毒蛇咬伤致多脏器损伤作用及机制研究进展

毒蛇咬伤是临床常见急重症,严重危害人类生命安全。蛇毒毒液螯入后会导致神经损伤、凝血障碍等致死性的全身性损伤,咬伤部位溃疡、肌坏死等致残性的局部损伤,以及多脏器组织损伤。近年来,毒蛇咬伤后血液毒性、神经毒性、细胞毒性被广泛研究,但对实体脏器的损伤研究较为缺乏,而蛇伤后多脏器损伤是其高致死率的重要原因。因此,该文对毒蛇咬伤后,合并致心脏、肝脏、肾脏、肺脏、脾脏、脑等实体脏器的功能性或器质性损伤作用及机制进行综述,旨在为蛇伤临床精准诊治提供参考与借鉴。     

Retrospective review of snake bite victims

Venomous snakebites are a rare but dangerous and potentially deadly condition in the U.S.. Most bites in the U. S. result from envenomation with snakes of the family Viperidae, subfamily Crotalinae, which includes rattlesnakes and copperheads. Treatment includes a comprehensive work-up to look for possible hematologic, neurologic, renal, and cardiovascular abnormalities, local wound care, systemic antivenom administration, tetanus prophylaxis, antibiotics in the presence of infection and surgical treatment if needed, which may include debridement, fasciotomy and rarely amputation. All these patients should be observed for a minimum of 8 hours. Any evidence of envenomation mandates a minimum of 24 hours of in-hospital observation. A grading system to classify the severity of envenomation is described. The most commonly used antivenom in the U.S. is CroFab, which has a much lower incidence of acute or delayed allergic reactions compared to the older antivenoms. When allergic reactions do occur, they are usually of mild to moderate severity. With the improved risk-benefit ratio of CroFab, antivenom is indicated with any grade of envenomation. In this a retrospective study, we will review our experience with 25 snakebite victims admitted to the West Virginia University over a five years period.     

Admissions for suspected snake bite to the Perth adult teaching hospitals, 1979 to 1988.

OBJECTIVE: To describe the epidemiology of snake bite in Perth, and the likelihood of envenomation. DESIGN: Information from case notes was retrospectively analysed. SETTING: Emergency medicine, teaching hospitals. PATIENTS: All patients admitted to the three adult teaching hospitals in Perth for suspected snake bite from 1979 to 1988. MAIN OUTCOME MEASURE: Systemic envenomation, was accepted as present if there were definite symptoms, signs or laboratory evidence (vomiting, abdominal pain, ptosis, convulsions, difficulty with breathing or swallowing, coagulopathy, haemolysis, rhabdomyolysis or renal failure). RESULTS: Ninety-nine patients were definitely bitten, with 53 envenomed, including three snake handlers. Thirty others may have been envenomed. Nearly half (44%) of the 82 patients with witnessed snake bite were envenomed. The dugite (Pseudonaja affinis) caused most cases of envenomation, most often producing coagulopathy only. The remainder were probably due to bites by the tiger snake (Notechis after occidentalis) and gwardar (Pseudonaja nuchalis), with one by a sea snake. The Commonwealth Serum Laboratories Snake Venom Detection Kit (VDK) enabled identification of the genus in 36% of definite cases of snake bite, and in 51% of cases of envenomation. It may occasionally produce false-positive results. The VDK is of greatest value in establishing the genus of snake in envenomed patients. CONCLUSIONS: It is suggested that a mixture of brown and tiger snake antivenom be used to treat patients envenomed by an unidentified snake in the Perth metropolitan area. This does not apply to patients bitten elsewhere in Western Australia or transferred to Perth from country regions where other snakes are more prevalent.     

Acute renal failure after envenomation by the common brown snake

A non-fatal case of acute renal failure after envenomation by a common brown snake (Pseudonaja textilis) is described. The renal failure required dialysis but resolved rapidly. There were no signs of neurotoxic envenomation or myoglobinuria. A mild disturbance of coagulation was noted with severe thrombocytopenia. This is the first documented case of renal failure (acute tubular necrosis) after envenomation by the common brown snake to present with this clinical picture. It is also the first clinical evidence that an Australian snake venom may contain a direct nephrotoxic component.     

