34例毒蛇伤急诊救治的体会

为提高毒蛇伤的抢救成功率，现将我科近年来救治的34例毒蛇咬伤，回顾性总结如下。1临床资料1．1一般资料男性27例，女性7例；年龄：6～67岁（平均33岁），平素身体健康；职业：农民13例（41．18％），从事卖、杀、养蛇业者9例（264％），其他（包括工人、干部、学生等）12例（32．25％）；咬伤至就诊时间：24小时以内者28例（82.35％），24小时以上者6例门人65％）。1．2毒蛇种类与蛇伤分型参照1990年第四届蛇伤学术会议（广州）制定的“毒蛇咬伤的临床病情分型”列如表1。1。3实验室检查全部病例分别作血、尿、粪常规、血电解质、BUN、…     

湖北地区毒蛇咬伤流行病学调查及随访分析

目的:了解湖北地区毒蛇咬伤流行病学特征及蛇伤患者出院后恢复情况，为本地区的蛇伤救治策略提供依据。方法:统计我院2017—2021年收治的2178例毒蛇咬伤患者的临床资料，回顾性分析年就诊量、性别年龄、地区分布、就诊时间、受伤时间、蛇种分布、费别费用、抗蛇毒血清剂量及住院相关指标统计，并电话随访573例出院患者，统计指标包括是否再次就医、复查检验指标、伤口愈合时间、肢体消肿时间及并发症。结果:湖北地区及周边蛇伤事件主要发生在4—10月份，最常见的为蝮蛇咬伤，其次为不明毒蛇类咬伤；昂贵的抗蛇毒血清费用是就诊费用高的主要原因，这对蛇伤患者造成了沉重的经济压力。出院后常见的并发症有血清病(12.04%)、伤口不愈合(8.20%)和肢体疼痛(9.25%)。结论:了解本地区的毒蛇伤流行病学特点及蛇伤患者出院后恢复情况，能够制定符合本地区的蛇伤救治策略。     

蛇咬伤的急救和护理体会

我院2003—06／2007—05急诊收治毒蛇咬伤患者76例，通过给予及时正规的急救和护理，临床效果良好。现报告如下。 1临床资料 本组男43例，女33例，年龄16～58（32±1．5）岁。依照1990年第4届全国蛇伤学会议通过的“毒蛇咬伤的临床分型”标准分为：轻型24例；重型38例；危重型14例。受伤至就诊时间1～24（2±0．35）h。蛇活动外出较多的4～9月受伤比例大，多为傍晚或夜间受伤，在没扩创的70例患者中有60例（86％）能在受伤处看到1对牙印。受伤部位：足部36例；小腿24例；手16例。大部分患者牙印小，伤口剧痛，肿胀明显并迅速上延、流血不止、患处起水泡、血泡及组织溃烂等，少数患者很快出现肢片状瘀斑青紫。     

利多卡因代替普鲁卡因封闭治疗蛇咬伤

我院1994年10月～1996年3月门诊治疗蛇咬伤28例，其中毒蛇咬伤24例，未明确毒蛇或无毒蛇咬伤4例，用盐酸利多卡因封闭局部伤口和伤肢，效果满意，总结如下。1临床资料1．1一般资料男22例，女6例。年龄13～45岁，20～30岁者20例，占71．4％。就医时间：咬伤后1h内就医18例，1～3h9例，10h以上1例。自救措施：包括捆扎伤肢、吸吮伤口、挤压伤口周围、制动患肢等。1．2临床表现局部症状：伤周红肿，伤口疼痛剧烈，牙痕处有出血；个别病例伤肢肿胀明显，迅速扩散，并出现不同程度的组织坏死。全身症状：全身症状轻，未见广泛内出血、休克、呼吸…     

毒蛇咬伤致急性呼吸衰竭7例的急救处理

1991年7月至1995年8月间，我院ICU收治毒蛇咬伤致急性呼吸衰竭7例病人，早期采用机械通气以纠正呼衰，疗效确切。现将结果报告如下。1临床资料1．1一般资料全组共7例，男性6例，女性1例。年龄31．8±9．4岁（19－52岁）。蛇伤至入院诊治时间14．1±11．1小时（1—35小时）。蛇伤原因：5例捕蛇时被咬伤，余2例洗衣、散步时被咬伤。蛇伤时间：19－23点。毒蛇类别：6例为银环蛇咬伤，1例为五步蛇咬伤。1．2临床表现蛇伤后1—2小时出现进行性呼吸困难。早期呼吸频数28－35次／分，6小时后呼吸减慢4－8次／分，其中1例来院时呼吸心跳停止。血气…     

