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  5. Clinical entry: Dendroaspis sp.

Clinic: Dendroaspis sp.

Examine for venom effects

Local Effects

  • Mild / minimal

Neurological effects

  • Descending flaccid paralysis
    • Ptosis (not to be mixed up with tiredness / drowsiness; test: lid retraction with upward gaze).
    • Double vision (external ophthalmoplegia)
    • Difficulties to swallow (dysphagia) (bulbar paralysis) > inhalation of vomitus!
    • Difficulties to lift the head when lying on the back (‘broken neck syndrome’)
    • Cyanosis, shallow breathing, respiratory arrest (respiratory paralysis); respiratory arrest may be precipitated by obstruction of the upper airway by the paralysed tongue or inhaled vomitus. 
    • Weakness or loss of voluntary movement; movements of digits may still be possible, allowing the patient to communicate.
    • Loss of consciousness and generalized convulsions caused by hypoxaemia in patients who have respiratory paralysis.
  •   Autonomic dyfunction
    • Nausea
    • Vomiting
    • Sweating

Species-specific envenoming pattern

The assessment of the envenoming pattern is based on the data from publication in which the identification of the snakes is clearly specified and in accordance with accepted criteria.

   Local effects1 Neurological effects2 
Dendroaspis angusticeps    
Dendroaspis jamesoni    
Dendroaspis polylepis    
Dendroaspis viridis    

1Local effect

Mild / minimal (Warrell 2023, WHO 2010a).

2Neurological effects 

Neuromuscular toxicity
Descending flaccid paralysis including respitroty muscles.
Autonomic neurotoxicity
Nausea, vomiting, sweating.

For references on the various venom effects, see 'Species-specific evidence' below.

Clinical management

See also Clinical Management: Central and Southern Africa

for advice on post-First Aid measures, diagnosis (clinical, laboratory) and treatment (supportive, antivenom).

First Aid

Neurological effects, which appear quickly and progress rapidly, can lead to death within a short time (Hilligan 1987, Visser and Chapman 1978).
Gradual removal of a tourniquet in two patients to avoid sudden venom influx and respiratory arrest (Pelle et al. 2022).
Release of any type of tourniquet follow link above.

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care
WHO (2010b) 

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

Follow SAMPLE & ABCDE ApproAch

Obey Dendroaspis sp. - specific features

see

  • 'Species-specific envenoming pattern above'.

and


Key issues:

Respiratory failure
Lifesaving in neurotoxic snakebite envenoming (as supportive treatment and when Antivenoms are not available or fail):
Airway management
Breathing: Oxygen⇨assisted ventilation⇨mechanical ventilation

Specific treatment (antivenoms)

References

  • National Snakebite Management Guidelines Kingdom of Eswatini 2021 https://eswatiniantivenom.org/newsite/wp-content/uploads/2021/12/WHO-Snake-Bite-Treatment-Protocol-Manuscript-A4.pdf 
  • Pelle RP, Engelbrecht A, Lalloo V. Case Report: Safe Tourniquet Removal in Black Mamba (Dendroaspis polylepis) Bites. Am J Trop Med Hyg. 2021 Nov 1;106(1):338-341. PMID: 34724630; PMCID: PMC8733543. https://doi.org/10.4269/ajtmh.21-0374
  • Warrell DA. Venomous and poisonous animals.In: Farrar J, Garcia PJ, Hotez T, Junghanss T, Kang G, Laloo D (eds.). Manson’s tropical diseases. 24th ed. Elsevier; 2023.
  • WHO (2010a) Guidelines for the prevention and clinical management of snakebite in Africa. https://www.who.int/publications/i/item/9789290231684
  • WHO (2010b) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139
  • WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured (2018)  https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured
  • WHO ABCDE Approach  https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
  • WHO Snakebite Information and Data Platform  https://www.who.int/teams/control-of-neglected-tropical-diseases/snakebite-envenoming/snakebite-information-and-data-platform

Species-specific evidence

Dendroaspis angusticeps

Case reports

South Africa

  • Visser and Chapman 1978.

Dendroaspis jamesoni

Case reports

Central African Republic

  • Le Gac and Lepesme (1940)

Dendroaspis polylepis

Review of the literature

  • Aalten et al. (2021)
    Publication up to 2020 (PubMed, Embase, Scopus, Saninet)
    29 cases fulfilled quality criteria.

Case reports

Zimbabwe

  • Blaylock (1982a)
  • Saunders (1980)

Transvaal

  • Crisp (1985)
  • Krengel and Walton (1967)
  • Louw (1967)


Swaziland

  • Hilligan (1987)

South Africa

  • Visser and Chapman (1978)
    10 cases, of which 5 were fatalities.

Captive snake

  • Greene et al. (2023)
    1 patient

Dendroaspis viridis

Case reports

  • Casale and Patel (1974)

Guinea

  • Lefrou (1951)

Nigeria

  • Gray (1962)

Côte d'Ivoire

  • Chippaux et al. (1977)

Signs & symptoms

Local effects
Local pain. Minor (erythema, mild oedema) or no local findings (Chippaux et al. 1977, Greene et al.. 2023, Hilligan 1987, Krengel and Walton 1967).

