Venomous Snake Bites in Taiwan

台灣毒蛇咬傷經驗

阮祺文(Chi-Wen Juan)

《中華民國急救加護醫學會雜誌》 23卷3期 (2012/09) Pp. 93-108

https://doi.org/10.30018/JECCM.201209.0001

摘要

台灣有6種毒蛇咬傷較為常見且有流行病學上的意義。赤尾鮐、龜殼花及百步蛇咬傷主要以出血症狀為主，一般稱之出血性毒蛇。眼鏡蛇和雨傘節咬傷因其具神經毒性，故稱之為神經性毒蛇。鎖鍊蛇兼具神經及出血症狀歸為兩者兼有之毒蛇。出血性毒毒素可造成全身性出血症狀；嚴重時並可導致全身擴散性血管內凝血病變。神經性毒毒素可以作用於運動神經與肌肉接合處，造成複視、構音及吞嚥困難、肌肉無力，甚至導致呼吸麻痺。混合性毒毒素具有神經毒性、溶血、橫紋肌溶解及腎毒性等症狀。赤尾鮐的咬傷是台灣最常見的毒蛇咬傷，百步蛇咬傷個案在六大毒蛇中反而最少。毒蛇咬傷後有臨床症狀出現，此時應儘速給予正確的抗蛇毒血清，雨傘節咬傷尚需考慮插管使用呼吸器維持呼吸，若毒蛇咬傷後未出現症狀，則最好觀察6-12小時確定無症狀再離院。抗蛇毒血清使用的劑量依咬傷的嚴重度、病人體重及咬傷後的時間長短給予不同的劑量，根據大多數毒物專家建議大人與小孩毒蛇咬傷應給予相同劑量，飯匙倩咬傷為6-12瓶、雨傘節咬傷為2瓶、龜殼花咬傷為1瓶、赤尾鮐咬傷為1瓶、百步蛇咬傷為2瓶、鎖鏈蛇咬傷為2-4瓶。急診醫護人員應根據毒蛇咬傷的病史，臨床進展的症狀及實驗室的檢查報告來決定適時給予何種抗蛇毒血清的注射量，滴注期間應密切注意病患各種生理現象的變化，才能降低毒蛇咬傷的死亡率。

關鍵字

毒蛇咬傷 ； 抗蛇毒血清 ； 出血性毒毒素 ； 神經性毒毒素

並列摘要

There are six kinds of poisonous snakes with epidemiological significance in Taiwan. Three species induce hemorrhagic symptoms (Trimeresurus mucrosquamatus, Trimeresurus stejnegeri, and Deinagkistrodon acutus), two species induce neurotoxic symptoms (Naja atra and Bungarus multicinctus) and one species induces hemorrhagic and neurotoxic symptoms (Vipera russelii formosensis). The hemorrhagic venom causes disorders of the clotting cascade such as prolonged bleeding, primary fibrinolysis and disseminated intravascular coagulopathy. The neurotoxic venom provokes respiratory distress from weakened respiratory muscles, blurred vision, diplopia, dysarthria, dysphagia, dysphonia and paralysis of muscles of the extremities. Mixed envenomation manifests as a combination of these neurotoxic and hemorrhagic effects as well as rhabdomyolysis and acute renal failure. Identification of the snake species is important if antivenom is to be used. Therefore, guidelines for snakebite identification based on clinical symptoms and laboratory analysis are important to improve the clinical diagnosis of snakebites. In Taiwan, Trimeresurus stejnegeri bites are the most common and Deinagkistrodon acutus the least common. Aggressive antivenom treatment can reduce the mortality rate for snakebites, but for Bungarus multicinctus bites, additional measures such as maintaining the patient's airway and supporting ventilation are vital. Patients with dry bites or bites with no envenomation should be observed for at least 6-12 hours. The emergency physician should determine the severity of envenomation and predominating venom activity before deciding on the type, dosage and duration of antivenin treatment. The history of exposure, local effects and systemic syndromes of envenomation, progression of symptoms and signs, and laboratory data obtained in the emergency department should guide decisions about antivenom therapy. The dosage most toxicologists use for treating pediatric patients with snakebites is the same as that for adults. In general, 6-12 vials of antivenom against neurotoxic venom are used for Naja atra bites and two vials are used for Bungarus multicinctus. One vial of antivenom against hemotoxic venom is used for both Trimeresurus stejnegeri and Trimeresurus mucrosquamatus bites. Two vials of anti-Deinagkistrodon acutus are used for Deinagkistrodon acutus bites and 2-4 vials of anti-Vipera russelli formosensis are used for Vipera russelli formosensis bite. During the infusion, the blood pressure, level of consciousness and skin reaction should be monitored. The varied clinical manifestations of snake bite must be considered for effective management. Ready availability and appropriate use of antivenom, close monitoring of patients and the institution of ventilatory support all help reduce mortality.

並列關鍵字

snake bites ； antivenom ； hemorrhagic venom ； neurotoxic venom