中药治疗毒蛇咬伤研究进展

中国幅员辽阔,是一个名副其实的地域大国,同时也是一个蛇类大国,毒蛇咬伤较为常见。目前,注射抗毒血清是最常见的治疗方法,但其在副作用、专一性、价格、有效期等方面却存在很大不足,而中药恰恰在这些方面具有无可比拟的优势。文章就对毒蛇咬伤的病机以及治疗有效中药的最新研究进展做一综述,以期为治疗毒蛇咬伤的中药研究及临床蛇伤救治提供借鉴。     

恩施地区民族医药治疗蛇伤特色探究

民族医药是祖国医药学的瑰宝,对疾病的治疗有自己的特色。恩施地区位于湖北省西部,特殊的地理条件和生态环境孕育了丰富的药材资源,因而有＂华中天然药库＂之称。该地区以土家族苗族为主,在长期的医疗实践中,逐渐形成了自己的民族医药理论,尤其对蛇伤的治疗,积累了丰富的用药经验和具有特色的理论体系。笔者从恩施地区民族药治疗蛇伤特色的形成,地理因素及蛇咬伤药用资源,恩施地区民族药治疗蛇伤的用药特色,开发利用前景,存在的问题几个方面对其进行了探讨,希望能为传承这一民族瑰宝做一点基础性的工作。     

Snakebite in northern Cameroon: 134 victims of bites by the saw-scaled or carpet viper, Echis ocellatus

Echis ocellatus is one of the most deadly snakes known to humans, yet the procurement of antivenom for the treatment of these snakebites in Africa has become increasingly difficult and expensive. There is no consensus for the management of victims, and little is known of actual recent experiences with these cases in ordinary health care settings in Africa. All cases of snakebite reliably identified as bites of E. ocellatus and admitted to Kolofata District Hospital, northern Cameroon, from January 1993 to December 2002 were described retrospectively or prospectively. Of 134 cases admitted, 63% were male, three-quarters were aged < 30 years, and 85% survived. Pasteur polyvalent antivenom for Africa was administered intravenously in all but 1 case, but patients rarely received more than 10 mL. In most cases, appropriate antivenom can be administered effectively at a fraction of the recommended dose (20-60 mL), even in patients with serious complications presenting days after having been bitten; however, death is more likely in late presenters.     

Envenoming by Bothrops jararaca in Brazil: association between venom antigenaemia and severity at admission to hospital

The association between the clinical severity of Bothrops jararaca envenoming at admission and serum venom and plasma fibrinogen concentrations before antivenom administration is reported in 137 patients admitted to Hospital Vital Brazil, Instituto Butantan, S?o Paulo, Brazil, between 1989 and 1990. Other variables such as age, gender, site of the bite, use of tourniquet and the time interval between the bite and start of antivenom therapy, spontaneous systemic bleeding, and the 20 minute whole blood clotting test (20WBCT) at admission showed no association with either severity or serum venom antigen concentration (SVAC). Mean SVAC in patients with mild envenoming was significantly lower than in the group with moderate envenoming (P = 0.0007). Patients with plasma fibrinogen concentrations > 1.5 g/L had a lower mean SVAC than patients with plasma fibrinogen concentrations < or = 1.5 g/L (P = 0.02). Those admitted with a tourniquet in place had significantly higher plasma fibrinogen concentrations than those without a tourniquet (P = 0.002). A multiple logistic regression model showed independent risk factors for severity: bites at sites other than legs or forearms, SVACs > or = 400 ng/mL, and the use of a tourniquet. Rapid quantification of SVAC before antivenom therapy might improve initial evaluation of severity in B. jararaca bites.     

Role of therapeutic plasma exchange in snake bite associated thrombotic microangiopathy—A case report with review of literature

Post snake bite renal failure due to thrombotic microangiopathy (TMA) is often overlooked and not considered as a separate entity while managing the patient. This case report highlights the efficacy of Therapeutic Plasma Exchange in managing the post envenomation TMA. Anti-snake venom was administered following severe hematotoxic envenomation, but later on developed acute kidney injury and hence hemodialysis was done for 2 days without much improvement. On third day of bite, diagnosis of TMA was made from microangiopathic hemolytic picture in peripheral blood smear, thrombocytopenia and renal failure. Therapeutic plasma exchange with human albumin solution was started on a daily basis and after 3 cycles, patient's condition improved as shown by the laboratory parameters. Though this entity is not well defined, the supporting evidence is found in few reports of published literature. Hence, we propose plasma exchange as an adjunctive therapeutic option in post snake TMA.     

