What are the other Names for this Condition? (Also known as/Synonyms)

• Common Sand Adder Snake Bite
• Long-Nosed Viper Snake Bite
• Vipera Ammodytes Snake Bite

What is European Nose-Horned Viper Snake Bite? (Definition/Background Information)

• The European nose horned viper (Vipera ammodytes) is a venomous snake found in many parts of mainland Europe including coastal regions, some countries belonging to the Commonwealth of Independent States (CIS), and a few areas in West Asia
• The snake belongs to the viper family or Viperidae and is known by a variety of names including the common sand adder and long-nosed viper. This stout-bodied terrestrial reptile preys on lizards, mice, and other smaller mammals, but can also climb trees to feed on eggs and young birds
• The European nose horned viper can grow to 2-3 feet in length, though some adult males are slightly longer. Males are generally grayish and sometimes brownish, but females come in a variety of colors including black, dark grey, brown, red-brown, green, and occasionally pink or yellow
• The snake may be identified by its characteristic nose-horn (a snout like scaly projection), long (half-inch) fangs, and a dark-shaded-to-black prominent zigzag band that runs along the body, almost continuously, against a lighter background
• During the hottest months of summer, it is nocturnal in behavior; although, in general, the snake is diurnal and mostly hunts during the day. The snake is known to hibernate during winters for about 2 to 6 months, depending on the geographical region it is found in
• Six sub-species of European nose horned vipers are described in the scientific literature (some researchers describe only 4 or 5):
  • Vipera ammodytes ammodytes, or the Western sand viper, it is found in parts of Austria, Italy, Romania, Bulgaria, Croatia, and Serbia
  • Vipera ammodytes gregorwallneri, which is mostly found in Austria and (former) Yugoslavia
  • Vipera ammodytes meridionalis, or the Eastern sand viper, it is observed in parts of Greece, Turkey, and some islands in the Ionian Sea
  • Vipera ammodytes montandoni, also called the Transdanubian sand viper, it is found in the European nations of Romania and Bulgaria
  • Vipera ammodytes ruffoi, which is reportedly found in Italian Alpine regions
  • Vipera ammodytes transcaucasiana, also called the Transcaucasian sand viper or Armenian sand viper, it is found in northern Turkey, Armenia, and Georgia (belonging to CIS). Some research indicates that this is a distinct snake species by itself
• The long-nosed viper is among the most venomous of all European snakes. This ambush predator inhabits a variety of terrain including dry grassy or rocky terrain with not too dense vegetation. It can also be found in fields, farms, gardens, and stone walls close to human population
• The European nose-horned vipers are generally languid and non-aggressive. They prefer flight over fight, or to hide and stay still, when it comes to confrontation with larger animals. However, as a warning sign, it can let out a loud hissing sound
• Due to its wide distribution across Europe, human interactions are not infrequent. European Nose-Horned Viper Snake Bite can result in fatalities due to systemic envenomation (venom injection through a bite) in the absence of treatment
• The signs and symptoms of European Nose Horned Viper Bite may include (at the bite site) pain and swelling, skin discoloration, and tissue destruction. As various body systems gets rapidly affected by the venom, it can result in widespread symptoms including clotting defects, low blood pressure, chest congestion, heart rhythm disorders, and kidney failure
• Early administration of suitable antivenom (or antivenin) is the mainstay of treatment. Apart from this, symptomatic treatment is necessary, which may include pain medication, respiratory support, blood transfusion, and peritoneal dialysis. The prognosis of European Nose-Horned Viper Snake Bite with prompt and effective therapy is usually good

Who gets European Nose-Horned Viper Snake Bite? (Age and Sex Distribution)

• European Nose-Horned Viper Snake Bite may occur to any individual exposed to the snake, in its natural habitat or near human development
• Individuals of any age and gender are prone to snake bites
• European nose horned vipers are distributed across several southeastern countries of continental Europe, some CIS nations, and a few pockets of West Asia, depending on the sub-species involved
• Some of the regions include parts of Austria, Italy, Hungary, Croatia, Slovenia, Bosnia and Herzegovina, Montenegro, Serbia, Romania, Bulgaria, Albania, Greece, Republic of Georgia, Armenia, Azerbaijan, Turkey, Iran, and Syria

What are the Risk Factors for European Nose-Horned Viper Snake Bite? (Predisposing Factors)

The risk factors for European Nose-Horned Viper Snake Bite include the following factors:

• Living or residing in areas where the European nose horned viper is found; especially, in the country side and rural regions of the endemic zones
• Near human dwellings, the snake can be found near boundary walls made of stone, neglected gardens, rocky piles, and dry lands with thin vegetation
• The snake can be found in vineyards, open fields, and agriculture lands posing a risk to farm workers, since it is mostly active during the day
• Walking barefoot or unprotected through dry, rocky terrain; the snake likes to bask in the sun and may be difficult to spot
• Venturing outdoors during the night
• The snakes are good swimmers and are also known to climb low-lying bushes, thus putting individuals at risk near water bodies and bushy thickets too
• Wildlife enthusiasts and scientific study groups, who explore the region
• Keeping them as pets
• Handling dead or live long-nosed vipers; intentionally or accidentally picking up the snake

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of European Nose-Horned Viper Snake Bite? (Etiology)

European Nose Horned Viper Snake Bite takes place when one comes into contact with the venomous nose-horned viper snake, usually unintentionally or inadvertently.

