Vol.1 No.3 (December 2011)
Snake Bites in Taiwan
Located at the juncture of tropical and subtropical regions, Taiwan has a warm and humid climate with abundant precipitation and food, which coupled with the island’s diverse vegetation and landscape, makes it a suitable environment for many snake species. Among these, there are six kinds of poisonous snake with epidemiological significance. Three species induce hemorrhagic symptoms (Trimeresurus mucrosquamatus, TM; Trimeresurus stejnegeri, TS; and Deinagkistrodon acutus, DA); two species induce neurotoxic symptoms (Naja naja atra, NA; and Bungarus multicinctus, BM); the other species induces hemorrhagic and neurotoxic symptoms (Vipera russelli formosensis. VR).The hemorrhagic venom causes disorders of the clotting cascade such as prolonged bleeding, primary fibrinolysis and disseminated intravascular coagulopathy. The neurotoxic venom provokes respiratory distress from weakened respiratory muscles, blurred vision, diplopia, dysarthria, dysphagia, dysphonia and paralysis of extremity muscles. The mixed envenomation manifests as a combination of neurotoxic and hemorrhagic effects previously described, as well as rhabdomyolysis and acute renal failure. The identification of snake species is important if antivenom is to be used. However, the species is not ably identified if the patient or companion fails to see or catch the responsible snake. Although these unidentifiable snakes could be non-venomous, venomous species are not uncommon. Therefore, guidelines for snakebite identification based on clinical symptoms and laboratory analysis is important to improve clinical diagnosis of snakebites. In Taiwan, T. stejnegeri bites are the most common. The second is T. mucrosquamatus. Naja naja atra is the third, Bungarus multicinctus is the forth and Vipera russelli formosen-sis is the fifth. Deinagkistrodon acutus is the least. Bites by Deinagkistrodon acutus and Vipera russelli for-mosensis generally occur in the south and east parts of the island. Aggressive antivenom treatment can reduce snakebite mortality rate, but for Bungarus multicinctus bites, maintaining the patient’s airway and supporting their ventilation is vital to reducing mortality rate in addition to antivenom treatment. For dry bites or no en-venomation, the patient should be observed for at least 6 - 12 hours before discharged. The emergency physi-cian should determine the severity of envenomation and predominate venom activity before decide what type of antivenin to administer, how much, and over what period. History of exposure, local effect and systemic syndromes of envenomation, progression of symptoms and signs, laboratory data obtained in emergency de-partment should guide the decision for antivenom therapy. The freeze-dried antivenom was diluted with 50 - 100 mL of normal saline and infused intravenously for half to one hour. The poisonous snake bites in the lat-ter 4 hours to give the effect to be best, surpasses 8 hours only then to inject the effect to be bad. The dosage most toxicologists used for treating pediatric patients with snakebites was the same as that for adults. In gen-eral, 6 - 12 vials of antivenom against neurotoxic venom were used for Naja atra bite and 2 - 4 vials for Bun-garus multicinctus; 1 - 2 vials of antivenom against hemotoxic venom was used for Trimeresurus stejnegeri and 2 - 4 vials for Trimeresurus mucrosquamatus; 2 - 4 vials of anti-Deinagkistrodon acutus were used for Deinagkistrodon acutus and 2 - 4 vials of anti-Vipera russelli formosensis were used for Vipera russelli for-mosensis bite. During the infusion, the blood pressure, consciousness and skin reaction were evaluated. Keeping the varied clinical manifestations of snake bite in mind is important for effective management. Ready availability and appropriate use of antivenin, close monitoring of patients and institution of ventilatory support, all help reduce mortality.
阮祺文 (2011) 毒蛇咬伤台湾经验。 临床医学进展， 1， 37-47. doi: 10.12677/acm.2011.13008
 毛寿先, 殷凤仪. 台湾常见陆地毒蛇简介[J]. 台湾省立博物馆, 1990.
 Y. Sawai. Snakebites on Taiwan. The Snake, 1969, 1: 9-18.
 洪东荣. 台湾常见的毒蛇及咬伤之治疗[J]. 毒药物季刊, 行政院卫生署临床毒药物咨询中心, 1996.
 B. L. Miao, R. J. Huang, M. S. Hu, et al. Venomous snakebite in Taiwan (1988-1991). Chinese Journal of Public Health (Taipei), 1995, 14: 455-460.