2014—2018年广州周边地区圆斑蝰蛇咬伤流行病学分析

目的了解圆斑蝰蛇咬伤患者在广州周边地区的流行病学特征,为防治圆斑蝰蛇咬伤提供依据。 方法对广州医科大学附属第一医院急诊科2014年1月1日至2018年12月31日收治的圆斑蝰蛇咬伤事件的流行病学特征进行描述性分析。采用线性相关分析的方法分析咬伤后就诊时间与咬伤后出现急性肾损伤时间的相关性。 结果5年共收治毒蛇伤1481例,死亡3例,其中43例圆斑蝰蛇咬伤,死亡2例,占毒蛇伤总死亡率的66.7%（2/3）;患者分布以广州珠三角地区（肇庆、云浮、佛山、江门）伤者居多,占74.4%,9~11月是咬伤高发月份,占44.2%（19/43）,被咬伤者以农民为主,占53.5%（23/43）,50~69岁为主要高发年龄,下肢咬伤占67.4%（29/43）,蛇伤严重程度评分重度病例占74.4%（32/43）。咬伤后就诊时间与咬伤后出现急性肾损伤的时间存在显著相关性（r=0.719,P<0.01）。 结论圆斑蝰蛇咬伤是广州周边地区毒蛇伤的主要死亡原因,应对高发月份、高发地区、高发人群及高发部位进行重点监测和干预,提高公众的自我保护能力,一旦发生圆斑蝰蛇咬伤,应立即到正规医院接受针对性诊治,必要时接受血液净化治疗。     

毒蛇咬伤临床治疗分析(附381例报告)

毒蛇咬伤是重要急诊之一，农村尤为多见，每年都有因抢救不及时而导致死亡。笔者从1980年5月至1994年6月，抢救治疗蝮蛇咬伤中毒381例，现介绍如下。1临床资料本组381例，男性346例，女性35例，年龄5～57岁，平均38．5岁，农民占95．6％，发病率以7～9月最高，占88．7％。毒蛇咬伤入院就诊时间最短1．5h，最长72h，平均6．2h。毒蛇咬伤中毒的主要临床表现，见表1。根据临床症状轻度程度，按照1973年全国蛇咬伤会议制定的“毒蛇伤病情分级标准”［1］，将381例毒蛇咬伤分成轻型253例，占66．4％，中型104例，占刀．3％，重型24例，占6．3％。…     

妊娠期毒蛇咬伤的护理12例

妊娠期被毒蛇咬伤在临床中较为少见。我院自 1977年以来共收治妊娠期毒蛇咬伤病人 12例。由于妊娠期蛇伤患者身体情况特殊 ,护理上有别于普通人毒蛇咬伤的患者 ,现将护理体会报告如下。1　临床资料本组病例均为住院病人。妊娠时间 :9周 2例 ,17周2例 ,18周 1例 ,2 5 + 2 周 2例 ,2 5 + 3 周 1例 ,2 6周 1例 ,34周 2例 ,38+ 3 周 1例。蛇种 :银环蛇咬伤 2例 ,尖吻蝮 (五步蛇 )咬伤 5例 ,眼镜蛇咬伤 4例 ,蝮蛇咬伤 1例。咬伤后就诊时间 :2h 2例 ,4h 5例 ,12h 4例 ,36h 1例。病情 (按中国的毒蛇及蛇伤防治中的分类标准 ) [1] :中型 6例 ,重型 4…     

鄂西宜昌及周边地区毒蛇咬伤流行病学分析

目的:分析湖北宜昌及周边地区毒蛇咬伤的发病情况,为本地区毒蛇咬伤的防治提供依据。方法:回顾性分析近2年我院收治入院、资料完整的毒蛇咬伤病例191例,并进行总结。结果:本地区蛇伤多发生在市郊夷陵区、点军区和邻近的宜都、枝江、长阳等地,时间集中在每年7~9月,以8~12时、16~24时高发,致伤蛇种主要为蝮蛇(83.25%),咬伤地点主要分布在农田和路边(81.68%),患者以男性居多,高发年龄40~60岁,四肢伤多见,被咬伤后多数患者(65.45%)能在6h内及时就诊,蛇伤多以轻型(82.72%)为主,大多预后良好,无死亡病例。结论:宜昌及周边地区毒蛇咬伤的流行病学特征明显,为该区域针对性预防和治疗毒蛇咬伤提供理论依据。     

