| 摘要: | 主題：這幾年來蛇咬傷案件的發生率逐漸減少，主要歸因於台灣社會環境的變遷以及對蛇類過度的捕殺。然而，蛇類咬傷因而導致嚴重的病況甚至是致死率，在全球各地仍被視為常見的緊急醫療議題，而台灣全年統計還是發生至少約400~600件蛇咬傷人的事件。這篇蛇咬傷流行病學的回顧研究將針對北台灣國軍桃園總醫院急診醫學部(emergency department, ED)自2006~2011整理的病例進行分析，內容包含流行病學，臨床症狀，治療經驗與被毒蛇噬咬毒害後病患的後遺症等。我們希望能夠藉此改善毒蛇咬傷之處置流程以及減少併發症的產生。
方法：將2006~2011年間於桃園國軍總醫院急診部被蛇咬傷的病人病歷資料進行整理回顧及分析。整理並收集病患的統計資料，導致疾病蛇的種類，不同種類毒蛇咬傷傷口表現，治療方式以及臨床流程等資訊。
結果：本研究分析收集來的156件蛇咬傷案例，其中病患年齡以40~49歲左右的病患占大多數的案例(約27%)。這些毒蛇種類包含龜殼花(58件，37.2%)，青竹絲(45件，28.2%)，眼鏡蛇(4件，2.65%)，雨傘節(4件，2.65%)，不知名蛇咬傷(29件，13.5%)以及無毒蛇咬傷(16件，10.3%)等。常見的蛇咬傷部位在患者上肢(52.5%)。這些案件中有十位病人(約占6.118%)需要進行外科手術治療，手術方式包含筋膜切開術，清創術以及皮膚移植。平均住院天數為2.08 ± 3.68天。其中9位毒蛇咬傷患者併發凝血功能障礙的後遺症，3位患者呈現急性腎衰竭的臨床病徵，這些患者透過積極的醫療救治後，患者康復的情形良好，沒有病患需要接受血液透析術治療。在156件被蛇咬傷的患者中，有77位(49.4%)患者住院接受更進一步的治療，74位(47.4%)患者在急診接受治療後直接返家，5位(3.2%)患者因不遵從醫囑而辦理自動出院。這些案件中只有一位患者因受到雨傘節的攻擊而導致死亡。
結論：毒蛇咬傷的病例在台灣並不少見，大多數發生在台灣的毒蛇咬傷病患由於能夠給予適時的治療，使得近幾年來因為毒蛇咬傷的致死率得到戲劇性的下降。造成致死率下降的主要因素當屬蛇咬傷的適度急救和及早給予抗蛇毒血清的標準急救程序之建立，雖然致死率下降但是毒蛇咬傷後卻會導致嚴重之併發症特別是人體軟組織的損傷。也因此目前更應該要發展針對毒蛇物種咬傷特定族群患者給予外科手術治療以及不同方法的治療程序來降低毒蛇咬傷的致死率。
Objective: To describe the epidemiology, clinical features, treatment and outcomes of patients with snake envenoming in northern Taiwan, Tauyuan. We hope to improve the management and decrease complications of snake bite.
Introduction: The incidence of snakebites decreased gradually in recent years due to change of the socioeconomic environment in Taiwan and uncontrolled killing. However, snake bite is a common medical emergency worldwide, still can cause severe morbidity and even death occasionally. There are at least 400-600 reported cases of snake bite annually in Taiwan. This is a retrospective study on the epidemiology of snakebites that were presented to an emergency department (ED) between 2006 and 2011. To describe the epidemiology, clinical features, treatment and outcomes of patients with snake envenoming in far north Taiwan, Tauyuan. We hope to improve the management and decrease complications.
Methods:Review of patients admitted with snake envenoming to Taoyuan Armed Forced General Hospital, Taiwan from 2006 to 2011. The patient’s demographic data, species of causative snake, manifestations of envenomation, treatment and clinical course were collected and analyzed.
Results:
There were 156 cases of snakebites collected. Most of the snakebites (27%) occurred in the fourth decade of age. The species of snakebites included: Taiwan habu bites (58 cases,37.2%),Taiwan bamboo viper bites (45 cases.28.2%), cobra bites (4 cases,2.65%), Taiwan banded krait bite (4 cases,2.65%), unknown bites (29 cases,13.5%) and non-poison snake bite(16 case,10.3%). The most common locations of the bite were in the upper extremity (52.5%). 10 patients (6.118%) required surgical intervention, including fasciotomy ,debridement and skin graft. The average lengths of hospital stay were 2.08±3.68 days. Nine patients developed some degree of coagulopathy Three patients developed laboratory features of acute renal insufficiency None of them received hemodialysis and all of them recovery well after aggressive treatment, Among 156 snake bite patients ,there are 77(49.4%) patients were admitted to hospital for further observation and treatment,74(47.4%) patients were discharged directly from ED, 5(3.2%) patients were discharged against medical advices. There was only one death in this series whom was bitten by Taiwan banded krait.
Conclusion: snake bite is not uncommon in Taiwan, in Northern Taiwan most of snake bite are due to hemorrhagic type appropriated first aid and early antivenin therapy were the gold standard treatment, the mortality rate of venomous snake bite was dramatically decreased in recent years but could cause severely complication especially soft tissue damage. Surgical intervention is indicated in a particular group of patients and different treatment algorithms should be developed according to snake species to decrease the morbidity of venomous snakebites. |
