VAPAGuide - Flowcharts

Emergency & clinical flowcharts

Autopharmacological
effects

Local
effects

Haemostatic
effects

Neurological
effects

Muscular
effects

Cardiac
effects

Renal
effects

Daboia russelli Trimeresurus sp. (in the old taxonomic sense, in particular Protobothrops flavoviridis)
Minutes (to hours)

Nausea, vomiting, abdominal pain, diarrhoea (urticaria, angio-oedema) (bronchospasm) arterial hypotension






Cardiovascular failure

Bungarus sp.
Naja sp.
Ophiophagus hannah
Gloydius blomhoffii

Minutes to hours

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

Paralysis of the skeletal musculature including the respiratory musculature

Respiratory failure

Daboia russelli
Gloydius blomhoffii

Hours to days

Flank pain, renal bed sensitive to percussion

Urinary output <400 ml/24 h

Renal failure

Rhabdophis sp. Naja sp. Ophiophagus hannah Daboia russelli Gloydius sp. Deinagkistrodon acutus Trimeresurus sp. (according to the former taxonomic classification, in particular Protobothrops flavoviridis)
Minutes (to hours)

Local pain and swelling

Painful swelling of the regional lymph nodes

Naja sp. Ophiophagus hannah Agkistrodon sp. Deinagkistrodon acutus Trimeresurus sp. and Protobothrops sp. (in particular P. flavoviridis)		Extensive swelling

		Hypovolaemia

Necrosis Loss of function of extremities Loss of extremities

Gloydius sp.?
Bungarus niger (and possibly other kraits)?

Hours

Myalgia (at rest, with active/passive movement, upon pressure), dark urine, ECG changes

Signs of paralysis

Skeletal muscle necrosis

Rhabdophis sp. Daboia russelli Deinagkistrodon acutus Trimeresurus sp. (according to the former taxonomic classification)
Hours

Clotting time¹ abnormal ¹^{or more complex clotting tests}

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