 D. Z. Hung. Taiwan’s venomous snakebite: Epidemiological, evolution and geographic differences. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2004, 98(2): 96-101.
 B. K. Nelson. Snake evenomation: Incidence, clinical presentation and management. Medical Toxicology, 1989, 4(1): 17-31.
 D. A. Warrell. Snake venoms in science and clinical medicine 1. Russell’s viper: Biology, venom and treatment of bites. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1989, 83(6): 732-740.
 M. Y. Justin, L. Mark, M. M. Lindsay, et al. Antivenom dosing in 35 patient with severe brown snake (Pseugonaja) envenoming in Western Australia over 10 years. Medical Journal of Australia, 2004, 181(11-12): 703-705.
 R. N. H. Pugh, R. D. G. Theakston. A clinical study of viper bite poisoning. Annals of Tropical Medicine and Parasitology, 1987, 81(2): 135-149.
 P. W. Coetzer, C. R. Tilbury. The epidemiology of snakebite in northern Natal. South African Medical Journal, 1982, 62(7): 206-212.
 Y. Sawai, et al. An Epidemiological study of snake bite in the southest Asia. South African Medical Journal, 1972, 42(3): 283- 307.
 C. Pochanugool, H. Wildde, K. Bhanganada, et al. Venomous snakebite in Thailand. II: Clinical experience. Military Medicine, 1998, 163(5): 318-323.
 R. Blaylock. Epidemiology of snakebite in Eshowe, KwaZulu- Natal, South Africa. Toxicon, 2004, 43(2): 159-166.
 Behrman: Nelson Textbook of Pediatrics, 17th Edition, Saunder, An Imprint of Elsevier. Chapter 708—Envenomations, 2004.
 C. C. Snyder, R. P. Knowles. Snakebites, Guidelines for practical management. Postgraduate Medical, 1988, 83(6): 52-60, 65- 68, 71-75.
 H. M. Parrish. Incidence of treated snakebites in the United States. Public Health Reports, 1966, 81(3): 269-276.
 C. A. Johnson. Management of snakebite. American Family Physician, 1991, 44(1): 174-180.
 P. Consroe, N. B. Egen, F. E. Russell, et al. Comparison of a new ovine antigen binding fragment (Fab) antivenin for United States Crotalidae with the commercial antivenin for protection against venom-induced lethality in mice. American Journal of Tropical Medicine and Hygiene, 1995, 53(5): 507-510.
 G. Juckett. Snakebite. In: R. E. Rakel, Ed., Saunders manual of medical practice. Saunders, New York, 2000: 1525-1528.
 T. P. Kuo, C. S. Wu. Clinico-pathological studies o snakebites in Taiwan. Journal of the Formosan Medical Association, 1972, 71(7): 447-466.
 J. C. Chen, S. J. Liaw, M. J. Bullard, et al. Treatment of poisonous snakebites in northern Taiwan. Journal of the Formosan Medical Association, 2000, 99(2): 135-139.
 W. B. Liao, C. W. Lee, Y. S. Tsai, et al. Influential factors affecting prognosis of snakebite patients’ management: Kaohsiung Chang Cung Momorial hospital experience. Chang Cung Medical Journal, 2000, 23(10): 577-583.
 M. Ovadia. Isolation and characterization of three hemorrhagic factors from the venom of Vipera palaestinae. Toxicon, 1978, 16(5): 479-487.
 I. H. Tsai, Y. M. Wang, Y. H. Chen, T. S. Tsai and Mc. Tu. Venom phospholipase A2 of bamboo veper (Trimeresurus stejnegeri): Molecular characterization, geographic variations and evidence of multiple ancestries. Biochemical Journal, 2004, 377: 215-223.
 C. Ouyang, C. M. Teng. Fibrinogenolytic enzymes of Trimeresurus mucrosquamatus venom. Biochimica et Biophysica Acta, 1976, 420(2): 298-308.
 C. Ouyang, C. M. Teng. The action mechanism of the purified platelet aggregation principle of Trimeresurus mucrosquanatus venom. Thrombosis and Haemostasis, 1976, 41(3): 475-490.
 F. McGain, L. Aaron, J. W. David, et al. Snakebite mortality at Port Moresby General Hospital, Papua New Guinea, 1992-2001. Medical Journal of Australia, 2004; 181(11-12): 687-691.
