Emergency & clinical flowcharts
| Signs and symptoms1 | Emergency medical treatment | Identification of the cause3 | Antivenom4 | |||
| Possible cause2 | ||||||
| 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:
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Antivenom efficacy8 |
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| Echis sp. Daboia russelii |
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| Generalised oedema → hypovolaemia → hypovolaemic shock (autopharmacological effects of the venom: increased capillary permeability) | Treatment of the hypovolaemia/hypovolaemic shock | |||||
| Daboia russelii siamensis | ||||||
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Pulmonary oedema, cerebral oedema (autopharmacological effects of the venom: increased capillary permeability) |
Treatment of the non-cardiogenic pulmonary oedema, treatment of the cerebral oedema |
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| Daboia russelii siamensis | ||||||
| Extensive local swelling possibly involving the trunk → hypovolaemia → hypovolaemic shock (local effects of the venom: regionally increased capillary permeability) |
Treatment of the hypovolaemia/hypovolaemic shock |
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Trimeresurus sp. (according to the former classification) |
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| Systemic bleeding → hypovolaemia → haemorrhagic shock (haemostatic effects of the venom) | Treatment of the haemorrhage-induced hypovolaemia/haemorrhagic shock | |||||
| Daboia russelii Calloselasma rhodostoma Trimeresurus sp. (according to the former classification) Hypnale sp. |
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| Intracranial bleeding → focal neurological deficits, coma, meningismus (haemostatic effects of the venom) |
Treatment of intracranial bleeding | |||||
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Daboia russelii5 |
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| 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 | |||||
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Bungarus sp |
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| Myalgia: spontaneous, with active/passive movement, upon pressure, ECG changes (hyperkalaemia), signs of paralysis, urine colour (differential diagnosis haemoglobinuria), renal failure (muscular effect of the venom: rhabdomyolysis) | Treatment of the hyperkalaemia, prevention and treatment of the acute renal failure, treatment of the respiratory insufficiency/ respiratory failure
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Bungarus niger (and possibly other kraits) |
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| Myocardial symptoms, cardiac dysrhythmias, ischaemia (ECG), cardiac insufficiency, heart failure (usually secondary, rarely primary cardiac effects of the venom) | Treatment of the cardiac disturbance | |||||
| (Naja sp.) (Calloselasma rhodostoma) |
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| Acute renal failure (usually secondary, rarely primary renal effects of the venom) | Treatment of the acute renal failure | |||||
| Daboia russelii Hypnale sp. |
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| No/insufficient data, no clinically relevant cases of envenoming known | ||||||
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Azemiops feae9 |
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| 1 | See also the 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 | Identification of the cause insofar as is necessary for differential treatment (see "Essentials of the management of envenoming and poisoning: 3. What level of identification of the animal that caused the accident is necessary?"). |
| 4 | See "Essentials of the management of envenoming and poisoning: 9. How is the appropriate antivenom chosen? When is it administered?". |
| 5 | Acute pituitary insufficiency (in particular D. russelli siamensis). |
| 6 | Local symptoms of envenoming in the eyes (Spitting cobras: Naja mandalayensis, Naja philippinensis. Naja samarensis, Naja siamensis, Naja sputatrix, Naja sumatrana and to some extend also Naja kaouthia). |
| 7 | Neurological effects with signs of paralysis, including the respiratory musculature, of varying severity. Very significant and well documented with Naja naja and Naja philippinensis. With other Naja species the local effects often dominate (e.g. Naja kaouthia). |
| 8 | If clinical information regarding the efficacy of an antivenom is available, it is presented in the relevant Biomedical database entry. |
| 9 | These cases are also dealt with in accordance with the corresponding problem-oriented section "Diagnosis & Treatment". |