Clinic: Cerastes sp.
Examine for venom effects
Autopharmacological effects
- Nausea, vomiting
- Sweating
- Urticaria, angiooedema
- Arterial hypotension / hypovolaemic shock (transient, recurrent; immediate; delayed (CLS))
- Diarrhoea
- Bronchospasm
Local Effects
- Pain
- Tender local (spreading) swelling
- Blistering
- Lymphangiopathy and lymphadenopathy
- Necrotic skin
Haematological effects
- Clotting disturbances:
- Bleeding from the fang marks and from injuries, in particular ones that are not located in the region in which venom application occurred.
- Bleeding into the skin (ecchymosis, petechiae)
- Gingival bleeding, bleeding from the nose, conjunctiva, haematemeis, bleeding per rectum, including melaena, haematuria, haemoptysis.
- Oliguria, anuria (VICC / AKI)
- Bleeding and/or haemolytic anaemia:
- Arterial hypotension (haemorrhagic shock)
- Acute abdomen (intra-abdominal bleeding!)
- Loin pain/renal bed sensitive to percussion (ischaemia, renal haemorrhage!)
- Local neurological signs, meningism, coma (intracranial bleeding!)
- Pale sclera (bleeding, haemolysis!)
- Oliguria, anuria (arterial hypotension / AKI!)
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
effects |
Haematological effects | |||
| Bleeding | Coagulopathy | Thrombotic
microangiopathy |
||
| Cerastes cerastes | ||||
1Local effects
Cerastes vipera
Local pain, minor local swelling (Ben-Baruch et al. 1986, Zimmerman et al. 1981).
Cerastes cerastes
Local pain, local swelling (the patient had incised the wound himself and tried to suck out the venom) (Prod'hom, Stahel, Thiebaud 1987, pers. comm.).
Haemorrhagic vesicle, marked swelling of the entire leg (Lifshitz et al. 2000).
Haemorrhagic wound, marked swelling of the entire hand extending to the wrist (Lifshitz et al. 2002).
Local pain, local swelling extending to the entire bitten limb. Local necrosis (Schneemann et al. 2004).
Haematological effects
Cerastes cerastes
Severe bleeding (bleeding from the venipuncture sites, haematemesis, rectal bleeding) starting 24h after being bitten and lasted 5 days requiring repeated blood transfusions and blood products (Lifshitz et al. 2000).
Bleeding from the venipuncture sites (Lifshitz et al. 2002).
Intracerebral haemorrhage in one of the reported patients, haemolysis in both (Schneemann et al. 2004).
Ischemic cerebrovascular accidents in 3 patients with extensive local swelling, disseminated intravascular coagulopathy, increased fibrinolysis, thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure (Rebahi et al. 2014).
1. Haemostasis
Type of haemostatic defect
Procoagulative and fibrinolytic activity of C. cerastes and C. vipera venom has been demonstrated (Labib et al. 1981); thombocytopenia.
Thrombotic microangiopathy
Described by Schneemann et al. (2004) in two patients, including renal failure requiring haemodyalisis in both. Also, Rebahi et al. (2014).
Other effects
Autopharmacological effects
Not explicitly mentioned in available reports.
Renal effects
Based on available evidence: secondary.
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
Any type of tourniquet follow link above.
Local treatment
Pain control
Tetanus prophylaxis
Standard wound care
WHO (2010a,b)
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
- ICRC Basic Emergency Care: approach to the acutely ill and injured (SAMPLE and ABCDE approach: first module)
Obey cerastes sp. - specific features
see
- 'Species-specific envenoming pattern above'.
and
Specific treatment (antivenoms)
References
see also references in section 'species specific evidence' (below).
- Labib, R. S., N. H. Azab, N. W. Farag (1981) Effects of Cerastes cerastes (Egyptian sand viper and Cerastes vipera (Sahara sand viper) snake venoms on blood coagulation: separation of coagulant and anticoagulant factors and their relation with arginine esterase and protease activites. Toxicon 19: 85-94
- Schneemann M, Cathomas R, Laidlaw ST, El Nahas AM, Theakston RD, Warrell DA. Life-threatening envenoming by the Saharan horned viper (Cerastes cerastes) causing micro-angiopathic haemolysis, coagulopathy and acute renal failure: clinical cases and review. QJM. 2004 Nov;97(11):717-27. PMID: 15496528. https://doi.org/10.1093/qjmed/hch118
- WHO-ICRC Basic Emergency Care: approach tothe 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 (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 Snakebite Information and Data Platform
https://www.who.int/teams/control-of-neglected-tropical-diseases/snakebite-envenoming/snakebite-information-and-data-platform - 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.
- Warrell DA, Williams DJ. Clinical aspects of snakebite envenoming and its treatment in low-resource settings. Lancet. 2023 Apr 22;401(10385):1382-1398. PMID: 36931290. https://doi.org/10.1016/s0140-6736(23)00002-8
Species-specific evidence
Cerastes vipera
Israel
- Ben-Baruch et al. (1986)
7 patients.
- Zimmerman et al. (1981)
2 patients.
Cerastes cerastes
Captive snakes
- Schneemann et al. (2004)
2 patients; identification: morphological. -
Prod'hom, Stahel, Thiebaud 1987, pers. comm.
Israel
-
Lifshitz et al. (2000)
1 patient; identification: morphological. -
Lifshitz et al. (2002)
1 patient; identification: morphological.
Morocco
- Rebahi et al. (2014)
3 patients; identification: "by its distinctive supraorbital horns".
Arab countries of the Middle East
- See also: Amr et al. (2020)
References
- Amr ZS, Abu Baker MA, Warrell DA. Terrestrial venomous snakes and snakebites in the Arab countries of the Middle East. Toxicon. 2020 Apr 15;177:1-15. Epub 2020 Jan 27. PMID: 32001320. https://doi.org/10.1016/j.toxicon.2020.01.012
- Ben-Baruch, N., A. Porath, A. Kleiner-Baumgarten, A. Keynan (1986) Cerastes vipera envenoming– a report of seven cases. Trans. roy. Soc. trop. Med. Hyg. 80: 664
- Lifshitz, M., J. Kapelushnik, M. Ben-Harosh, S. Sofer (2000) Disseminated intravascular coagulation after Cerastes vipera envenomation in a 3-year-old child: A case report. Toxicon 38: 1593-1598
- Lifshitz, M., H. Kastel, I. Harman-Boehm (2002) Cerastes cerastes envenomation in an 18 year old female: A case report. Toxicon 40: 1227-1229
- Rebahi H, Nejmi H, Abouelhassan T, Hasni K, Samkaoui MA. Severe envenomation by Cerastes cerastes viper: an unusual mechanism of acute ischemic stroke. J Stroke Cerebrovasc Dis. 2014 Jan;23(1):169-72. Epub 2012 Sep 8. PMID: 22964421. https://doi.org/10.1016/j.jstrokecerebrovasdis.2012.07.008
- Schneemann M, Cathomas R, Laidlaw ST, El Nahas AM, Theakston RD, Warrell DA. Life-threatening envenoming by the Saharan horned viper (Cerastes cerastes) causing micro-angiopathic haemolysis, coagulopathy and acute renal failure: clinical cases and review. QJM. 2004 Nov;97(11):717-27. PMID: 15496528. https://doi.org/10.1093/qjmed/hch118
- Zimmermann, J., G. Mann, H. Y. Kaplan, U. Sagher (1981) Envenoming by Cerastes vipera-a report of two cases. Trans. roy. Soc. trop. Med. Hyg. 75: 702-705