 C. Ouyang, T. F. Huang. Platelet aggregation inhibitors from Agkistrodon acutus snake venom. Toxicon, 1986, 24(11-12): 1099-1106.
 R. H. Chen, Y. C. Chen. Isolation of an acidic phospholipase A2 from the venom of Agkistrodon acutus (five pace snake) and its effect on platelet aggregation. Toxicon, 1989, 27(6): 675-682.
 C. C. Chen, C. M. Yang, F. R. Hu and Y. C. Lee. Penetrating ocular injury caused by venomous snakebite. American Journal of Ophthalmology, 2005, 140(3): 544-546.
 C. Y. Lee. Elapid Neurotoxins and mode of action. Clinical Toxicology, 1970, 3(3): 457-472.
 M. K. Lai, C. Y. Wen and C. Y. Lee. Local lesions caused by cardiotoxin isolated from Formosan cobra venom. Journal of the Formosan Medical Association, 1972, 71(6): 328-332.
 D. Z. Hung, M. Y. Liau and S. Y. Lin-Shiau. The clinical significance of venom detection in patients of cobra snakebite. Toxicon, 2003, 41(4): 409-415.
 T. L. Kao, C. W. Juan. Tongue viability after snakebite-an unusual occupational hazard. American Journal of Emergency Medicine, 2007, 25(9): 1083.e5-1083.e7.
 C. W. Juan, F. S. Wu, W. H. Chang, C. N. Lee and C. C. Chou. A case of envenomation by Bungarus Multicinctus. Journal of Emergency and Intensive Care Medicine, 1999, 10(2): 109-113.
 S. Limthongdul, C. Pochanugool and K. Meemano. Respiratory failure and its non-antivenin treatment in 37 adult neurotoxin snake-bite patients. In: P. Gopalakrishnakone and C. K. Tan, Eds., Progress in Venom and Toxin Research. Singapoye: Faculty of Medicine, National University of Singapore, 1987: 52-59.
 D. Z. Hung, M. L. Wu, J. F. Deng and S. Y. Lin-Shiau. Russell’s viper snakebite in Taiwan: Differences from other Asian countries. Toxicon, 2002, 40(9): 1291-1298.
 T. S. Chou, T. J. Lin, M. C. Kuo, T. Mee-Sun, D. Z. Hung and J. L. Tsai. Eight cases of acute renal failure from Vipera russelli formosensis venom after administration of antivenom. Veterinary and Human Toxicology, 2002, 44(5): 278-282.
 D. Z. Hung, Y. J. Yu, C. L. Hsu and T. J. Lin. Antivenom treatment and renal dysfunction in Russell’s viper snakebite in Taiwan: A case series. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2006, 100(5): 489-494.
 D. Z. Hung, M. L. Wu, J. F. Peng, D. Y. Yang and S. Y. Lin-Shiau. Multiple thrombotic occlusions of vessels after Russell’s Viper Envenoming. Pharmacology amd Toxicology, 2002, 91(3): 106-110.
 K. P. Chang, C. S. Lai and S. D. Lin. Management of poisonous snake bites in southern Taiwan. Kaohsiung Journal of Medical, 2007, 23(10): 511-518.
 C. M. Yu, W. C. Huang, K. Y. Tung, H. T. Hsiao and S. Y. Ou. Prognostic factors of local necrosis due to poisonous snakebite-a clinical reciew in Mackay Memorial Hospital. Journal of Plastic Surgical Association R.O.C. 2005, 14(1): 31-40.
 J. B. Lopoo, J. F. Bealer, P. C. Mantor and D. W. Tuggle. Treating the snakebitten child in North America: A study of pit viper bites. Journal of Pediatric Surgery, 1998, 33(11): 1593-1595.
 H. M. Parrish, J. C. Goldner and S. L. Silberg. Comparison between snakebites in children and adults. Pediatrics. 1965, 36(2): 251-256.
 R. A. Weber, R. R. White. Crotalidae envenomation in children. Annals of Plastic Annals of Plastic Surgery, 1993, 2: 142-145.
 C. F. Chen, T. J. Lin, W. C. Hsu and H. W. Yang. Appropriate antivenom doses for six types of envenomations caused by snakes in Taiwan. Journal of Venomous Animals and Toxins Including Tropical Diseases, 2009, 15(3): 479-490.