蝮蛇咬伤致急性肾功能衰竭18例临床分析

蝮蛇是我国分布景广、最常见的毒蛇。1985－1994年，我们收治因蝮蛇咬伤后致急性肾功能衰竭（ARF）18例，现将临本资料和抢救结果报告如下。1临床资料11一般资料本组病例中男性10例，女性8例，年龄16－63岁，平均年龄36．5岁。蛇咬伤部位：足部9例，手部7例，小腿2例；蛇伤发生在5月份者6例，8月份9例，9月份3例．急性肾功能衰竭（ARF）发生时间：9例于伤后24－48h，4例48－72h，5例72h以上。1．2临床表现蛇伤后出现中度休克2例，重度休克4例，其中1例血压倒不到，4例收缩压低于12kPa，脉压小于2．71kPa．蛇伤后5－72h出现血红蛋白尿，…     

Snake bites by the jararacucu (Bothrops jararacussu): clinicopathological studies of 29 proven cases in Sao Paulo State, Brazil

The jararacucu, one of the most dreaded snakes of Brazil, southern Bolivia, Paraguay and northeastern Argentina, is a heavily-built pit viper which may grow to a length of 2.2 m. Up to 1000 mg (dry weight) of highly-lethal venom may be milked from its venom glands on a single occasion. It has accounted for 0.8% to 10% of series of snake bites in Sao Paulo State, Brazil. We examined 29 cases of proven jararacucu bites recruited over a 20-year period in two Sao Paulo hospitals. Severe signs of local and systemic envenoming, (local necrosis, shock, spontaneous systemic bleeding, renal failure) were seen only in patients bitten by snakes longer than 50 cm; bites by shorter specimens were more likely to cause incoagulable blood. Fourteen patients developed coagulopathy, six local necrosis (requiring amputation in one) and five local abscesses. Two became shocked and four developed renal failure. Three patients, aged 3, 11 and 65 years, died 18.75, 27.75 and 83 h after being bitten, with respiratory and circulatory failure despite large doses of specific antivenom and intensive-care- unit management. In two patients, autopsies revealed acute renal tubular necrosis, cerebral oedema, haemorrhagic rhabdomyolysis at the site of the bite and disseminated intravascular coagulation. In one survivor with chronic renal failure, renal biopsy showed bilateral cortical necrosis; the patient remains dependent on haemodialysis. Effects of polyspecific Bothrops antivenom were not impressive, and it has been suggested that anti-Bothrops and anti-Crotalus antivenoms should be given in combination.      

中西医结合治疗毒蛇咬伤773例

目的：探讨中西医结合治疗各类型毒蛇咬伤的方法。方法：分析３４例来收治的各类型毒蛇咬伤患者７３例的临床资料,分别采用中草药、西医综合对症治疗及灵活应用抗蛇毒血清治疗,观察其临床疗效。结果：治愈７２５例,显效４０例,总有效率９９．０％,无效８例,病死率１．０％。对于银环蛇咬伤和眼镜蛇咬伤的主要症状改善时间,综合对症治疗组明显优于中医药和抗蛇血清单独治疗。结论：采用中西医结合的综合性治疗方法,可明显临床     

Most lay people can correctly identify indigenous venomous snakes

We attempted to determine how accurately members of the public can identify venomous snakes. Six different snakes indigenous to southern California were displayed in cages for 265 people to view at a street fair. These included 4 nonvenomous snakes and 2 venomous snakes. People were asked whether the snake was venomous and the name of the snake, if they knew it. Overall, people recognized whether a snake was venomous or nonvenomous 81% of the time. They were most accurate at identifying rattlesnakes as being venomous (95%) but incorrectly identified nonvenomous snakes as being venomous 25% of the time. Men were more accurate than women, and adults were more accurate than children. Subjects were less well able to identify the exact species of snakes. The results suggest that there may be no need to capture, kill, or bring a snake to the hospital for identification, at least in this geographic area.     

