蛇咬伤的综合管理：几个主要问题与治疗策略思考

葛欣博; 陈松; 冯卢; 颜时姣; 吕传柱

doi:10.13201/j.issn.1009-5918.2024.03.001

(编者按

蛇咬伤作为可防可治的疾病，全球每年却仍发生约540万例，8至13万人因此死亡，另约有三分之一的人永久性残疾。世卫组织已将毒蛇咬伤列为应高度重视的被忽视热带病之一，敦促各国加强预防、规范诊治和科普宣传。我国蛇咬伤多发生于农村偏远地区，目前尚缺乏流行病学监测和报告体系，蛇咬伤的发病率也被严重低估。面对这一公共卫生问题，尚需严谨、规范、严肃的态度来应对。本辑蛇伤专刊的推出，目的在于剖析中国蛇伤诊疗的系统性问题，推动系统性规范解决方案的全面实施，提高蛇伤防治的整体水平，进而降低我国蛇咬伤致死、致残率，这对于中国蛇咬伤防治具有重要意义。一起努力，让蛇伤患者零死亡零致残！让蛇伤患者的家庭不会因伤返贫和致贫！

)

蛇咬伤的综合管理：几个主要问题与治疗策略思考

- 1.
  海南医学院急诊创伤学院(海口，570216)
- 2.
  万宁市人民医院(海南医学院第一附属医院万宁医院)急诊科
- 3.
  四川省人民医院急诊外科
- 4.
  海南医学院公共卫生学院
- 5.
  四川省医学科学院·四川省人民医院急诊科、急救与创伤研究教育部重点实验室、中国医学科学院海岛急救创新单元
基金项目:
国家自然科学基金(No：81960346)

详细信息

作者简介:
专家简介：吕传柱，主任医师、二级教授、博士生导师、博士后合作导师、国务院特殊津贴专家、海南省B类高层次人才。四川省医学科学院·四川省人民医院、电子科技大学医学院急诊医学学科带头人、学术主任。兼任急救与创伤研究教育部重点实验室、中国医学科学院海岛急救创新单元、海南省创伤与灾难救援研究重点实验室、海南生物材料与医疗器械工程研究中心(急诊与创伤)、海南省急危重症临床医学研究中心、创伤医学院士工作站主任

通讯作者: 吕传柱，E-mail：lvchuanzhu677@126.com

中图分类号: R646

收稿日期: 2023-12-10

刊出日期: 2024-03-10

Comprehensive management of snakebite: key issues and consideration of treatment strategies

- 1.
  Emergency and Trauma College, Hainan Medical University, Haikou, 570216, China
- 2.
  Department of Emergency, People's Hospital of Wanning, Wanning Hospital, the First Affiliated Hospital of Hainan Medical University
- 3.
  Department of Emergency Surgery, Sichuan Provincial People's Hospital
- 4.
  Hainan Medical University International School of Public Health and One Health
- 5.
  Department of Emergency, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Key Laboratory of Emergency and Trauma of Ministry of Education

More Information

Corresponding author: LV Chuanzhu, E-mail: lvchuanzhu677@126.com

Received Date: 10 December 2023

Publish Date: 10 March 2024

摘要

摘要: 毒蛇咬伤作为临床常见的急危中毒性疾病，具有发病速度快、症状多样，致残率及死亡率高的特点。自2009年世界卫生组织将蛇咬伤纳入被忽视的热带病名单以来，蛇咬伤的问题引起了全球范围内的广泛关注。近年来，中国发布了《2018年中国蛇伤救治专家共识》和《常见动物致伤诊疗规范(2021年版)》(国家卫健委)，这些指导性的专家意见和政府文件对规范蛇咬伤的临床诊疗起着非常重要的作用。尽管如此，中国蛇咬伤的总体死亡率、致残率和总体卫生经济负担依然较高。本文通过广泛收集、整理和分析国内外代表性文献及指南，以问题为导向，对蛇咬伤的救治现状进行系统述评。
- 蛇咬伤 /
- 流行病学 /
- 抗蛇毒血清 /
- 治疗策略 /
- 综合管理
Abstract: As a common acute and critical toxic disease in clinic, snakebite has the characteristics of rapid onset, diverse symptoms, high disability rate and high mortality rate. Since the World Health Organization added snakebites to its list of neglected tropical diseases in 2009, the issue of snakebites has attracted widespread attention worldwide. In recent years, China has issued the 2018 Expert Consensus on the Treatment of Snake Wounds and the National Health Commission's Code for the Diagnosis and Treatment of Common Animal Injuries (2021 edition), which play a very important role in regulating the clinical diagnosis and treatment of snake bites. However, the overall mortality rate, disability rate and overall health economic burden from snakebites in China remain high. Through extensive collection, collation and analysis of domestic and foreign representative literature and guidelines, this paper systematically reviews the current situation of treatment of snakebite.
- snakebite /
- epidemiology /
- antivenom /
- treatment strategies /
- comprehensive management

