• 1.

    Gutierrez JM, Calvete JJ, Habib AG, Harrison RA, Williams DJ, Warrell DA, 2017. Snakebite envenoming. Nat Rev Dis Primers 3: 17063.

  • 2.

    Chippaux JP, 1998. Snake-bites: appraisal of the global situation. Bull World Health Organ 76: 515524.

  • 3.

    Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F, 2010. Snake bite in South Asia: a review. PLoS Negl Trop Dis 4: e603.

  • 4.

    Mao YC, Liu PY, Chiang LC, Lai CS, Lai KL, Ho CH, Wang TW, Yang CC, 2018. Naja atra snakebite in Taiwan. Clin Toxicol (Phila) 56: 273280.

  • 5.

    Mao YC, Liu PY, Chiang LC, Liao SC, Su HY, Hsieh SY, Yang CC, 2017. Bungarus multicinctus snakebite in Taiwan. Am J Trop Med Hyg 96: 14971504.

  • 6.

    Lin CC, Chaou CH, Tseng CY, 2016. An investigation of snakebite antivenom usage in Taiwan. J Formos Med Assoc 115: 672677.

  • 7.

    Liu CH, Xie WQ, 2017. Analysis of the Use of Antivenom in 2008–2012 by the Health Insurance Database. Available at: https://www.cdc.gov.tw/File/Get/N_uqcZoh1VZrxEfY1JUigA. Accessed May 9, 2017.

    • Search Google Scholar
    • Export Citation
  • 8.

    Warrell DA, 2010. Guidelines for the Management of Snake-Bites. Geneva, Switzerland: World Health Organization.

  • 9.

    WHO, Staff ROfS-EA, 2016. Guidelines for the Management of Snakebites, 2nd Edition. Geneva, Switzerland: World Health Organization.

  • 10.

    Vasaruchapong T, Laoungbua P, Tangrattanapibul K, Tawan T, Chanhome L, 2017. Protobothrops mucrosquamatus (Cantor, 1839), a highly venomous species added to the snake fauna of Thailand (Squamata: Viperidae). Trop Nat Hist 17: 111115.

    • Search Google Scholar
    • Export Citation
  • 11.

    Leviton AE, Wogan G, Koo M, Zug GR, Lucas R, Vindum J, 2003. The dangerously venomous snakes of Myanmar. Illustrated key and checklist. Proc Calif Acad Sci 54: 407462.

    • Search Google Scholar
    • Export Citation
  • 12.

    Aengals R, Kumar VS, Palot MJ, 2011. Updated checklist of Indian reptiles. Occasional Papers, Zoological Survey of India, 24 pp.

  • 13.

    Guo P, Liu Q, Zhu F, Zhong GH, Che J, Wang P, Xie YL, Murphy RW, Malhotra A, 2019. Multilocus phylogeography of the brown-spotted pitviper Protobothrops mucrosquamatus (Reptilia: Serpentes: Viperidae) sheds a new light on the diversification pattern in Asia. Mol Phylogenet Evol 133: 8291.

    • Search Google Scholar
    • Export Citation
  • 14.

    Zhong G, Liu Q, Li C, Peng P, Guo P, 2017. Sexual dimorphism and geographic variation in the asian lance-headed pitviper Protobothrops mucrosquamatus in the mainland China. Asian Herpetol Res 8: 118122.

    • Search Google Scholar
    • Export Citation
  • 15.

    Tan CH, Tan KY, Ng TS, Quah ESH, Ismail AK, Khomvilai S, Sitprija V, Tan NH, 2019. Venomics of Trimeresurus (popeia) nebularis, the cameron highlands pit viper from Malaysia: insights into venom proteome, toxicity and neutralization of antivenom. Toxins (Basel) 11: 95.

    • Search Google Scholar
    • Export Citation
  • 16.

    Orlov N, Ananjeva N, Khalikov R, 2002. Natural history of pitvipers in eastern and southeastern Asia. Biol Vipers 345361.

  • 17.

