Envenomation by Trimeresurus stejnegeri stejnegeri: clinical manifestations, treatment and associated factors for wound necrosis

Abstract Background: Trimeresurus stejnegeri stejnegeri bite induces tissue swelling, pain, thrombocytopenia, rhabdomyolysis, and acute renal failure. However, the incidence of coagulopathy, factors associated with wound necrosis, and the appropriate management of this condition have not been well characterized yet. Materials: This study included patients bitten by T. s. stejnegeri that were admitted to the study hospitals from 2001 to 2016. Patient characteristics, laboratory data, and management approaches were compared in victims with and without wound necrosis. Results: A total of 185 patients were evaluated: three patients (1.6%) were asymptomatic; whereas tissue swelling and pain, local ecchymosis, wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and renal impairment were present in 182, 53, 13, 15, 10, 1, and 3 patients, respectively. One patient died from coagulopathy and hemorrhagic shock. Antivenom was administered to all envenomed patients at a median time of 1.8 h after the bite. The median total dose of antivenom was five vials. Chi-square analysis showed that bitten fingers, using cold packs during first aid, presence of bullae or blisters, lymphangitis or lymphadenitis, local numbness and suspected infection to be significantly associated with wound necrosis. After adjustment using a multivariate logistic regression model, only cold packs as first aid, bulla or blister formation, and wound infection remained significant. Conclusions: The main effects of T. s. stejnegeri envenomation are tissue swelling, pain, and local ecchymosis. We do not recommend the use of cold packs during first aid to reduce wound pain, as this may be a risk factor for wound necrosis. In addition, patients with bulla or blister formation should be carefully examined for subsequent wound necrosis. Antiplatelet use may worsen systemic bleeding. No severe rhabdomyolysis or renal failure was observed in this large case series, we therefore considered that they were not prominent effects of T. s. stejnegeri bite.

摘要
背景：三索蛇属 Stejnegeri stejnegeri 的咬伤可引起组织肿胀、疼痛、血小板减少症、横纹肌溶解和急性肾衰竭。然而，关于凝血功能障碍、与伤口坏疽相关的因素以及该状况的适宜管理方法尚未得到充分描述。
材料：本研究纳入了2001年至2016年间被三索蛇属 Stejnegeri stejnegeri 咬伤并入住研究医院的患者。比较了有伤口坏疽和无伤口坏疽的患者的临床特征、实验室数据和治疗方法。
结果：共评估了185名患者：其中3名患者（1.6%）无症状；182名患者分别出现组织肿胀和疼痛、局部瘀斑、伤口坏疽、凝血功能障碍、血小板减少症、横纹肌溶解和肾脏损伤；1名患者因凝血功能障碍和失血性休克死亡。所有被咬伤的患者在咬伤后1.8小时的中位时间内接受了抗蛇毒血清治疗。抗蛇毒血清的总中位剂量为五瓶。卡方分析显示，咬伤手指、急救时使用冰袋、出现水疱或泡、淋巴管炎或淋巴结炎、局部麻木以及疑似感染与伤口坏疽显著相关。在多因素逻辑回归模型调整后，仅急救时使用冰袋、水疱或泡的形成和伤口感染仍然具有统计学意义。
结论：三索蛇属 Stejnegeri stejnegeri 毒液的主要影响为组织肿胀、疼痛和局部瘀斑。我们不推荐在急救时使用冰袋以减轻伤口疼痛，因为这可能是伤口坏疽的风险因素。此外，对于出现水疱或泡的患者，应仔细检查以防止后续发生伤口坏疽。抗血小板药物的使用可能会加剧全身出血。在本大病例系列中未观察到严重的横纹肌溶解或肾衰竭，因此我们认为它们不是三索蛇属 Stejnegeri stejnegeri 咬伤的显著影响。