HTML全文

参考文献(31)

[1]	WHO. Snakebite envenoming[EB/OL]. World Health Organization, 2023. https://www.who.int/news-room/fact-sheets/detail/snakebite-envenoming.
[2]	Roberts NLS, Johnson EK, Zeng SM, et al. Global mortality of snakebite envenoming between 1990 and 2019[J]. Nat Commun, 2022, 13(1): 6160. doi: 10.1038/s41467-022-33627-9
[3]	杨展正, 张作鹏, 岑青燕, 等. 2010-2019年广州及周边地区毒蛇伤流行病学分析[J]. 岭南急诊医学杂志, 2021, 26(1): 29-32. doi: 10.3969/j.issn.1671-301X.2021.01.011
[4]	龚旭初, 杨万富. 国内毒蛇咬伤流行病学研究现状[J]. 中国中医急症, 2012, 21(5): 778-780. doi: 10.3969/j.issn.1004-745X.2012.05.051
[5]	国家卫生健康委员会. 常见动物致伤诊疗规范(2021版)[S/OL]. [2021-07-29]. http://www.gov.cn.
[6]	Silva A, Hodgson WC, Isbister GK. Antivenom for Neuromuscular Paralysis Resulting From Snake Envenoming[J]. Toxins(Basel), 2017, 9(4): 143.
[7]	Valenta J, Hlavackova A, Stach Z, et al. Fibrinogenolysis in Venom-Induced Consumption Coagulopathy after Viperidae Snakebites: A Pilot Study[J]. Toxins(Basel), 2022, 14(8): 538.
[8]	王威, 李其斌, 陈泉芳, 等. 中华眼镜蛇咬伤中毒患者256例临床特点分析[J]. 山东医药, 2012, 52(33): 46-48. doi: 10.3969/j.issn.1002-266X.2012.33.017
[9]	Seifert SA, Armitage JO, Sanchez EE. Snake Envenomation[J]. N Engl J Med, 2022, 386(1): 68-78. doi: 10.1056/NEJMra2105228
[10]	Li QB, Huang GW, Kinjoh K, et al. Hematological studies on DIC-like findings observed in patients with snakebite in south China[J]. Toxicon, 2001, 39(7): 943-948. doi: 10.1016/S0041-0101(00)00232-4
[11]	中国蛇伤救治专家共识专家组. 2018年中国蛇伤救治专家共识[J]. 中华急诊医学杂志, 2018, 27(12): 1315-1322. https://cpfd.cnki.com.cn/Article/CPFDTOTAL-JXZX201919001003.htm
[12]	Avau B, Borra V, Vandekerckhove P, et al. The Treatment of Snake Bites in a First Aid Setting: A Systematic Review[J]. PLoS Negl Trop Dis, 2016, 10(10): e0005079. doi: 10.1371/journal.pntd.0005079
[13]	Smyrnioudis ME, O'Rourke DP, Rosenbaum MD, et al. Long-term efficacy of pressure immobilization bandages in a porcine model of coral snake envenomation[J]. Am J Emerg Med, 2014, 32(9): 1024-1026. doi: 10.1016/j.ajem.2014.06.002
[14]	Spyres MB, Skolnik AB, Moore EC, et al. Comparison of Antivenom Dosing Strategies for Rattlesnake Envenomation[J]. Crit Care Med, 2018, 46(6): e540-e544. doi: 10.1097/CCM.0000000000003079
[15]	Dart RC, McNally J. Efficacy, safety, and use of snake antivenoms in the United States[J]. Ann Emerg Med, 2001, 37(2): 181-188. doi: 10.1067/mem.2001.113372
[16]	Noutsos T, Currie BJ, Lek RA, et al. Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis[J]. PLoS Negl Trop Dis, 2020, 14(12): e0008936. doi: 10.1371/journal.pntd.0008936