Cardiac failure following Irukandji envenomation

This paper presents a case of Irukandji syndrome (envenomation by the jellyfish, Carukia barnesi) with pulmonary oedema and hypokinetic cardiac failure. This case highlights the need for victims (and operators of tours venturing into the waters of North Queensland) to treat even apparently innocuous stings with vinegar and to avoid freshwater bathing and rubbing of stings immediately after such incidents. It also reinforces the use of phentolamine to treat the symptoms of catecholamine release associated with the syndrome. This patient required inotropic support and further underlines the need for practitioners to be aware that the syndrome can have severe sequelae and that central venous monitoring and inotropic management should be available when treating Irukandji stings.     

Envenomation by the Eastern coral snake (Micrurus fulvius fulvius). A study of 39 victims

We gathered data on 39 victims of Eastern coral snake bite over a 12-year period. The most common situation resulting in snakebite was erroneous identification of the snake as the nonpoisonous scarlet king snake. While no patient died, several experienced severe envenomation, including bulbospinal respiratory paralysis. We found that neurologic symptoms may be delayed for 12 hours, and then may be precipitous. Envenomation occurs in 75% of the persons bitten by a coral snake. Antivenin is effective and should be intravenously administered early to patients who have been bitten by a positively identified coral snake, depending on the clinical presentation.     

Common krait (Bungarus caeruleus) bite in Anuradhapura,Sri Lanka: a prospective clinical study, 1996-98

Common krait (Bungarus caeruleus) is the deadliest snake found commonly in the dry zone of Sri Lanka. In Anuradhapura, 210 farmers bitten by the common krait over a three year period were investigated prospectively from 1 January 1996. The sex ratio was equal, 110 (52%) patients were in the age group 10-30 years. One hundred and one (48%) patients were severely envenomed and needed mechanical ventilation from 12 hours to 29 days (mode two days). The bite occurred at night while the victims were asleep on the floor. In 99 (47%) situations killed specimens were available for identification. The cardinal symptom was abdominal pain developing within hours of the bite. Alteration in the level of consciousness was observed in 150 (71%) patients: drowsy in 91 (43%), semiconscious in 24 (11%), and deep coma in 35 (17%). Autonomic disturbances included transient hypertension, tachycardia, lacrimation, sweating, and salivation. These manifested in 139 (66%) patients with moderate to severe envenomation. One hundred and forty nine (71%) had hypokalaemia and 105 (50%) metabolic acidosis, anterograde memory loss in 84 (40%), and delayed neuropathy in 38 (22%) patients. Polyvalent antivenom had no significant benefit (t = 0.5) in reversing respiratory paralysis and preventing delayed neurological complications. Sixteen (7.6%) patients died and a submucosal haemorrhage in the stomach was seen at necropsy in three cases. Mortality could be minimised with early and free access to mechanical ventilation.     

Urban envenomation

Over a 12-year period, 61 patients were admitted to a metropolitan hospital on 67 occasions with envenomation from snakes, spiders, ticks or bees. We describe the epidemiology of the bites and the patient's response to treatment. First aid was used in only 50% of patients with potentially-lethal bites. All patients who developed severe envenomation showed symptoms within 30 minutes, and all patients survived.     

