1. 謝政昇 李俊達 鄭立福 王健興 吳孟熹 花蓮慈濟醫院外科部整形外科 Date: 2017/03/03
A five-year experience of the poisonous snakebites in the eastern Taiwan
謝政昇 李俊達 鄭立福 王健興 吳孟熹
花蓮慈濟醫院外科部整形外科
Date: 2017/03/03

2. Do you know about them?

3. Purpose of the study

4. To identify the demographic data, treatment, and result of the poisonous snakebites in the Eastern Taiwan.

5. Study method

6. Data collection: 2010/8/1~2015/6/30
ICD-9 code: 989.5, E905, and E906
Unknown snake bite with antivenom therapy at ER were included.
Total 48 patients
All of the data were reviewed from the chart

7. Result

8. Total patients number: 48
Male: 35 (72.9%), female: 13 (27.1%)
Mean age 53.33±14.45
龜殼花: 11 (23%), 青竹絲: 9 (19%), 百步蛇: 3 (6%), 眼鏡蛇: 17 (35%), 鎖鏈蛇: 1 (2%), 雨傘節: 1 (2%), Unknown: 6 (13%)
Non OP patients: 29(60.4%), OP patients:19 (39.6%)

9. Table 2 Demographics(N=48)
W/O OP
W/I OP
Total
P-value N
29 (60.4%)
19 (39.6%) 48
Age
53.69±11.92
52.79±18.01
53.33±14.46
0.836
LOS
6.76±6.42
29.32±11.80
15.69±14.22
<0.001*
Gender -
0.741
Male
22(75.9%)
13(68.4%)
35(72.9%)
Female
7(24.1%)
6(31.6%)
13(27.1%)
Site
0.452
Hand
17(58.6%)
8(42.1%)
25(52.1%)
Foot
11(37.9%)
9(47.4%)
20(41.7%)
Forearm
0(0.0%)
1(5.3%)
1(2.1%)
Leg
1(3.4%)
2(4.2%)
Extension
23(79.3%)
11(57.9%)
34(70.8%)
0.193
Antivenin
0.001*
Neutropic
4(13.8%)
15(31.3%)
Hemorrhagic
5(26.3%)
27(56.3%)
Combine
2(6.9%)
3(6.3%) NA
2(10.5%)

10. W/O OP
W/I OP
Total
P-value
Antivenin amount(ml)
54.29±27.68
70.00±33.54
60.22±30.64
0.096
Allergy
3(10.3%)
0(0.0%)
3(6.3%)
0.267
就醫間格時間 -
0.164
<1天
25(86.2%)
13(68.4%)
38(79.2%)
≧1天
4(13.8%)
6(31.6%)
10(20.8%)
毒蛇種類
<0.001*
眼鏡蛇/雨傘節
14(73.7%)
18(37.5%)
龜殼花/青竹絲/百步蛇
20(69.0%)
3(15.8%)
23(47.9%)
鎖鏈蛇/NA
5(17.2%)
2(10.5%)
7(14.6%)

12. Table 1 臨床症狀(N=48)
Clinical features
No. (%)
Systemic syndrome
Nausea
2(4%)
Vomiting
1(2%)
Drooling
Ptosis
Dysarthria
Dizziness
Fever
4(8%)
Shock
3(6%)
Oliguria
Dyspnea
Skeletal muscle injury
5(10%)
Pneumonia
Heart failure
Local symptoms
Swelling
46(96%)
Tenderness
Erythematous change
45(94%)
Bulla formation
15(31%)
Ecchymosis
12(25%)
Numbness
11(23%)

13. Cefazolin
Gentamycin
Oxacillin
Augmentin
Cephradine
毒蛇種類 N
眼鏡蛇
17 (35%) 2 3 5
龜殼花
11 (23%) 8 1
青竹絲
9 (19%) 6
百步蛇
3 (6%)
雨傘節
1 (2%)
鎖鏈蛇
Unkown
6 (13%) 4
Total 48 20 9
Penicillin
Flumarin
Tapimycin 1
Ceftazidine
Ertapenem
毒蛇種類 N
眼鏡蛇 17 1
龜殼花 11
青竹絲 9
百步蛇 3
雨傘節
鎖鏈蛇
Unkown 6
Total 48

14. Table 3 手術相關處置(N=19)
Item
No. (%) 術式
Debride
19(100%)
Fasciotomy
14(74%)
NPWT
8(42%)
傷口最後處理方式
STSG
9(47%)
Primary closure
5(26%)
Cross finger flap and FTSG
2(11%)
Open amputation
Free flap
FDMA flap
1(5%)
Rotation flap
術中發現
Necrosis
17(89%)
Abscess and pus
13(68%)
Hematoma accumulation
術後診斷
Necrotizing fascitis
10(53%)
Compartment syndrome
4(21%)
Wound infection with necrosis