Patterns of health care resource utilization after macrolide treatment failure: results from a large, population-based cohort with acute sinusitis, acute bronchitis, and community-acquired pneumonia

BACKGROUND: Macrolide antibiotics are used as first-line therapy for the treatment of respiratory tract infections. The recent emergence of macrolide-resistant pathogens is a major concern. OBJECTIVE: This study quantifies the frequency of macrolide treatment failure in respiratory infections and examines its impact on health care use. METHODS: Patients with respiratory infections treated with macrolides in outpatient clinics from January to December 2002 were identified from a health insurance claims database. Macrolide treatment failure was defined as the receipt of a second antibiotic, different from the first, within 4 weeks after the initial macrolide. The end points were numbers of hospitalizations and emergency department and office visits within 1 month after the initial macrolide. We examined diagnostic codes on claim forms for posttreatment hospitalizations and visits to identify those most likely to be related to treatment failure as opposed to other causes. Utilization data were analyzed by Poisson regression to control for confounding variables. RESULTS: The patients were divided into acute sinusitis (n = 111,135), acute bronchitis (n = 157,360), and community-acquired pneumonia (n = 36,212). Of these respective groups, 11,285 (10.2%), 15,498 (9.9%), and 4144 (11.4%) received a second antibiotic within 4 weeks. This subgroup with macrolide treatment failure was older, included more women, and had used more medical care before the index visit compared with patients with treatment success. After adjustment for age, sex, and previous health care use, patients experiencing treatment failure were more likely to be admitted to the hospital or to use emergency department or outpatient care after the index visit. This association was strongest for admissions and visits pertaining to the care of respiratory infections. CONCLUSIONS: By our definition, about 10% of patients with respiratory infections who were treated with macrolide antibiotics experienced treatment failure within 4 weeks. Macrolide treatment failure was associated with increased health care utilization.     

Strong vasopressor support may be futile in the intensive care unit patient with multiple organ failure

OBJECTIVE: The aim of the study was to determine the prognosis in patients who needed norepinephrine treatment in our institution in relation to the degree of organ failure and the evolution of the disease process. DESIGN: Retrospective case note analysis of outcome of those patients who needed norepinephrine according to our institutional regimen. PATIENTS: A total of 100 consecutive patients admitted to our 31-bed medical-surgical intensive care unit (ICU) who were treated with norepinephrine for severe hypotension and evidence of end-organ hypoperfusion unresponsive to both fluid resuscitation and dopamine treatment at 20 microg/kg/min. MEASUREMENTS: The degree of organ dysfunction at the time of starting norepinephrine treatment was assessed by the sequential organ failure assessment (SOFA) score. The time before starting norepinephrine treatment was defined as the time elapsed between ICU admission and that of starting norepinephrine administration. The patients were defined as survivors or nonsurvivors according to their ICU outcome. RESULTS: There were relationships between mortality and the degree of organ dysfunction and mortality and the duration of ICU stay before starting norepinephrine treatment. The mortality rate was 100% in the 30 patients with a total SOFA score of >12 and a delay before starting norepinephrine treatment of >1 day. The mortality rate of the other patients was 63%. The lowest mortality was seen in patients with lower SOFA scores and early norepinephrine administration after admission. CONCLUSIONS: Both the time of starting norepinephrine treatment after admission to the ICU and the degree of organ dysfunction have an important bearing on subsequent outcome. Although norepinephrine may be a lifesaving catecholamine in some cases, its administration to patients who have already developed multiple organ failure during their stay in the ICU is associated with a poor outcome.     

Suspected snakebite: One year prospective study of emergency department presentations

Aim: Snakebite is an uncommon, but potentially life‐threatening condition. The more common clinical scenario is suspected snake‐bite. Our aim was to characterise the epidemiology, diagnosis and management of patients with suspected snakebites. Methods: Prospective cohort study of patients presenting with suspected snakebites to a tertiary referral hospital serving a large rural region in tropical northern Australia where a standard admission protocol for suspected snakebites is used. Results: Of 70 suspected snakebite cases, there were 45 definite bites: three severe envenomings (two western brown snakes [Pseudonaja nuchalis] and one mulga snake [Pseudechis australis]); seven mild/moderate envenomings by other snakes, two non‐envenomings by identified P. nuchalis, five bites by identified non‐venomous snakes and 28 definite bites without envenoming. The remaining 25 cases were either suspected bites (8), unlikely bites (15) and two people hit by snakes. Definite snake‐bites occurred throughout the year, peaking in May and December. There were three severe envenomings (mainly coagulopathy), requiring antivenom treatment, but no deaths or major complications. Most patients had appropriate investigations. Of 47 venom detection kit swabs collected, 34 were not tested, venom was not detected in nine and was positive in the three envenomings with one false‐positive tiger snake. Whole blood clotting time was highly sensitive for procoagulant coagulopathy and envenoming in this study. Median length of time from the bite to discharge was 20 h (interquartile range: 12–27). Conclusions: The study shows that although suspected snakebite was common, severe envenoming occurred in less than 5% of cases. The study supports the proposition that a structured approach and admission policy of suspected snakebites leads to the appropriate management of severe envenoming, with no cases discharged early and no cases of non‐envenoming treated with antivenom.     

