergency Care: approach tothe 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 (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
  • 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 

Species-specific evidence

Deinagkistrodon acutus

China

  • Sawai et al. (1992)
    64 patients. Identification: snakes not clearly identified or evidence for identification lacking
  • Hu et al. (2024)
    185 patients. Identification: "The snake species was confirmed by examining the specimen or photograph of the culprit snake. Clear identification was also made when patients unambiguously reported the snake species (some experienced patients could recognize the biting snake and report its common or local name). Suspected snake species were diagnosed based on the patient’s description, bite circumstances, or knowledge of the venom’s clinical effects."

 Taiwan

  • Cheng et al. (2017)  
    3 cases. Identification: morphological (2 dead snakes brought to the ospital, 1 pictue identification).
  • Kuo and Wu (1972)
    4 cases, 3 of which are described in detail; no information regarding the basis on which species identification was made.
  • Mao et al. (2024) 
    Description of Deinagkistrodon acutus envenoming and review of published cases.

References

  • Cheng CL, Mao YC, Liu PY, Chiang LC, Liao SC, Yang CC. Deinagkistrodon acutus envenomation: a report of three cases. J Venom Anim Toxins Incl Trop Dis. 2017 Mar 23;23:20. doi: 10.1186/s40409-017-0111-1. PMID: 28344596; PMCID: PMC5364662. https://doi.org/10.1186/s40409-017-0111-1
  • Hu S, Bao S, Shen Y, Tu M. The Epidemiology and Clinical Features of Deinagkistrodon acutus Envenomation: A Retrospective Study from a Medical Center in Hangzhou, Southeast China. Am J Trop Med Hyg. 2024 Jul 2;111(3):676-681. PMID: 38955198; PMCID: PMC11376154. https://doi.org/10.4269/ajtmh.23-0680
  • Kuo TP, Wu CS. Clinico-pathological studies on snakebites in Taiwan. Taiwan Yi Xue Hui Za Zhi. 1972 Jul 28;71(7):447-66. PMID: 4507795.
  • Mao YC, Liu PY, Lai KL, Luo Y, Chen KT, Lai CS. Clinical Characteristics of Snakebite Envenomings in Taiwan. Toxins (Basel). 2024 Dec 30;17(1):14. PMID: 39852967; PMCID: PMC11769513. https://doi.org/10.3390/toxins17010014
  • 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