Irukandji syndrome in northern Western Australia: an emerging health problem

OBJECTIVES: (1) To assess the number and severity of episodes of Irukandji syndrome in Broome, Western Australia. (2) To correlate demographic, seasonal, geographic and climatic features of Irukandji stings. (3) To assess treatment of Irukandji syndrome at Broome Health Service. (4) To assess the public health impact. DESIGN AND SETTING: (1) A retrospective analysis of jellyfish data forms and charts of 111 patients, identified from Broome Health Service Emergency Department with a discharge diagnosis of marine sting between 1 January 2001 and 1 July 2003. (2) Correlation between climate and Irukandji envenomation data. MAIN OUTCOME MEASURES: Number of patients with Irukandji syndrome; their demographic and environmental features; the clinical syndrome; treatment requirements. RESULTS: 111 patients were prospectively identified with marine stings; 88 were identified with Irukandji syndrome. Non-Irukandji syndrome data were excluded for analysis. The "jellyfish season" extends from January to May, although stings occur all year round. Only 38% of patients had vinegar applied to the sting site before hospital presentation. Signs and symptoms were variable between individuals, with 20% having no signs of sting at all and welts found in 16%. Fifty per cent of patients were hypertensive at presentation. Distress was found in the majority of patients, with 90% requiring opioid analgesia (morphine equivalent: mean, 20 mg; median, 13 mg) and 17% requiring admission. There was one evacuation to Perth with cardiotoxic marine envenomation resulting in pulmonary oedema, which necessitated 4 days in intensive care. Stings were significantly more common when the ambient median temperature was greater than 28.3 degrees C, after midday, on an incoming high tide and on windy days. CONCLUSION: The rate of envenomation in northern WA is likely to be the highest currently documented in Australia. There is syndromic variability when compared with the north Queensland experience. This implies different causative jellyfish species that are not yet identified. Stings in Broome can be severe and life threatening; there are significant commercial and public health implications as a result. Management at Broome Hospital is contemporary and effective.     

Thrombocytopenia after brown snake envenomation

The marked coagulation disturbances in patients after severe envenomation by brown snakes (genus Pseudonaja) were examined with particular emphasis on the sequential platelet counts. The common finding (in almost half the studied patients) of a progressive depletion in platelet numbers leading to thrombocytopenia, which in one case was severe, suggests that thrombocytopenia should be considered as a possible complicating factor in the management of these patients. This trend was not a feature of the cases that involved bites by tiger snakes. The finding of this study in relation to envenomation by brown snakes is in contrast to the widely held opinion that thrombocytopenia is not an outcome of snake-bites in Australia.     

Management of bee-sting anaphylaxis

A retrospective case analysis of 101 adverse reactions to bee-stings and a prospective questionnaire analysis of the proposed management by local medical practitioners and resident hospital staff members of three hypothetical bee-sting reactions has revealed that understanding of the use of adrenaline in patients with reactions to bee envenomation is confused with regard to the indications for its use, dosage and route; that corticosteroid agents are used or are recommended too frequently, sometimes as the sole therapeutic agent; and that there is a lack of awareness of the need for volume replacement in hypotensive shocked patients. These conclusions highlight the urgent need for a greater understanding of the optimal forms of management for patients with acute anaphylactic reactions to bee envenomation.     

家庭暴力受虐者的求助方式研究

目的 分析家庭暴力受虐者的求助方式.方法 采取多级分层抽样方法,用自编家庭暴力求助方式问卷,对306名家庭暴力受虐者进行访谈.结果 33.7%的家庭暴力受虐者感到无处求助.受虐者的求助对象居前3位的依次为:家庭其他成员(34.6%)、邻居亲友(17.0%)和村/居委会(12.5%),其中向村/居委会求助的有效率最高(71.1%).城市受虐者向家庭其他成员和妇联的求助率高于农村和工业区(向家庭其他成员求助率44.6%,35.8%和23.0%,x2=9.962;向妇联求助率8.9%,0和2.0%,x2=10.310,均P＜0.01),农村受虐者向村/居委会的求助率高于城市和工业区(30.3%,3.0%和2.0%,x2=49.397,P＜0.01).男性受虐者的求助对象居前3位的依次为:家庭其他成员(27.3%)、村/居委会(15.8%)和邻居亲友(10.9%),女性则为:家庭其他成员(38.0%)、邻居亲友(20.0%)和村/居委会(10.8%),女性向邻居亲友的求助率高于男性(20.0%,10.9%,x2=3.980,P＜0.05).成年受虐者向家庭其他成员求助率低于儿童和老年者(31.6%,42.0%和46.9%,x2=5.993,P＜0.05),老年受虐者向村/居委会的求助率高于成年和儿童(28.1%,12.1%和4.0%,x2=9.930,P＜0.01).大学及以上文化程度者的无处求助率最高(47.8%),向家庭其他成员和村/居委会的求助率均以小学文化者最高(分别为38.5%和24.0%),大学及以上文化者最低(分别为17.4%和0).结论 家庭暴力受虐者的求助方式因地域、年龄、性别和文化程度不同而有所差异.

