Clinical Flowchart
Autopharmacological effects
| Daboia siamensis | ||
| Minutes1 to days2 | ||
|
1Nausea, vomiting, abdominal pain, diarrhoea
2Chemosis, periorbital, and facial oedema, bilateral parotid swelling, pleural effusions, ascites, macular oedema, acute angle-closure glaucoma, haemoconcentration, proteinuria, and hypovolaemic shock |
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| Cardiovascular failure |
| 1 | Autopharmacological syndrome
“Acute profound hypotension with or without other features of anaphylaxis is part of the autopharmacological syndrome which may occur within minutes of bites by Daboia species. It may be caused by release of endogenous vasoactive compounds such as nitric oxide, kinins, histamine, serotonin and endothelins.” (Warrell 2023) |
| 2 | Capillary leak syndrome (CSL)
CLS is unique for Russell's viper envenoming and includes chemosis, periorbital, and facial oedema, bilateral parotid swelling, pleural effusions, ascites, macular oedema, acute angle-closure glaucoma, haemoconcentration, proteinuria, and hypovolaemic shock with low central venous pressure. Patients with CLS are unresponsive to antivenom and are at increased risk of acute kidney injury and death. Symptoms usually appear 12–48 h after the bite (Warrell and Williams 2023). |
Local effects
| Naja sp.1
Ophiophagus hannah (Daboia siamensis)2 Gloydius sp. Deinagkistrodon acutus Trimeresurus sp. Rhabdophis sp. |
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| Minutes to hours | ||
| Local pain and swelling | ||
| Painful swelling of the regional lymph nodes | ||
|
Naja sp.
|
Gloydius sp.
Deinagkistrodon acutus Trimeresurus sp. |
|
| Necrosis | Extensive swelling | |
| Loss of function of extremities
Loss of extremities |
Hypovolaemia / hypovolaemic shock | |
| 1 | Envenoming in the eyes (Asian spitting cobras) |
| 2 | Local signs & symptoms can be mild or absent (Warrell 1989). |
Haematological effects
| Daboia siamensis1,2
Deinagkistrodon acutus Trimeresurus sp. Rhabdophis sp. |
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| < 1 hour to hours | ||||
| Gingival bleeding | ||||
| Bleeding from wounds remote from the site of the bite | ||||
| Haematemesis, bleeding per rectum, haematuria | ||||
| Systemic bleeding |
Intracranial bleeding2
|
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| Hypovolaemia/haemorrhagic shock | ||||
| Cardiovascular failure | Renal failure | CNS failure | ||
| 1 | Additionally, thrombotic microangiopathy (TMA). TMA with acute kidney injury is increasingly recognised in patients envenomed by Russell’s vipers and a variety of other species.” (Warrell and Williams 2023). |
| 2 |
? Addionally, bleeding into pituitary and / or adrenal glands (haemostatic effects of the venom) → Acute, delayed and chronic pituitary or adrenal insufficiency and diabetes insipidus. Hypopituitarism following Daboia siamensis envenoming (Antonypillai et al 2011, Warrell and Williams 2023).
|
Neurological effects
| Bungarus sp.1
Naja sp.2 Ophiophagus hannah2 Gloydius blomhoffii |
| Minutes to hours |
| Cranial nerve deficits (ptosis, ophthalmoplegia, dysphagia, dysarthria) |
| Paralysis of the skeletal musculature including the respiratory musculature |
| Respiratory failure |
| 1 | Krait bites in particular may be completely unnoticed and unrecognised initially, as these snakes often bite people at night while they are asleep. A krait bite is thus an important differential diagnosis of signs of paralysis (of the cranial nerves, extremities, respiratory musculature).
Abdominal pain is recognized as a characteristic symptom of kraits. Hyponatraemia → Hypotension / shock; brain damage. |
| 2 | “Intractable hypotension can occur in patients envenomed by Asian cobras and king cobras, despite adequate respiratory support.” (Warrell 2023) |
Muscular effects
Gloydius tsushimaensis: Rhabdomyolysis with a CK value of more than 40,000 IU/L (with renal dysfunction) (Yokoi et al. 2020).
Daboia siamensis (Taiwan): mostly mild
?B. niger in China: no reports identified.
Cardiac effects
No convincing case reports identified.
Renal effects
| Daboia siamensis
|
| Hours to days |
| Flank pain, renal bed sensitive to percussion |
| Urinary output <400 ml/24 h |
| Renal failure
|
“Envenoming by many snake species occasionally results in acute kidney injury, but Russell’s vipers are the most dangerous. Acute kidney injury is the major cause of mortality and morbidity among people who have been bitten by these species. 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).