[17]	Isbister GK, Noutsos T, Jenkins S, et al. D-dimer testing for early detection of venom-induced consumption coagulopathy after snakebite in Australia(ASP-29)[J]. Med J Aust, 2022, 217(4): 203-207. doi: 10.5694/mja2.51589
[18]	Maduwage K, Isbister GK. Current treatment for venom-induced consumption coagulopathy resulting from snakebite[J]. PLoS Negl Trop Dis, 2014, 8(10): e3220. doi: 10.1371/journal.pntd.0003220
[19]	陈康德, 羊梅兰. 抗蛇毒血清的研究和临床应用概述[J]. 蛇志, 2000, 12(3): 65-68. https://www.cnki.com.cn/Article/CJFDTOTAL-SZZZ200003041.htm
[20]	Sriapha C, Rittilert P, Vasaruchapong T, et al. Early Adverse Reactions to Snake Antivenom: Poison Center Data Analysis[J]. Toxins(Basel), 2022, 14(10): 694.
[21]	Seifert SA, Boyer LV. Recurrence phenomena after immunoglobulin therapy for snake envenomations: Part 1. Pharmacokinetics and pharmacodynamics of immunoglobulin antivenoms and related antibodies[J]. Ann Emerg Med, 2001, 37(2): 189-195. doi: 10.1067/mem.2001.113135
[22]	Brown SA, Seifert SA, Rayburn WF. Management of envenomations during pregnancy[J]. Clin Toxicol(Phila), 2013, 51(1): 3-15. doi: 10.3109/15563650.2012.760127
[23]	Langley RL. Snakebite during pregnancy: a literature review[J]. Wilderness Environ Med, 2010, 21(1): 54-60. doi: 10.1016/j.wem.2009.12.025
[24]	de Silva HA, Ryan NM, de Silva HJ. Adverse reactions to snake antivenom, and their prevention and treatment[J]. Br J Clin Pharmacol, 2016, 81(3): 446-452. doi: 10.1111/bcp.12739
[25]	Morais V. Antivenom therapy: efficacy of premedication for the prevention of adverse reactions[J]. J Venom Anim Toxins Incl Trop Dis, 2018, 24: 7. doi: 10.1186/s40409-018-0144-0
[26]	Walls R, Hockberger R, Gausche-Hill M, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice[M]. 10th ed. Philadelphia: Elsevier, 2023.
[27]	中华中医药学会外科分会. 毒蛇咬伤中医诊疗方案专家共识(2016版)[J]. 中医杂志, 2017, 58(4): 357-360. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZYZ201704022.htm
[28]	陈海东, 龚旭初, 张允申, 等. 蝮蛇解毒汤治疗蝮蛇咬伤的临床研究[J]. 中华中医药杂志, 2018, 33(12): 5738-5742. https://www.cnki.com.cn/Article/CJFDTOTAL-BXYY201812124.htm
[29]	李果, 高云水, 容伟明, 等. 中西医治疗毒蛇咬伤的研究进展[J]. 中国中医急症, 2023, 32(9): 1681-1684, 1692. https://www.cnki.com.cn/Article/CJFDTOTAL-ZYJZ202309046.htm
[30]	Xiao H, Pan H, Liao K, et al. Snake Venom PLA2, a Promising Target for Broad-Spectrum Antivenom Drug Development[J]. Biomed Res Int, 2017, 2017: 6592820.
[31]	Lewin M, Samuel S, Merkel J, et al. Varespladib(LY315920) Appears to Be a Potent, Broad-Spectrum, Inhibitor of Snake Venom Phospholipase A2 and a Possible Pre-Referral Treatment for Envenomation[J]. Toxins(Basel), 2016, 8(9): 248.