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  5. Clinical entry: Aspidelaps sp.

Clinic: Aspidelaps sp.

Examine for venom effects

Local Effects

Bite site

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

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.  

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
Aspidelaps sp. ?   

 1Local Effects

  • No local signs (Barton et al. 2019).

2Neurological effects

  • Ptosis, slurred speech, peripheral facial nerve paralysis, paralysis of the left medial rectus muscle, slight general muscle weakness (Zaltzman et al. 1984).
  • Vomiting, respiratory failure ca. 1 hour after the bite requiring mechanical ventilation. Paralysis of the bulbar and upper extremity muscles, with retention of voluntary motor control in the lower extremities. Paralysis and respiratory failure resolved 12 hours after the onset (Barton et al. 2019).

Case fatality

  • Description of the patient (2 year-old child; "rural area about 65 km of gravel road away from the next district hospital") and review of the literature (published Aspidelaps sp. cases) (Theart et al. 2024).

Clinical management

First Aid

Local treatment

Bite site

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

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.

ABCDE approach

WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured

Guidelines for the Prevention and Clinical Management of snakebite in Africa

National Snakebite Management Guidelines (2021) WHO Eswatini, Eswatini Antivenom Foundation

Eswatini Antivenom Foundation 

Obey Aspidelaps sp. - specific features

see 'Species-specific envenoming pattern above'.

Key issues:

  • Descending paralysis, respiratory failure.
    • Lifesaving:
      Airway management
      Breathing: Oxygen ⇨ assisted ventilation ⇨ mechanical ventilation
    • A trial of anticholinesterase drugs to improve neuromuscular transmissionappears reasonable (though no positive reports available!): Edrophonium (Tensilon®) test/neostigmine 

Specific treatment (antivenoms)

WHO Snakebite Information and Data Platform

Guidelines for the Prevention and Clinical Management of snakebite in Africa

National Snakebite Management Guidelines (2021) WHO Eswatini, Eswatini Antivenom Foundation

Eswatini Antivenom Foundation 

References

  • Barton DJ, Shao S, Marino RT, Reichmeider A, Yanta JH, Pizon AF. Neurotoxic envenomation by the South African coral snake (Aspidelaps lubricus): A case report. Toxicon. 2019 Mar 1;159:38-40.  Epub 2019 Jan 17. PMID: 30660557. https://doi.org/10.1016/j.toxicon.2019.01.001
  • 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 
  • Theart F, Kemp L, Buys C, Hauptfleisch M, Berg P. A confirmed human fatality due to envenomation by the Kunene Coral Snake (Aspidelaps lubricus cowlesi) in Namibia. Toxicon. 2024 Jan;237:107537. Epub 2023 Dec 1. PMID: 38043715.  https://doi.org/10.1016/j.toxicon.2009.04.019
  • 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

Aspidelaps scutatus

South Africa

  • Zaltzman et al. (1984)

Aspidelaps lubricus

Namibia 

  • Theart et al. (2024)
    1 patient; identification: photograph of the snake. Review of the literature.

Captive snakes

  • Barton et al. (2019)
    1 patient; identification: morphological

References

  • Barton DJ, Shao S, Marino RT, Reichmeider A, Yanta JH, Pizon AF. Neurotoxic envenomation by the South African coral snake (Aspidelaps lubricus): A case report. Toxicon. 2019 Mar 1;159:38-40.  Epub 2019 Jan 17. PMID: 30660557. https://doi.org/10.1016/j.toxicon.2019.01.001
  • Theart F, Kemp L, Buys C, Hauptfleisch M, Berg P. A confirmed human fatality due to envenomation by the Kunene Coral Snake (Aspidelaps lubricus cowlesi) in Namibia. Toxicon. 2024 Jan;237:107537. Epub 2023 Dec 1. PMID: 38043715.  https://doi.org/10.1016/j.toxicon.2009.04.019
  • Zaltzman, M., M. Rumbak, M. Rabie, S. Zwi (1984) Neurotoxicity due to the bite of the Shield-nose snake (Aspidelaps scutatus), a case report. S. Afr. med. J. 66: 111-112