Implementation of standing field treatment protocols in an urban EMS system.

The objective was to describe our experience with implementation of standing field treatment protocols (SFTP) in a large, urban EMS system. A prospective, consecutive observational study examining the first 21 days of implementation of SFTPs in the City of Los Angeles, California. SFTPs were developed for 7 medical chief complaints and all major trauma patients. There were 13,586 EMS incidents, of which 4,037 (30%) received ALS treatment. SFTPs were used on 2,177 of these incidents, representing 54% of all ALS runs and 16% of all EMS incidents. The most frequently used SFTPs were for altered level of consciousness (29%), and chest pain (25%). The most common errors found were failure to document reassessment of the patient after each medication administration (45% fallout rate), and failure to document and attach a copy of the ECG to the EMS report (40%). The mean fallout rate for failure to establish or attempt IV access, administer oxygen, or provide cardiac monitoring was 7%. Out of 1,450 incidents with outcome data provided by the receiving hospitals, only 3 cases (2%) involved incorrect treatment, with an additional 2 involving the unnecessary use of lidocaine. None of these instances resulted in adverse effects or complications. SFTPs were integrated into a large EMS system with few procedural errors or adverse outcomes.     

急性肾功能衰竭96例临床研究

目的研究急性肾功能衰竭(ARF)患者的病因、预后和影响预后的因素。方法回顾性研究我院2004年6月至2008年6月住院ARF患者的临床资料。结果观察期间住院患者共34 622例次,其中ARF患者96例,占同期住院患者的0.28%。ARF主要病因为感染、心力衰竭和药物。ARF患者病死率为30.2%,进行肾替代治疗者病死率(24.1%)低于保守治疗者(35.8%),二者比较差异有统计学意义(P0.01)。结论住院ARF患者的主要病因是感染、心力衰竭和药物,ARF的发病率和病死率较高,肾替代治疗预后较好。     

连续性肾脏替代疗法治疗顽固性心衰患者的临床疗效

【目的】观察连续性肾脏替代疗法（CRRT）对临床药物治疗无效的难治性心衰的治疗效果。【方法】对在本院住院的85例难治性心衰患者进行CRRT治疗,观察患者心衰治疗的疗效及治疗前后血尿素氮（BUN）、血肌酐（SCr）浓度变化。【结果】CRRT治疗后,患者总有效率为98．8％（84／85）,治疗后血BUN、SCr浓度较治疗前明显下降,且差异有显著性（P〈0．05）。【结论】对临床药物治疗无效的心衰患者,CRRT治疗可以快速清除患者容量负荷,纠正心衰,提高生存率。     

抗凝与抗血小板治疗心力衰竭的临床疗效对比分析

目的对比分析采用抗凝与抗血小板治疗心力衰竭的临床疗效,为临床治疗方案的选择提供参考依据。方法将2008年10月至2012年12月收治的210例慢性心力衰竭患者,按随机数字表法,分为华法林组105例与阿司匹林+波立维组105例,分别进行抗凝治疗与抗血小板治疗,对比2组患者的临床治疗效果。结果随访至2014年1月,华法林组患者的脑栓塞发生率为1.90%,显著低于阿司匹林+波立维组的16.19%,2组对比差异有统计学意义(P<0.05);华法林组患者的脑出血发生率及治疗有效率分别为7.62%与95.24%,与阿司匹林+波立维组患者的4.76%、92.38%相比,差异无统计学意义(P>0.05)。结论采用抗凝与抗血小板治疗心力衰竭患者,均能取得显著的疗效,但抗凝治疗法更能降低患者脑栓塞发生率,临床上应根据患者的病情及耐受程度,选择最佳的治疗方法,以确保患者的整体治疗质量。