VAPAGuide - Flowcharts

Bitis arietans

?

Cardiac dysrhythmias, ischaemia (ECG)

Arterial hypotension, pulmonary oedema

Heart failure

Bitis arietans Echis sp. Daboia palaestinae
Minutes (to hours)

Nausea, vomiting, abdominal pain, diarrhoea (urticaria, angio-oedema) (bronchospasm) arterial hypotension	Bitis arietans Daboia palaestinae
	Hours

	Non-cardiogenic pulmonary oedema Cerebral oedema	Generalised oedema

		Hypovolaemia/hypovolaemic shock

Cardiovascular failure

Naja haje (N. anchietae?)
Walterinnesia sp.?
Naja oxiana

Minutes to hours

Cranial nerve deficits (ptosis, ophthalmoplegia, dysphagia, dysarthria)

Paralysis of the skeletal musculature including the respiratory musculature

Respiratory failure

Bitis arietans

? Cerastes cerastes

Hours to days

Flank pain, renal bed sensitive to percussion

Urinary output <400 ml/24 h

Renal failure

Causus sp. Cerastes sp. Naja nigricollis¹ Naja pallida¹ Walterinnesia sp. Bitis arietans Echis sp. Daboia palaestinae
Minutes (to hours)

Local pain and swelling

Painful swelling of the regional lymph nodes

Naja nigricollis¹ Naja pallida¹ Bitis arietans		Naja nigricollis¹ Naja pallida¹ Bitis arietans Daboia palaestinae
Days		Hours

		Extensive swelling

		Hypovolaemia

Necrosis Loss of function of extremities Loss of extremities

¹ Can also cause local symptoms of envenoming in the eyes (Spitting cobras).

Echis sp. Cerastes cerastes	Naja nigricollis Bitis arietans Cerastes cerastes	Daboia palaestinae¹
Hours

CT↑	Tc↓

Gingival bleeding

Bleeding from wounds remote from the site of the bite

Haematemesis, bleeding per rectum, haematuria

Systemic bleeding		Focal neurological deficits, meningismus, coma

Hypovolaemia/haemorrhagic shock

Cardiovascular failure	Renal failure	CNS failure

¹ ? Effect of haemorrhagins.

CT↑: abnormal clotting time (or more complex clotting test).

Tc↓: thrombopaenia, impaired platelet function.

Emergency & clinical flowcharts