Emergency Flowchart

Signs and symptoms¹	Emergency medical treatment	Identification of the culprit	Antivenom

	Possible culprit²


Nausea, vomiting, abdominal pain, diarrhoea, urticaria, angio-oedema, bronchospasm, arterial hypotension (autopharmacological effects of the venom including anaphylaxis)	Treatment of anaphylactic/anaphylactoid reactions	Identification strategies 1. Morphological identification key (if snake is available for identification) 2. Narrowing down the cause with the aid of indirect criteria (if the snake is unavailable or could not be unequivocally identified) Which snake species are present in the country where the snake bite took place? Syndromic approach: How does the clinical picture of snakebite envenoming develop? Comparative observations of the various species responsible in the region. Follow also links to species- and family-specific 'clinical entries' in the column `possible culprit' of this flowchart.	WHO Snakebite Information and Data Platform Check for nationally / regionally available antivenoms (assure safety and effectiveness) Antivenom indications and antivenom therapy: go to 'clinical management' Check for updates in case of an accident

	European vipers

Generalised oedema → hypovolaemia → hypovolaemic shock (autopharmacological effect of the venom: increased capillary permeability)	Treatment of the hypovolaemia/hypovolaemic shock

	European vipers

Pulmonary oedema, cerebral oedema (autopharmacological effect of the venom: increased capillary permeability)	Treatment of the non-cardiogenic pulmonary / cerebral oedema

	European vipers

Extensive local swelling possibly involving the trunk → hypovolaemia → hypovolaemic shock (local effect of the venom: regionally increased capillary permeability)	Treatment of the hypovolaemia/hypovolaemic shock

	European vipers

Systemic bleeding (Gerrard and Pugh 1982) is the exception even in cases of severe envenoming (Reid 1976). Clinical features of a bleeding diathesis are unusual, but bleeding from the gums and nose and into the lungs, gastrointestinal and genitourinary tracts, and serosal cavities and retroperitoneally can occur (Warrell 2005).	Treatment of the haemorrhage-induced hypovolaemia/haemorrhagic shock

	European vipers

Cases of envenoming due to V. aspis with neurological signs (predominately cranial nerve deficits, such as facial diplegia, pharyngo-laryngeal paralysis, bilateral ptosis and external ophthalmoplegia, dysphonia, dysphagia, but also dyspnoea) have been described in Italy (Antonini et al. 1991, Beer and Putorti 1998, Re et al 1999) and in South-Eastern France (de Haro et al 2002).	Treatment of the respiratory insufficiency/respiratory failure:

	European vipers

Myocardial symptoms, cardiac dysrhythmias, ischaemia (ECG), cardiac insufficiency, heart failure (usually secondary, rarely primary cardiac effects of the venom)	Treatment of the cardiac disturbance

	European vipers

This section contains genera and species for which clinical data is either sparse or entirely missing. In this case, the link will lead you to the biological file. Under 'Risk', you will find what is known about the potential harm to humans which are well described for adjacent regions but not for the region you are currently looking at. The link will take you to the biological file and from there to the clinical file. When using the clinical information, however, you must consider that it is not from your region and therefore may not be applicable to your situation.	ABCDE approach

	Colubridae Montivipera xanthina Macrovipera schweizeri Gloydius halys

1	See also Clinical flowchart as a guide to the dynamics of envenoming.
2	Taxonomic name without parentheses/(in parentheses)/((in double parentheses)): these signs and symptoms are regularly/(rarely)/((questionably)) observed following bites by these species.