解毒通腑汤治疗毒蛇咬伤肢体肿胀的临床研究

目的 观察中药解毒通腑汤对毒蛇咬伤致肢体肿胀患者的临床疗效.方法 将68例毒蛇咬伤患者随机分为治疗组34例、对照组34例.对照组采用中西医结合常规的毒蛇咬伤治疗方案,治疗组在对照组治疗方案的基础上,予中药解毒通腑汤加减口服.观察2组患者咬伤后第2天及第6天的肢体肿胀程度,5-羟色胺水平的变化,促炎细胞因子白介素-6（IL-6）、肿瘤坏死因子-α（TNF-α）与抗炎细胞因子白介素-10（IL-10）水平的变化.结果 肢体肿胀程度2组在咬伤后第2天比较,差异无统计学意义（P＞0.05）,治疗组咬伤后第6天较本组咬伤后第2天降低（P＜0.01）,对照组咬伤后第6天较本组咬伤后第2天降低（P＜0.05）,治疗组前后差值与对照组比较差异有统计学意义（P＜0.05）,治疗组优于对照组.5-羟色胺水平2组在咬伤后第2天比较,差异无统计学意义（P＞0.05）,2组咬伤后第6天均较本组咬伤后第2天降低（P＜0.01）,治疗组前后差值与对照组比较差异有统计学意义（P＜0.01）,治疗组优于对照组.IL-6水平2组在咬伤后第2天比较,差异无统计学意义（P＞0.05）,治疗组咬伤后第6天较本组咬伤后第2天降低（P＜0.01）,对照组咬伤后第6天较本组咬伤后第2天降低（P＜0.05）,治疗组前后差值与对照组比较差异有统计学意义（P＜0.05）,治疗组优于对照组.TNF-α水平2组在咬伤后第2天比较,差异无统计学意义（P＞0.05）,治疗组咬伤后第6天较本组咬伤后第2天降低（P＜0.01）,对照组咬伤后第6天较本组咬伤后第2天降低（P＜0.05）,治疗组前后差值与对照组比较差异有统计学意义（P＜0.05）,治疗组优于对照组.IL-10水平2组在咬伤后第2天比较,差异无统计学意义（P＞0.05）,治疗组咬伤后第6天较本组咬伤后第2天升高（P＜0.01）,对照组咬伤后第6天较本组咬伤后第2天升高（P＜0.05）,治疗组前后差值与对照组比较差?     

Acute renal failure following poisonous snakebite

This study describes acute renal failure (ARF) following snakebite in humans and the effects of viperide venoms on the renal structure and function in subhuman primates. ARF developed in 45 of 157 patients with a history of snakebite admitted to the hospitals of the Postgraduate Medical Institute, Chandigarh, India. They were studied clinically, hematologically, and in 35 cases, for renal histopathology. All 45 were treated with antibiotics, and 8 received anti-snake venom. Ten cases had bilateral renal cortical necrosis (BRCN), eight of whom died; less severe acute tubular lesions (ATL) occurred in 23 patients, four of whom died (P less than .001). Sepsis was significantly more common with BRCN than ATL (P less than .05). No statistical difference was found between these groups in bleeding incidence, disseminated intravascular coagulation (DIC), hemolysis, or hypotension. Monkeys given lethal doses of viperide venom developed hypotensive shock, DIC, and hemolysis, with significantly reduced serum complement, and died within 24 hours. However, no renal functional changes or lesions were found. Monkeys given sublethal doses of viperide venom showed a significant increase in serum creatinine levels after 48 hours, and renal lesions were observed in a majority of animals. In conclusion, ARF in snakebite victims appears to be multifactorial in origin. Although hypotension, hemolysis, and DIC are likely to be important pathogenetic factors, a direct cytotoxic effect of the venom on the kidney in producing ARF cannot be excluded.     

抗蝮蛇毒血清应用方式对重症蝮蛇咬伤预后的影响

目的:探讨抗蝮蛇毒血清应用方式对重症蝮蛇咬伤预后的影响。方法:将47例重症蝮蛇咬伤患者随机分为治疗组、对照组,2组患者均接受常规治疗,治疗组加用抗蝮蛇毒血清局部封闭。比较2组患者的器官功能损害程度、治愈率、平均住院时间。结果:2组患者入院0天器官功能损害程度比较无统计学差异(P>0.05)。而入院3天后治疗组、对照组Hgb、STB、Scr分别为91.3±15.6、21.8±9.5、266±62,86.4±16.4、23.7±8.9、274±73,无统计学差异(P>0.05);ALT、CK-MB、LDH分别为195±102、546±653、2343±2289,448±331、995±896、5124±4969,有显著的统计学差异(P<0.01)。治疗组、对照组患者的平均住院日分别为13.55±7.86、19.24±10.38,有统计学差异(P<0.05),治愈率比较无统计学差异(P>0.05)。结论:联合抗蝮蛇毒血清局部封闭,能明显减轻重症蝮蛇咬伤患者的器官功能损害程度,缩短患者的平均住院时间,值得临床推荐。