    Chen YW, Chen MH, Chen YC, Hung DZ, Chen CK, Yen DHT, Huang CI, Lee CH, Wang LM, Yang CC, 2009. Differences in clinical profiles of patients with Protobothrops mucrosquamatus and Viridovipera stejnegeri envenoming in Taiwan. Am J Trop Med Hyg 80: 2832.

    • Search Google Scholar
    • Export Citation
  • 18.

    Juan CW, 2012. Venomous snake bites in Taiwan. Taiwan Soc Crit Care Med 23: 93108.

  • 19.

    Hung DZ, 2004. Taiwan’s venomous snakebite: epidemiological, evolution and geographic differences. Trans R Soc Trop Med Hyg 98: 96101.

    • Search Google Scholar
    • Export Citation
  • 21.

    Villalta M et al. 2012. Snake venomics and antivenomics of Protobothrops mucrosquamatus and Viridovipera stejnegeri from Taiwan: keys to understand the variable immune response in horses. J Proteomics 75: 56285645.

    • Search Google Scholar
    • Export Citation
  • 22.

    Liu CH, Li CJ, Li J, 2015. Application research of snake venom protein and anti-venom serum manufacturing technology. Taiwan Epidemiol Bull 31: 7685.

    • Search Google Scholar
    • Export Citation
  • 23.

    Tsai YH, Hsu WH, Huang KC, Yu PA, Chen CL, Kuo LT, 2017 Necrotizing fasciitis following venomous snakebites in a tertiary hospital of southwest Taiwan. Int J Infect Dis 63: 3036.

    • Search Google Scholar
    • Export Citation
  • 24.

    Chen YC, Chen MH, Wang LM, Wu JJJ, Huang CI, Lee CH, Yen DHT, Yang CC, 2007. Antivenom therapy for crotaline snakebites: has the poison control center provided effective guidelines? J Formos Med Assoc 106: 10571062.

    • Search Google Scholar
    • Export Citation
  • 25.

    Lin CC, Wang PJ, Liu CC, 2019. Venom concentrations in blisters and hemorrhagic bullae in a patient bitten by a Taiwan habu (Protobothrops mucrosquamatus). Rev Soc Bras Med Trop 52: e20180160.

    • Search Google Scholar
    • Export Citation
  • 26.

    Mao YC, Hung DZ, 2015. Management of snake envenomation in Taiwan. In: Gopalakrishnakone P, Faiz A, Fernando R, Gnanathasan C, Habib A, Yang CC, eds. Clinical Toxinology in Asia Pacific and Africa. Toxinology, vol 2. Dordrecht: Springer.

    • Search Google Scholar
    • Export Citation
  • 27.

    Anderson VE et al. 2019. Early administration of Fab antivenom resulted in faster limb recovery in copperhead snake envenomation patients. Clin Toxicol (Phila) 57: 2530.

    • Search Google Scholar
    • Export Citation
  • 28.

    Chen JC, Bullard MJ, Chiu TF, Ng CJ, Liaw SJ, 2000. Risk of immediate effects from F(ab)2 bivalent antivenin in Taiwan. Wilderness Environ Med 11: 163167.

    • Search Google Scholar
    • Export Citation
  • 29.

    Sampson HA et al. 2006. Second symposium on the definition and management of anaphylaxis: summary report--Second national institute of allergy and infectious disease/food allergy and anaphylaxis network symposium. J Allergy Clin Immunol 117: 391397.

    • Search Google Scholar
    • Export Citation
  • 30.

    Chuang PC, Chang KW, Cheng FJ, Wu MH, Tsai MT, Li CJ, 2019. Risk factors associated with snake antivenom reaction and the role of skin test. Acta Trop 203: 105293.

    • Search Google Scholar
    • Export Citation
  • 31.

    Thiansookon A, Rojnuckarin P, 2008. Low incidence of early reactions to horse-derived F(ab′)(2) antivenom for snakebites in Thailand. Acta Trop 105: 203205.

    • Search Google Scholar
    • Export Citation
  • 32.

    Seak CJ, Fang CC, 2018. Celebrating the 20th anniversary of emergency medicine specialty in taiwan. J Acute Med 8: 15.