Abstract：

Objective To analysis the victim's help-seeking behavior of domestic violence. Methods Using a multi-stage sampling strategy,306 victims of domestic violence were randomly selected and face-to-face interviewed. A self-designed help-seeking questionnaire of domestic violence was administered. Results 33.7%victims felt nowhere to seek help. The three leading helpers they seek were the other family member (34.6%),neighbor and friend( 17.0% ) and community office ( 12.5% ) ,and the community office had highest prevalence of effect (71. 1% ). The prevalence of seeking help from other family member and Women's Federation were highest in urban victims (P＜0.01) ,and seeking help from community office was highest in rural victims (P＜0.01). The three leading helpers were other family member (27.3%) ,community office ( 15.8% ) and neighbor and friend ( 10.9% ) by male victims, and other family member ( 38.0% ), neighbor and friend ( 20.0% ) and community office ( 10.8% ) by female victims. The prevalence of seeking help from neighbor and friend was higher in female than in male ( 20.0% vs 10.9%, x2 = 3. 980, P＜ 0.05 ). Adult victims seek help from other family member were less than children and the elderly (31.6% vs 42.0% and 46.9%, x2 =5.993, P＜0.05),and the elderly seek help from community office were more than adults and children (28.1% vs 12. 1% and 4.0%, x2 =9.930, P＜0.01 ). The victims with higher level of education were with higher prevalence of feeling nowhere to seek help (47.8%). Seeking help from other family member and community office were most in victims with lower level of education( 38.5% and 24.0% ,respectively) and were least in victims with higher level of education ( 17.4% and 0,respectively, P ＜ 0.05, P ＜ 0. 01 ). Conclusion Help-seeking behaviors of victims of domestic violence are varied by geographic settings,age,gender and education levels.     

Platypus envenomation--a painful learning experience.

OBJECTIVE: To describe in detail for the first time, the clinical course and medical management of a significant human envenomation by the Australian platypus (Ornithorhynchus anatinus). CLINICAL FEATURES: A 57-year-old man was envenomated via two spur wounds to the right hand from each hind leg of a male platypus. Pain was immediate, sustained, and devastating; traditional first aid analgesic methods were ineffective. INTERVENTION AND OUTCOME: On admission to hospital, narcotics administered intravenously, both intermittently and by infusion, provided inadequate analgesia. A right wrist block was dramatically effective. After the blockade narcotic analgesic support was required for several days. The patient spent six days in hospital, and the envenomated area remained painful, swollen and with little movement for three weeks. Significant functional impairment of the hand persisted for three months, the cause of which is uncertain. CONCLUSIONS: Male platypus venom remains largely unstudied. It produces savage local pain and marked local swelling, but no apparent tissue ischaemia. No antivenom is available; in its absence the only effective analgesia appears to be regional nerve blockade, when the envenomation site and available skills permit. Immobilisation assists.     

