Version June 2024
| Site of action | Clinical features | Ancillary testing | Management |
| Local tissue | Pain Fang marks Swelling Blistering Ecchymoses Tissue necrosis Lymph node swelling and tenderness | Antivenom Manage signs of compartment syndrome (Rare) | |
| Neuromuscular junction | Ptosis Diplopia Dysphagia Bulbar palsy: "drooling" pooling of secretions in pharynx Dyspnea Limb weakness | Positive neostigmine trial indicates post-synaptic paralysis responsive to antivenom and anticholinesterase* Low maximal inspiratory and expiratory forces | Antivenom Anticholinesterase (eg, neostigmine)* Maintain and support airway and breathing, as needed |
| Coagulopathy | Epistaxis Gingival oozing Bleeding from venipuncture site Ecchymoses and bruising Clinically evident bleeding (hemoptysis, hematemesis, hematuria, intracranial hemorrhage) | Thrombocytopenia (Complete blood count) Anemia Prolonged INR or aPTT Decreased fibrinogen Increased fibrin degradation products or D-dimer 20-minute whole blood clotting test (resource-limited settings)¶ | Antivenom primary treatment Blood products (eg, whole blood, fresh frozen plasma, or platelets) only if life-threatening bleeding and, when available, after antivenom administration Heparin, aminocaproic acid not helpful |
| Shock | Hypotension Tachycardia Signs of poor perfusion (prolonged capillary refill, decreased urine output, altered mental status) | Central pressure monitoring | Antivenom Intravenous isotonic fluids (eg, normal saline) and vasoactive infusions to maintain perfusion pressure depending upon whether shock is hypovolemic, cardiogenic, or both |
| Rhabdomyolysis | Red or brown urine Oliguria | Rapid urine dipstick positive for blood with microscopic urinalysis showing no red blood cells Positive urine for myoglobin Increased serum creatine kinase, potassium, creatinine, and/or blood urea nitrogen EKG changes indicating hyperkalemia | Intravenous normal saline in volumes sufficient to reestablish urinary outputΔ Hemodialysis, as needed, for acute kidney injury
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