Early symptoms of systemic envenomation include goose bumps, sweating, tingling around the mouth and tongue, twitching (initially facial and intercostal), salivation, watery eyes, elevated heart rate, and elevated blood pressure. As systemic envenomation progresses, symptoms include nausea, vomiting, shortness of breath (caused by airway obstruction), agitation, confusion, writhing, grimacing, muscle spasms, pulmonary oedema (of neurogenic or hypertensive origin), metabolic acidosis, and extreme hypertension. The final stages of severe envenomation include dilation of the pupils (often fixed), uncontrolled generalised muscle twitching, unconsciousness, elevated intracranial pressure, and death. Death generally is a result of progressive hypotension or possibly elevated intracranial pressure consequent on cerebral oedema.