• Even though seemingly lethargic, the snake is dangerous and can strike quickly when it feels sufficiently threatened, injecting a potent hemotoxic-neurotoxic venom into the arm or leg
• The venom can cause the breakdown of proteins, dilation of blood vessels, and moderate to severe bleeding. This leads to local and systemic signs and symptoms depending on the sub-species involved and the amount of venom that is injected

Note: Not all European nose-horned vipers are of mild disposition. Some sub-species are sometimes known to attack almost immediately on the slightest of provocation.

What are the Signs and Symptoms of European Nose-Horned Viper Snake Bite?

The signs and symptoms of European Nose-Horned Viper Snake Bite can vary from one individual to another. The signs and symptoms depend on the age (whether child or adult), weight, and overall health status of the individual (whether having an underlying condition or illness). Also, the signs and symptoms vary according to the potency and amount of venom injected.

The common signs and symptoms of European Nose-Horned Viper Bite that may develop within a period of few hours may include:

• Severe pain at the bite site; presence of noticeable fang marks
• Skin discoloration and swelling (hemorrhagic edema) that slowly involves a wider region
• Blistering of skin (like formation of bubbles)
• Bleeding from the wound
• Swollen lymph nodes
• Swollen tongue, lips, and parts of one’s face
• Breathing difficulties
• Nausea and vomiting, vomiting of blood
• Blood in urine
• Abdominal pain and diarrhea
• Sweating
• Death of tissue (or necrosis) around the affected region or limb, observed within a few days
• Low blood pressure
• Fainting, dizziness
• Weakness and malaise
• Partial consciousness or unconsciousness

Some of the systemic signs and symptoms may include:

• Heart-related abnormalities such as slow or fast ‘resting heart rate’
• Decreased blood platelets resulting in clotting defects
• Internal hemorrhage and gastrointestinal bleeding
• Anemia due to spontaneous bleeding
• Acute kidney injury or kidney failure
• Pulmonary congestion
• Neurological symptoms

Note: 

• In some cases, the fang marks may not be pronounced or even visible on the skin. Sometimes only small scratch marks or lacerations may be observed. Thus, any contact with a European nose horned viper merits immediate medical attention
• Severe anxiety may also result in some misleading symptoms of snakebites, such as sweating, fatigue, and shock, even when no bite has taken place (the individual may be imagining), or when it is a dry bite. Nevertheless, even in suspect cases, the presence of any such symptoms requires the attention of a qualified medical professional
• Also, if the individual has been treated using alternative/native medicines, it may present additional confusing symptoms. Thus, it is important to always consult a qualified healthcare provider promptly

How is European Nose-Horned Viper Snake Bite Diagnosed?

European Nose Horned Viper Snake Bite may be diagnosed using the following tests and exams:

• Complete physical examination with comprehensive evaluation of medical history; a physical examination of the affected site by the physician may be normally sufficient to diagnose a snake bite
• The individual may be asked to provide an account (history) of the events that occurred (what took place and how), if possible
• Assessment of the signs and symptoms exhibited by the individual may be carefully observed
• Blood tests that may include: (many of these tests are repeated over the course of treatment)
  • Complete blood count (CBC) with differential and platelet count
  • White blood cell count
  • Hematocrit blood test: Hematocrit is the proportion of blood that is made up of red blood cells
  • Prothrombin time (PT) and partial thromboplastin time (PTT) tests
  • Fibrinogen blood test
  • Lactate dehydrogenase (LDH) test
  • Calcium and phosphorus blood tests
  • Serum electrolytes including blood urea nitrogen (BUN) and creatinine levels
  • Arterial blood gas
• Urine test or urinalysis to test for free protein, myoglobin, and hemoglobin levels
• Continuous urine output monitoring is helpful to determine damage to the kidneys, if any
• Electrocardiogram (ECG)
• Kidney function test
• Liver function test
• Nerve conduction studies and neurological evaluation

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of European Nose-Horned Viper Snake Bite?

