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? Under what circumstances did the snake bite occur, and how did the snake behave? 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.

	Actractaspis sp. Bitis arietans Daboia palaestinae Echis sp.

Generalised oedema → hypovolaemia → hypovolaemic shock (Increased capillary permeability)	Treatment of the hypovolaemia/hypovolaemic shock

	Bitis arietans Daboia palaestinae

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

	Bitis arietans Cerastes cerastes Daboia palaestinae Naja nigricolis

Systemic bleeding (haemostatic effects of the venom) → haemorrhagic shock. Intracranial bleeding (haemostatic effects of the venom) → focal neurological deficits, coma, meningismus	Treatment of blood loss Treatment of intracarnial bleeding

	Bitis arietans Cerastes cerastes Daboia palaestinae³ Echis sp.³ (Naja nigricollis)

Cranial nerve deficits, paralysis of the skeletal musculature including the respiratory musculature → respiratory insufficiency, respiratory failure (neurological effects of the venom)	Treatment of the respiratory insufficiency/respiratory failure: acetylcholinesterase inhibitors, endotracheal intubation and artificial respiration

	Naja sp. (neurotoxic cobras) (Walterinnesia sp.?)

Acute renal failure (usually secondary, rarely primary* renal effects of the venom)	Treatment of acute renal failure

	Bitis arietens⁴(?) Cerastes cerastes³(?)

Eyes: Intense local pain; blepharospasm; palpebral oedema; leucorrhoea; photophobia, clouding of vision, temporary blindness	see 'Clinical management', 'Local treatment'

	Naja sp. (spitting cobras)

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.	Follow ABCDE approach
	Follow ABCDE approach


	ColubridaeBungarus sp. Elapsoidea semiannulata Causus sp. Cerastes sp. Eristicophis macmahoni Macrovipera sp. Pseudocerastes persicus Vipera sp. Montivipera sp. Gloydius halys Various Naja sp.

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.
3	Additionally, thrombotic microangiopathy is observed in Echis sp. and Daboia palaestinae envenoming.
4	For Bitis arietans and Cerastes cerastes venom a primary nephrogenic effect is discussed (Warrell et al. 1975, Schneemann et al. 2004).