15. 1. Total patients number: 19
Table 5 Bacterial isolates identified from snakebite wounds
Organisms
N(%)
Aerobic gram-negative bacteria
25(49%)
Morganella morganii 12
Acinetobacter baumannii 2
Pseudomonas aeruginosa
Enterobacter aerogenes 1
Shewanella putrefaciens
Serratia marcescens
Aeromonas hydrophila
E.coli
Acinetobacter lwoffii
Proteus vulgaris
Proteus mirabilis
Achromobacter
Aerobic gram-positive bacteria
20(39%)
Enterococcus species 10
CoNS 7
S.aureus
Bacillus species
Propionibacterium acnes
Anaerobic bacteria
5(10%)
Bacteroides fragilis 3
Bacteroides eggerthii
Clostridium paraputrificum
Eubacterium limosum
1(2%)
1. Total patients number: 19
2. 17 patients (89.5%) had positive culture finding.
3. 眼鏡蛇:14 (74%). 百步蛇:1 (5%), 龜殼花:1 (5%), Unknown:1 (5%)
3. Total pathogen numbers: 51

16. Table 6 毒蛇種類與細菌配養菌種的相關性
Species N
OP(%)
Aerobic gram -
Morganella morganii
Aerobic Gram +
Enterococcus species
Anaerobic
眼鏡蛇 17
14(82%)
12(70.6%)
11(64.7%)
9(52.9%)
5(29.4%)
龜殼花 11
2(18%)
0(0.0%)
青竹絲 9
0(0%)
百步蛇 3
1(33%)
1(33.3%)
2(66.7%)
雨傘節 1
鎖鏈蛇
Unknown 6
2(33%)
1(16.7%)
P-value
<0.001*
0.005*
0.199
Data are presented as n or percentage. *p-value<0.05 was considered statistically significant after test

17. Discussion

18. Patient number:21
Table 4 Bacterial isolates identified from snakebite wounds
Organisms
N(%)
Aerobic gram-negative bacteria
25(49%)
Morganella morganii 12
Acinetobacter baumannii 2
Pseudomonas aeruginosa
Enterobacter aerogenes 1
Shewanella putrefaciens
Serratia marcescens
Aeromonas hydrophila
E.coli
Acinetobacter lwoffii
Proteus vulgaris
Proteus mirabilis
Achromobacter
Aerobic gram-positive bacteria
20(39%)
Enterococcus species 10
CoNS 7
S.aureus
Bacillus species
Propionibacterium acnes
Anaerobic bacteria
5(10%)
Bacteroides fragilis 3
Bacteroides eggerthii
Clostridium paraputrificum
Eubacterium limosum
1(2%)
23%
63.9%
13.1%

19. 17 patients had cobra bite, 1 was bitten by T. mucrosquamatus, 1 by T
17 patients had cobra bite, 1 was bitten by T.mucrosquamatus, 1 by T. stejnegeri, and 2 by unknown species.
Our data showed the same tendency

20. Mixed bacterial infections were commonly observed
Cobra oral cavities=> M. morganii and Enterococcus
Snakebite wound abscesses=> M. morganii was the main GNB in many bacteriological studies
Our data also showed the same result

22. Combined broad spectrum antibiotics were needed to cover aerobes and anaerobes
In our cobra bite patients, 2 patient received cefazolin treatment, 3 patients received gentamycin treatment, 5 patients received augmentin treatment

23. Incomplete pathogen cover
Not enough sensitivity
Single antibiotic use (68.8%)
The combination antibiotics treatment may improve the infection rate from the cobra bite.

24. Conclusion
In this study, the cobra bite was related to the highest operation rate due to the high infection and tissue necrosis possibilities.
The most common pathogen from the cobra bite including M.morganii, Enterococcus, and B. fragilis.
Combined antibiotics treatment for GNB, GPC, and anaerobic pathogens may have benefit for patient who had a Cobra bite.

25. Limitation Retrospective study Data collection bias
We did not include the non-admission patient
No underlying disease collection
No antivenom dosage, antibiotics data, and local symptom data after admission.

26. Reference
Bacterial infection in association with snakebite: A 10-year experience in a northern Taiwan medical center Journal of Microbiology, Immunology and Infection (2011) 44, 456e460
Taiwan’s venomous snakebite: epidemiological, evolution and geographic differences Transactions of the Royal Society of Tropical Medicine and Hygiene (2004) 98, 96—101
MANAGEMENT OF POISONOUS SNAKE BITES IN SOUTHERN TAIWAN Kaohsiung J Med Sci 2007;23:511–8
Treatment of Venomous Snakebites in Eastern Taiwan J Plast Surg Asso R.O.C. 2009;18:257∼265
Can surgery in patient with Protobothrops mucrosquamatus envenomation be predicted in emergency department? Hong Kong j.emerg.med. 2016;23:
Can surgical need in patients with Naja atra (Taiwan or Chinese cobra) envenomation be predicted in the emergency department? Hong Kong Med J 2016;22:Epub DOI: /hkmj154739
Antivenom Therapy for Crotaline Snakebites: Has the Poison Control Center Provided Effective Guidelines? J Formos Med Assoc 2007;106(12):1057–1062

27. Thanks for your listening

28. W/O OP
W/I OP
Total
P-value
毒蛇種類
<0.001*
龜殼花 9
2 (18%) 11
青竹絲
眼鏡蛇 3
14 (82%) 17
百步蛇 2
1 (33%)
雨傘節 1
鎖鏈蛇
Unknown 4
2(33%) 6 29 19 48
W/O OP
W/I OP
Total
P-value
WBC count
0.097
<10000 14 9 23
10000~15000 10 4
15000~20000 5 3 8
>20000
N.seg -
0.452
<75% 18 28
>75% 11 20
N.Band
0.236
<3% 26 40
>3%
Platelet
0.687
<150000 2 7
>150000 24 17 41