The complications of European Nose Horned Viper Snake Bite are uncommon, but may include:

• Multiple bites, causing injection of a large quantity of venom
• Impaired blood coagulation resulting severe internal bleeding
• Disseminated intravascular coagulation (DIC) resulting in blood clot formation in the body
• Severe deep tissue and muscle damage of the affected leg or hand, which can result in superimposed infections and gangrene formation
• Increased pressure causing compartment syndrome, which is an urgent medical condition
• Loss of limb function, necessitating amputation
• The snake toxin can damage the muscle resulting in muscle breakdown known as rhabdomyolysis. Extensive muscle breakdown can lead to a variety of complications including kidney failure
• Severe chest congestion and respiratory distress
• Severe shock and convulsions
• Flaccid paralysis
• Seizures and coma
• Kidney failure

Presence of misleading symptoms due to fear and anxiety, which may be also aggravated by those around the individual, such as one’s family members, can sometimes result in inappropriate or over-treatment.

Antivenom reactions:

• Some individuals may develop an allergic reaction, such as anaphylaxis, to the antivenom that may be serious. This may develop within 10 minutes or even after 6 hours, typically starting with itchiness over the scalp and other skin areas
• Life-threatening anaphylactic reactions that require immediate medical treatment may include:
  • Low blood pressure or hypotension
  • Bronchospasm causing narrowing of the airways (bronchi) resulting in breathing difficulties
  • Angioedema: Swelling of skin tissue layers at various locations including the throat, causing speaking and breathing difficulties
• Serum sickness may develop as a complication of antivenom therapy causing fever, nausea, itchy skin, muscle and joint pain, etc. It may develop after 4 days or even 2 weeks (average 7 days) following the administration of antivenom serum

Cardiovascular, hematological, and kidney abnormalities can result in severe complications including death.

How is European Nose-Horned Viper Snake Bite Treated?

All snake bites should be considered as medical emergencies and evaluated by trained medical professionals, as soon as possible; the first 6-8 hours are particularly vital for preventing life-threatening symptoms. Failure to obtain early assessment and management from the highest level of care (available within the community) may potentially result in severe complications and death.

The following measures may be considered in the treatment of European Nose Horned Viper Snake Bite, based on the medical evaluation of a trained healthcare professional:

• Administration of Ringer's lactate solution (to keep the patient well-hydrated)
• Administration of anti-snake venom (ASV) to neutralize the venom through slow intravenous injection or infusion method
• Address any signs or early allergic reaction: A close observation of the patient is necessary for a minimum of 60 minutes immediately following antivenom administration, to detect early allergic reactions, if any
• Periodic blood and urine tests are undertaken for 12-24 hours or more
• Tetanus vaccination is usually required, if it is not up to date
• The patient is generally admitted and placed in an ICU setting and monitored for at least a day following the abatement of symptoms; the patient has to be rested and kept warm
• Strict bed rest to prevent trauma may be advocated in case of hemostatic abnormalities that arises from a hemotoxic/cytotoxic venom (the venom can result in increased bleeding tendencies leading to substantial blood loss even to minor trauma)
• If necessary, blood and plasma transfusions for severe cases
• Medications to increase blood pressure such as vasopressor drugs and plasma expanders
• Peritoneal dialysis for acute kidney failure
• Providing life support, such as ventilation assistance and treatment for shock, for those with severe symptoms leading to potential organ failure
• Pressure management (using wick catheter or appropriate pressure devices) of affected limb for compartment syndrome; in rare cases, it may merit a fasciotomy
• Rehabilitation of the affected limb through physical therapy
• Unless infection or tissue necrosis is observed, the administration of prophylactic antibiotics is generally not recommended in snake bites. However, the healthcare provider will determine whether antibiotics administration is necessary or not, based on one’s individual circumstances

Note:

• Consultation with a medical toxicologist is recommended for all cases requiring the administration of anti-snake venom
• Even though antivenom therapy is the key treatment for systemic envenomation; on its own, it may never be adequate enough to completely resolve the condition. Other supportive and symptomatic measures are always necessary to save the patient
• The dose of antivenom does not vary for a child, adult, or even for a pregnant woman, since the snake typically injects the same quantity of venom into an individual
• Gynecological evaluation may be necessary for pregnant women bitten by snakes to evaluate the health of the fetus
• In many instances, the type of venomous snake involved in the bite is unknown; hence, all vital organs and systems should be closely monitored and treated appropriately, as necessary

How can European Nose-Horned Viper Snake Bite be Prevented?