重症毒蛇咬伤的治疗

目的探讨血液灌流对重症毒蛇咬伤的临床效果。方法回顾性分析2010年1月-2013年9月该院收治的重症毒蛇咬伤患者60例。其中常规治疗组30例,血液灌流组30例。常规治疗组在西医对症抢救治疗的同时配合中药治疗,在明确毒蛇种类后,使用抗蛇毒血清,在排除伤口局部蛇毒后,及时处理伤口,抢救毒效应危象,为患者维持生命功能稳定,提高患者机体应激功能,预防治疗可能出现的并发症;血液灌流组,则在此常规治疗基础上加血液灌流治疗。结果常规治疗组痊愈10例,占总百分比的33.3％,总有效率为60％。血液灌流组痊愈17例,占总百分比的56．7％,总有效率为86．7％。血液灌流治疗组疗效明显优于常规治疗组（P〈0．05）;通过对两组治疗方式,常规治疗组与血液灌流组两组血小板正常、肿胀消退和住院时间比较：常规治疗组,血小板恢复正常时间为（7．48±2．13）h,肢体肿胀消退时间为（12．93±1．67）h,住院时间为（188．2±82．4）h。血液灌流组,血小板恢复正常时间为（3．56±1．22）h,肢体肿胀消退时间为（10．04±2．04）h,（87．0±15．2）h（P〈0．05）。结论对于重症毒蛇咬伤的患者,在常规治疗基础上采用血液灌流这一治疗方法,安全可靠,直接清除患者血液中的毒素,达到血液净化的目的,疗效显著值得临床推广。     

Envenomation by the billygoat plum stinging caterpillar (Thosea penthima)

We report the first case of envenomation by the billygoat plum stinging caterpillar, Thosea penthima Turner (Limacodidae). The sting, on the forearm, caused immediate burning pain and local wheal formation. Pain radiated up the arm and there was severe "crushing" chest pain lasting four hours. The local pain persisted for 10 hours and required opiate analgesia.     

Pattern of injury in fatal road traffic accidents in a rural area of western Maharashtra,India

Background

Fatal road traffic accidents (RTA) are a major cause of concern all over the world. The outcome of injuries sustained in an RTA depends on various factors including but not limited to: the location of the event, type of vehicle involved, nature of the roads, the time of accident, etc.

Aims

This study aims to investigate and evaluate prospectively the socio-demographic profile and pattern of injuries in victims of RTA in the rural area of the Ahmedanagar district of Maharashtra state.

Method

This prospective study included all victims of RTA that presented to our emergency room from 1 June 2007 to 31 May 2009 and were either found dead on arrival or died during treatment. All the victims were autopsied at the post-mortem centre of Rural Medical College, Loni.

Results

Ninety-eight RTA victims were studied during the period. The most commonly affected age group was 20-39 years. Men died in RTA more than women. Fatal RTA were more prevalent on the secondary road system (47.97 per cent) and especially involved pedestrian and two wheeler vehicle users. Large numbers (n=63, 64.28%) of victims either died on the scene or during transportation. Numbers of skeletal injuries (199) and internal organ injuries (202) exceeded the total number of victims (98) clearly indicating the multiplicity of injuries. The majority of RTA victims (n=46, 46.93%) died due to head injury. The study showed that most deaths in RTA, brought to a tertiary care rural hospital, took place either on the spot or within 24 hours of injury which is very alarming and highlights the need to take urgent steps to establish good pre-hospital care and provision of trauma services at site.

Conclusion

A computerised trauma registry is urgently needed to highlight risk factors, circumstances and chains of events leading to accidents. This would be extremely helpful in policy making and health management in India.     

汶川地震后1月内脱离/未脱离震区的亲历者PTSD筛查阳性的发生及心理影响因素

目的：探讨汶川地震后1月内脱离/未脱离震区的亲历者创伤后应激障碍(posttraumatic stress disorder, PTSD)筛查阳性的发生及心理健康的影响因素。方法：对什邡地区235人(现场组, 称A组)、转入湘雅二医院住院的伤病员44人(伤病员组, 称B组)及家属36人(家属组, 称C组)采用事件影响量表修订版等进行心理评估。结果：(1)灾后1月内PTSD筛查总阳性率为35.56%,女性明显高于男性(χ2=16.27,P＜0.001);A组、B组和C组PTSD筛查阳性率分别为39.15%, 31.82%和16.67%,差异有统计学意义(χ2mh=5.243,P＜0.05);在PTSD筛查阳性者的3组人群中,A组在“麻木/回避”和“过度唤起”症状得分上明显高于B组和C组(均P＜0.01)。(2)A组和B组的“焦虑”、“抑郁”和“躯体化”因子得分均明显高于C组(均P＜0.05);(3)性别、居住地和是否脱离震区是PTSD症状的影响因素。结论：震后1月内对亲历者的心理影响较大,PTSD症状群、焦虑与抑郁症状是其主要心理问题,尤其是女性群体,应予更多关注。早期脱离震区环境、扩大和强化支持系统是其保护性因素。早期心理干预有助于提高亲历者的心理承受力,有效预防PTSD的发生。     