Neurological effects
Cranial nerve deficits (ptosis, dysarthria, dysphagia), paralysis of the musculature of the extremities and the respiratory musculature (Casale and Patel 1974, Chippaux et al. 1977, Crisp 1985, Gray 1962, Greene et al. 2023, Krengel and Walton 1967, Lefrou 1951, Le Gac and Lepesme 1940, Louw 1967, Visser and Chapman 1978).
Muscle fasciculations, muscle spasms (Chippaux et al. 1977, Krengel and Walton 1967, Visser and Chapman 1978, Blaylock 1982).

Other signs & symptoms
Vomiting, sweating, tachycardia, arterial hypotension, shock (Hilligan 1987); neither of the 2 patients had neurological (somatic) deficits! Spasmodic epigastric pain (Gray 1962, Chippaux et al. 1977, Krengel and Walton 1967, Visser and Chapman 1978).

Case fatality rate
Mortality high in the absence of medical care if significant amounts of venom have been injected (respiratory failure). Fatalities (Gray 1962, Strover 1967, Visser and Chapman 1978: report of 5 fatalities: 4/5 died within 3–8 h).

Morbidity
If the victim survives the acute phase, there are generally no sequelae.

First aid

Compression-immobilisation method. Neurological effects, which appear quickly and progress rapidly, can lead to death within a short time (Hilligan 1987, Visser and Chapman 1978).

Gradual removal of a tourniquet in two patients to avoid sudden venom influx and respiratory arrest. (Pelle et al. 2022).

Treatment (symptomatic)

Endotracheal intubation and artificial respiration (Visser and Chapman 1978).

References

  • Aalten M, Bakhuis CFJ, Asaggau I, Wulfse M, van Binsbergen MF, Arntz ERAN, Troenokarso MF, Oediet Doebe JLR, Mahamuud U, Belbachir L, Meurs M, Kovalenko NA, van der Heyden MAG. The clinical course and treatment of black mamba (Dendroaspis polylepis) envenomations: a narrative review. Clin Toxicol (Phila). 2021 Oct;59(10):860-868. Epub 2021 Jul 5. PMID: 34219550. https://doi.org/10.1080/15563650.2021.1943427
  • Blaylock, R. S. M. (1982a) Snake bites at Triangle Hospital January 1975 to June 1981. Centr. Afr. J. Med. 28: 1-11
  • Chippaux, J. P., B. Courtois, D. Roumet, R. Eyebiyi (1977) Envenimation par morsure de mamba (Dendroaspis viridis) à propos d’une obsérvation à évolution favorable. Méd. trop. 37: 545-549
  • Casale, F. F., S. M. Patel (1974) Elapid snake bite. Brit. J. Anaesth. 46: 162
  • Crisp, N. G. (1985) Black mamba envenomation. S. Afr. med. J. 68: 293-294
  • GRAY HH. Green mamba envenomation: case report. Trans R Soc Trop Med Hyg. 1962 Sep;56:390-1. PMID: 13949980. https://doi.org/10.1016/0035-9203(62)90011-1
  • Greene SC, Cue K, Khan R, Gilbert MB, Rahimi J. Captive Black Mamba (Dendroaspis Polylepis) Bite Leading to Respiratory Failure. J Emerg Med. 2023 Mar;64(3):311-314.  Epub 2023 Mar 14. PMID: 36925444. https://doi.org/10.1016/j.jemermed.2023.01.011
  • Hilligan, R. (1987) Black mamba bites, a report of 2 cases. S. Afr. med. J. 72: 220-221
  • Krengel, B., J. Walton (1967) A case of mamba bite. S. Afr. med. J.: 1150-1151
  • Lefrou, G. (1951) Deux cas de morsure par le serpent Dendraspis viridis suivis de guérison. Bull. Soc. Pathol. Exotique: 234-239
  • Le Gac, P., P. Lepesme (1940) Sur un cas d’envenimation non mortel par morsure de Dendraspis (colubridé protéroglyphe). Bull. Soc. Pathol. exot.: 256-259
  • Louw, J. X. (1967) Specific mamba antivenom-report of survival of 2 patients with black mamba bites treated with this serum. S. Afr. med. J.: 1175
  • Pelle RP, Engelbrecht A, Lalloo V. Case Report: Safe Tourniquet Removal in Black Mamba (Dendroaspis polylepis) Bites. Am J Trop Med Hyg. 2021 Nov 1;106(1):338-341. PMID: 34724630; PMCID: PMC8733543. https://doi.org/10.4269/ajtmh.21-0374
  • Saunders, C. R. (1980) Report on a black mamba bite of a medical colleague. Centr. Afr. J. Med. 26: 121-122
  • Visser, J., D. S. Chapman (1978) Snakes and snake bite. Venomous snakes and management of snake bite in Southern Africa. Purnell, Cape Town: 152