  • 33.

    Kobayashi KJ, Knuesel SJ, White BA, Bravard MA, Chang Y, Metlay JP, Raja AS, Mattison MLp, 2019. Impact on length of stay of a hospital medicine emergency department boarder service. J Hosp Med 14: E1E7.

    • Search Google Scholar
    • Export Citation
  • 34.

    Pham HX, Mullins ME, 2018. Safety of nonsteroidal anti-inflammatory drugs in copperhead snakebite patients. Clin Toxicol (Phila) 56: 11211127.

    • Search Google Scholar
    • Export Citation
  • 35.

    Butler MM et al. 2016. Emergency department prescription opioids as an initial exposure preceding addiction. Ann Emerg Med 68: 202208.

  • 36.

    Shah A, Hayes CJ, Martin BC, 2017. Factors influencing long-term opioid use among opioid naive patients: an examination of initial prescription characteristics and pain etiologies. J Pain 18: 13741383.

    • Search Google Scholar
    • Export Citation
  • 37.

    Freiermuth CE, Lavonas EJ, Anderson VE, Kleinschmidt KC, Sharma K, Rapp-Olsson M, Gerardo C; Copperhead Recovery Workgroup, 2019. Antivenom treatment is associated with fewer patients using opioids after copperhead envenomation. West J Emerg Med 20: 497505.

    • Search Google Scholar
    • Export Citation
 
 
 

 

 
 
 

 

 

 

 

 

 

Benefits of Early In-Hospital Antivenom Administration to Patients with Protobothrops mucrosquamatus Envenomation

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  • 1 Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan;
  • | 2 Chang Gung University College of Medicine, Taoyuan City, Taiwan

ABSTRACT

Protobothrops mucrosquamatus is one of the common venomous snakes in Southeast Asia. This retrospective cohort study conducted in six medical institutions in Taiwan aimed to obtain information on the optimal management strategies for P. mucrosquamatus snakebite envenomation. Data were extracted from the Chang Gung Research Database from January 2006 to December 2016. The association between early antivenom administration and patient demographics, pain requiring treatment with analgesic injections, and hospital length of stay was analyzed. A total of 195 patients were enrolled; 130 were administered antivenom within 1 hour after emergency department arrival (early group), whereas 65 were treated later than 1 hour after arrival (late group). No in-hospital mortality was identified. The difference in surgical intervention rates between the early and late groups was statistically insignificant (P = 0.417). Compared with the early group, the late group showed a higher rate of antivenom skin test performance (46.9% versus 63.1%, respectively, P = 0.033), longer hospital stay (42 ± 62 hours versus 99 ± 70 hours, respectively, P = 0.016), and higher rate of incidences of pain requiring treatment with analgesic injections (29.2% versus 46.2%, respectively, P = 0.019). After adjusting for confounding factors, early antivenom administration was associated with decreased pain requiring treatment with analgesic injections (adjusted odds ratio: 0.51, 95% CI: 0.260–0.985). Antivenom administration within 1 hour of arrival was associated with a decreased likelihood of experiencing pain and hospital length of stay in patients with P. mucrosquamatus snakebites. Antivenom skin testing was associated with delays in antivenom administration.

Author Notes

Address correspondence to Po-Chun Chuang, Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Rd., Niaosong District, Kaohsiung 83301, Taiwan. E-mail: zhungboqun@gmail.com

Authors’ addresses: Po-Chun Chuang, Kang-Wei Chang, Shih-Yu Cheng, Hsiu-Yung Pan, Kuo-Chen Huang, Yii-Ting Huang, and Chao-Jui Li, Chang Gung Memorial Hospital Kaohsiung Branch, Department of Emergency Medicine, Kaohsiung City, Taiwan, E-mails: zhungboqun@gmail.com, andy79817@hotmail.com, ma6021@cgmh.org.tw, fornever@cgmh.org.tw, bluescratch7@gmail.com, kkkk@cgmh.org.tw, and chaojui@cgmh.org.tw.

These authors contributed equally to this work.

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