European Nose-Horned Viper Snake Bite may be avoided by:

• Learning to recognize European nose horned vipers using the following tips:
  • Presence of dark/black zigzag band along the length of the body, seen usually against a light background
  • A horn-like projection, about 5 mm in size, on its nose
  • The snake can hiss loudly when it feels threatened
  • It stays perfectly still, until approached very closely or disturbed
  • The fangs of the snake are long and can reach about 13 mm (half inch) in size
• If you spot a European Nose Horned Viper, step back slowly and keep a safe distance of at least 8-10 feet or more (between yourself and the snake)
• Avoiding being outdoors at night in forested areas; be careful while camping outdoors
• Be particularly vigilant during agricultural activities, harvest times, and rainy periods
• Avoid tall grassy areas or thick bushes; if you plan to explore the area, use heavy boots and thick pants
• Be on the lookout for snakes and other animals while trekking or hiking; also, if you are with a pet, do not allow the pet to wander away
• Always allow snakes crossing your path the right of way
• Always stay on established paths and clearings, while walking in the woods, grasslands, or through thick undergrowths
• Avoid picking up firewood sticks, stones, or rocks without checking the area for any concealed creatures
• Always step on top of large rocks and fallen trunks; never place one’s foot by the side of big rocks and rotting tree stumps. Some snake species are known to take shelter or warm themselves on the sides, during the day
• Always check before sitting on stone walls, dead tree logs, stumps, or a pile of rocks; use a stick to stir or probe around the area
• Do not reach out to move or hold bushes or tree branches without properly examining them for any camouflaged creatures such as snakes
• Watch where you place your hands while climbing a ledge, trees, rocky slopes, or mountains
• While walking through areas with thick undergrowth, pay attention to the sound of birds or monkeys that may warn of potential dangers such as snakes
• While walking outdoors at night, use a flashlight or lamp and make constant noise (singing or talking to others) or large stomping sounds that may alert the snake to move away from the region
• While walking through tall grass or undergrowth, try to walk one behind the other in a single file
• Avoid snake-infested regions or even walking on cleared forest paths and roads during nights, immediately after heavy rains that may flush snakes out to the open, due to flooding of their burrows and holes
• Keep homes and surrounding areas clean and clear of rubbish or leafy piles, termite mounds, even building materials (like bricks and large stones)
• Cut tall and unkempt grass or low-lying shrubs and bushes around dwelling areas that provides hiding places for snakes and other rodents
• Carry a snake bite kit, if possible, when traveling through areas containing highly venomous snake species
• Never intentionally run over snakes on the road while on a vehicle (cycle, other 2-wheeler, or 4-wheeler); the injured snake lying on the road may strike other pedestrians, or get entangled in the vehicle and be carried to the parking lot or even inside one’s garage
• Avoid playing with or teasing snakes such as by touching their tails
• Do not pick up dead snakes - they may be poisonous and still bite through a reflex action
• Do not reach into dark nooks/corners/recesses with your bare hands/foot
• Educate local communities on how to identify such venomous snakes, their activities, habitats, whether they are ‘day-snakes’ or ‘night-snakes’, their weather preferences, recognize bite symptoms, and how to avoid encounter with snakes
• Teach and educate children about the dangers and importance of snakes
• Completely avoid any form of native or traditional treatment for snake bites

Both large and small snakes have the potential for severe envenomation; hence, all snake bites should be treated promptly and appropriately.

What is the Prognosis of European Nose-Horned Viper Snake Bite? (Outcomes/Resolutions)

• The prognosis of European Nose Horned Viper Snake Bite is dependent on the type of snake sub-species, site of bite, overall health of the individual, and promptness of medical response. In many cases, the prognosis is good with immediate treatment and administration of antivenom
• Without treatment or access to proper healthcare, deaths from severe complications, such as internal bleeding, organ failure, circulatory shock, and heart conditions, have been reported

Additional and Relevant Useful Information for European Nose-Horned Viper Snake Bite:

• It is not advisable to pick up the European nose horned viper by its neck without adequate training, since these reptiles have strong muscles; they are known to quickly jerk, break-free, and inflict painful bites
• In some cases, the snake bite may be a ‘dry bite’, meaning that even though there is a bite mark, no venom injection occurs. However, even for dry bites, the patient must be placed under observation and monitored closely for a period ranging anywhere from 12-24 hours, prior to discharge

Depending on the geographical region, either monovalent antivenom or polyvalent antivenom may be administered for systemic envenomation. Monovalent antivenom neutralizes venom of a single snake species only, whereas polyvalent antivenom can neutralize the venom of several snake species.

The snake venom is a highly complex mix of several proteins, enzymes, amino acids, peptide chains, fats, and even certain metals. The bite causing venom injection into the body may be categorized as:

• Intramuscular injection: Long-fanged snakes have a potential for injecting venom directly into the muscles (this is highly infrequent though)
• Intraperitoneal injection: When the snake bite involves the stomach or abdomen region
• Intravenous injection: In very rare cases, the snake fangs may inject venom directly into a blood vessel, releasing venom directly into blood (posing an even greater danger than normal snake bites)
• Subcutaneous injection: A majority of snake bites involve the subcutaneous skin layers (venom is injected just below the skin surface)