Clinical effects of bites from formally identified spiders in tropical Northern Territory

OBJECTIVE: To determine the types of spiders causing bites and the clinical effects of their bites in tropical Northern Territory (north of the town of Katherine). DESIGN: A prospective study of confirmed and suspected spider-bites and a retrospective analysis of data from a standardised, local database of spider- and snake-bites. Confirmed spider-bites were those in which there was a clear history of the bite, and the captured spider was identified by an arachnologist. SETTING: Emergency department of a teaching hospital. SUBJECTS AND DATA SOURCE: All subjects with confirmed or suspected spider-bite presenting to the Emergency Department or referred from August 1999 to August 2000, or identified from the database. RESULTS: Thirty-four subjects had a confirmed spider-bite from an identified spider: 25 in the prospective group and nine in the retrospective group. The spiders were Sparassidae (huntsman spider) (12 bites), Missulena pruinosa (northern mouse spider) (7), Latrodectus (widow spider) (4), Araneidae (orb-weaver) (4), Salticidae (jumping spider) (4), Nemesidae (trapdoor spider) (1), Conothele (1) and Selenocosmia (whistling spider) (1). Clinical effects were local pain in 97% (severe in 29%), redness in 47% and swelling in 24% of cases. Systemic effects occurred in three victims, two of whom were bitten by M. pruinosa. There were no cases of confirmed necrotic arachnidism. CONCLUSIONS: None of the spider-bites resulted in severe effects. Compared with data from other parts of Australia, different species were involved and latrodectism was uncommon. Our study highlighted the importance of correctly identifying the spider species.     

Latrodectism: a prospective cohort study of bites by formally identified redback spiders

OBJECTIVE: To determine the spectrum of severity and early diagnostic predictors of redback spider bites (Latrodectus hasselti), and to examine the effect of intramuscular redback antivenom. DESIGN AND SETTING: Prospective cohort study of calls to New South Wales, Queensland and Western Australian poisons information centres and presentations to Royal Prince Alfred Hospital and Royal Darwin Hospital emergency departments. PATIENTS: 68 people with definite redback spider bites in which the spider was immediately collected and expertly identified (1 February 1999 to 30 April 2002). INTERVENTIONS: Intramuscular redback spider antivenom in a smaller cohort of hospitalised patients. MAIN OUTCOME MEASURES: Pain severity and duration, local effects and systemic envenomation (effects, prevalence, and persistence > 24 hours). RESULTS: The median duration of effects was 48 hours (interquartile range, 24-96 hours). Pain occurred after all bites and was severe in 42 (62%). Forty-five patients (66%) had pain lasting longer than 24 hours, and 22 (32%) were unable to sleep because of pain. Systemic effects occurred in 24 (35%). Increasing pain over one hour occurred in 37 cases (54%), and local/regional diaphoresis in 23 (34%); both these features were highly predictive of L. hasselti bites compared with bites of other spiders. One of six patients treated with intramuscular antivenom (17%) had no pain at 24 hours, compared with two of 17 untreated patients (12%) (difference, 5%; 95% CI, -36% to +64%; P = 0.95). There was no difference in duration of systemic effects with antivenom administration. CONCLUSIONS: Most redback spider bites cause severe and persistent effects. Intramuscular antivenom appears to be less effective than previously thought and its use by this route needs review.