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A Five-Year Experience of Poisonous Snake Bite Treatment in Eastern Taiwan

東台灣毒蛇咬傷治療之五年期經驗

Abstracts


Background: Although several studies have examined poisonous snake bites in Northern, Central, and Southern Taiwan, data on snake bites in Eastern Taiwan remain scant. Many mountainous areas of Eastern Taiwan are inhabited by numerous venomous snakes, and snake bites are a common problem. Insufficient infrastructure in these areas means that treatment may be delayed. Although medical treatment may be sufficient, some patients may require surgery because of tissue necrosis and infection. Aim and Objectives: Our hospital is the only medical center in Eastern Taiwan; insights into the characteristics of snake bites can improve clinical management. We previously reviewed the data of patients admitted from 2000 to 2004. The present study conducted 10 years later reviewed the data of patients from 2010 to 2015 to determine whether the epidemiology and treatment of snake bites have changed. Materials and Methods: We retrospectively recruited patients who were admitted for venomous snake bites from August 2010 to June 2015. Data were extracted from emergency room and outpatient department records as well as admission notes, outpatient records, and discharge summaries. We reviewed demographic information, snake species, clinical presentations, treatments, and outcomes. Data were analyzed using Pearson's chisquare test, Fisher's exact test, and the Mann-Whitney U test. Results: We enrolled 48 patients, of whom 35 (72.9%) were men and 13 (27.1%) were women. In our patients the species of snake were Naja atra (35%), Protobothrops mucrosquamatus (23%), Trimeresurus stejnegeri (19%), Deinagkistrodon acutus (6%), Bungarus multicinctus (2%), Daboia russelii siamensis (2%), and unknown (13%). Overall, 19 (40%) patients required surgery, including wound fasciotomy, wound debridement, and various types of reconstruction. Of patients bitten by cobras, 14 (82%) underwent surgery primarily for necrotizing fasciitis. Wound cultures were performed for all surgical patients, of whom approximately three-fourths were bitten by cobras. Common pathogens were Morganella morganii, Enterococcus spp., and Bacteroides fragilis. Antibiotic regimens initiated in the emergency room did not provide sufficient coverage for cultured pathogens. Conclusion: N. atra is responsible for the majority of hospital admissions for snake bite in Eastern Taiwan. Tissue necrosis and wound infection are frequent complications of snake bite that lead to a high surgical rate. Our study indicated that prophylactic antibiotics should be administered because they can provide sufficient coverage for both aerobic and anaerobic pathogens including M. morganii, Enterococcus spp., and B. fragilis.

Keywords

snake bite antivenom surgery

Parallel abstracts


背景:關於台灣的毒蛇咬傷已有不少研究報告,但多侷限於台灣北部、中部以及南部,東部的報告並不常見。台灣東部多山區地形,毒蛇咬傷的個案屢有所聞,且因地理狹長和山區交通不便導致就醫時間可能有所延誤。部分個案單靠藥物即可成功治療,但有些因為感染及組織壞死可能需要手術治療。目的及目標:本院為東台灣唯一的醫學中心,分析毒蛇咬傷個案用以協助改善治療實屬必要。本院曾蒐集2000至2004年間的毒蛇咬傷案例並發表報告,如今我們想知道過去十年間針對東部毒蛇咬傷的流行病學及相關治療是否有所變化。材料及方法:本研究回溯性收集2010至2015年間因毒蛇咬傷的住院病例,並查閱相關急診、門診、入出院病歷及手術紀錄等。將病患基本資料、蛇種、臨床表現、治療方式及結果紀錄整理後,並進一步利用統計學方法進行分析比較。結果:本次研究共收錄48位病患,其中男性佔35人,女性佔13人。六種毒蛇中最多的是眼鏡蛇(35%),其次依序為龜殼花(23%)、青竹絲(19%)、百步蛇(6%)、雨傘節(2%)、鎖鏈蛇(2%)以及不明蛇種(13%)。所有病人中,有19位(40%)接受手術治療,包括傷口清創、筋膜切開術及後續各類重建手術等。在被眼鏡蛇咬傷的病人中,有14位(82%)須接受手術治療,而這些病患大部分的診斷為壞死性筋膜炎。所有接受手術的病患都有做傷口的細菌培養,約四分之三為眼鏡蛇咬傷的病人。其中最常被培養出的三種細菌為Morganella morganii、Enterococcus specis、以及Bacteroides fragilis。我們的病患在送來本院後就會開始接受預防性抗生素的治療,但常用的抗生素對培養出的菌種效果不佳。結論:本研究結果顯示目前在東台灣地區因毒蛇咬傷而需住院治療的患者多肇因於眼鏡蛇咬傷,而在此類病患亦常見傷口組織壞死及細菌感染等併發症因而導致較高的手術比例。在一開始的抗生素選擇上,應該使用多種或廣效性抗生素,以期能有效對抗格蘭氏陽性、陰性、有氧及厭氧菌的感染。

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