蛇咬伤的治疗（Treatment of snake bite）

蛇咬伤的治疗（Treatment of snake bite） 蛇咬伤的治疗(Treatment of snake bite) Snake bite diagnosis and treatment Venom gland by discharge, translucent liquid, and some are white, gray, yellow, yellow or yellow green, with the smell of. Containing protein, base, yeast and mucus, often fatty substances and epithelial cells. There are different kinds of vipers. The components of their venoms are different. The lethal ingredient is a polypeptide. It is a small molecule protein without enzyme activity, and the main toxicity is as follows: (I) neurotoxicity: Department of peptides or small molecule proteins, including nerve poison a and B. Selective damage to the central nervous system, respiratory paralysis, or damage of peripheral nerve and skeletal muscle movement - conduction, resulting in skeletal muscle contraction was not excited, flaccid paralysis, especially respiratory muscle paralysis, even threatened the life of the injured man was bitten by a snake. (two) cardiac toxicity: This is the direct lytic factor and cytotoxic basic polypeptide, can cause irreversible cell membrane depolarization, make the cell structure changes and dysfunction, not only cause myocardial necrosis, myocardial and brief excitement to suppress, then also can produce shock, arrhythmia, heart failure, cardiac arrest. (three) blood poisoning: 1, prothrombins can promote the conversion of fibrinogen into fibrin, but also some venom can activate factor X, thromboplastin formation in V factor, calcium, phospholipids, the prothrombin into thrombin, promote blood coagulation, fibrinogen and thrombin can lead to more system consumption of blood coagulation disorder, and development for disseminated intravascular coagulation. 2, bleeding can damage the blood capillary wall, intercellular adhesion and substance, so that capillary permeability increased, The blood seeps out of the blood vessel. Such snake venom can also destroy the blood clotting factor, protease can increase bleeding activity, resulting in snake bites have varying degrees of bleeding tendency. The direct hemolytic factors of 3, hemolysin venom cause hemolysis in snake bite. Another phospholipase A can hydrolyze lecithin or phosphatidyl choline into hemolytic lecithin or hemolytic brain phospholipids, which can also lyse erythrocytes. (four) the role of lecithin, proteolytic enzymes and hyaluronidase A variety of snake venom gland secretion may contain different enzyme components, such as proteolytic enzymes can not only dissolve protein, prompting snakebite local edema, hemorrhage, necrosis, can affect fibrinogen into fibrin and prothrombin to thrombin, also can promote the release of histamine, directly affect the cardiovascular system; arginine lipid hydrolase can promote the release of bradykinin, promote the transformation of the thrombin system; the lack of ATP ATPase, affect the body's energy, the acetylcholine synthesis is blocked, the nervous system, heart and liver damage; hyaluronic acid enzyme hydrolysis of hyaluronic acid, the barrier between the fibers and cell injury, increased permeability, prompting the poison absorption into the blood and diffusion; phospholipase A hydrolysis of erythrocyte membrane phospholipid and lecithin into lysolecithin, red Cell membrane rupture and hemolysis, and can promote mast cells release histamine, 5- serotonin, produce local reaction, also can make striated muscle spasm, muscle tissue swelling, dissolution, etc.. In addition to the above enzymes, the venom also contains 5 - nucleotide enzymes, L-, amino acid oxidase and other enzymes. Snake bites are common in the limbs, Accounting for more than 90% of snake injuries. The venom injected by the fangs, along the lymphatic centripetal flow after entering the blood, tissues and organs all over the body, cause systemic symptoms of poisoning, it takes about 30min. Individual patients directly injected into the blood vessels, systemic symptoms occur rapidly. The venom is mainly composed of the reticuloendothelial system phagocytic cells and immune function in damaged liver toxin, played a very important role in the detoxification process; only about 1/3 of the venom excreted by the kidneys, in time. Clinical manifestation (a) the blood poison caused by clinical manifestations, 1 local manifestations of severe swelling, diffusion proximally, skin ecchymosis, blister, blood blister, tissue necrosis and hemorrhage, wound pain, with near lymphangitis, lymphadenitis, lymph node swelling. 2, the whole body performance of skin and mucous membrane bleeding, manifested as extensive skin bleeding spots, nose bleeding, bleeding gums. Visceral hemorrhage showed hemoptysis, hematemesis, hematochezia or hematuria, female vaginal bleeding etc.. May also occur hemolytic jaundice and hemoglobinuria, these factors can lead to shock, major organs and body damage, such as thrombosis prone to pulmonary embolism, hepatic steatosis caused by abnormal liver function, liver steatosis and bleeding, fracture, myocardial interstitial edema, arrhythmia, heart failure, can appear abnormal ECG. Renal epithelial cell shedding, necrosis, renal failure can occur. (two) the clinical manifestations caused by neurotoxicity, 1, local mild numbness, no exudate, no red, no swelling, no pain. 2, the whole body showed fat degeneration and degeneration of muscle fibers in anterior horn of spinal cord, Cell infiltration and necrosis, the skeletal muscle was flaccid paralysis, the head and neck, ocular damage, showing ptosis, also can appear diplopia, facial damage, performance and mouth dysphagia, trismus, and respiratory muscle damage, dyspnea, even stopping breathing. Poisoning dizziness, drowsiness, salivation, feel nausea, vomiting, hearing loss, even incontinence, severe cases of tetany, pain and other systemic abnormal feeling, who was in a coma in critical performance. (three) the clinical manifestations of mixed poison were urgent, and the local and systemic symptoms were serious. 1, local manifestations were swelling, blisters or blood blisters, skin ecchymosis, tissue necrosis, wound pain, proximally spread quickly. 2, systemic manifestations of limb muscle weakness, muscle pain, trismus, dyspnea, arrhythmia, circulatory failure, oliguria or anuria, disturbance of consciousness, and even cardiac and respiratory arrest. Diagnosis: 1, there is a snake bite left after the bite marks, typical local reactions and systemic poisoning clinical manifestations. 2, if the scene has been seized or killed snakes, will help to analyze and judge. 3. Observe routine tests of blood and urine in snake bite patients, and pay attention to anemia, thrombocytopenia, proteinuria or hematuria, hemoglobinuria, etc.. 4, check the blood biochemistry, pay attention to whether bilirubin increases, and the blood potassium, urea nitrogen, creatinine rise. 5. The manifestation of extensive intravascular hemolysis: coagulation time is more than 15min, coagulation factor, fibrin and fibrinogen are decreased, and the degradation products are increased, and the positive of DIC is positive. D- dimer (D-dimer) assay was more positive. 6, the specificity of immunoassay: enzyme-linked immunosorbent assay (enzyme-linked immunosorbent, assay, ELISA) and radioimmunoassay (radioimmunoas-say, RIA) are specific for diagnosis, the positive rate is high, the value of early diagnosis and differential diagnosis. But snake bites are often negative after more than 24h. 7, the diagnosis of suspected snake bites can try to neutralize the toxin test, using monovalent antivenin negative skin test after routine intravenous administration, if symptoms of poisoning was controlled, there may be this kind of snake bite. Emergency treatment: (a) to prevent the venom absorption and diffusion, 1 victims of snake bite immediately supine, reduce activity should be escorted to the hospital. 2, applying a tourniquet was bitten by a snake in 2 ~ 5min after wound in the proximal end of the 4 ~ 5cm with a cloth, rope, or strap tourniquet Zhazhu, to prevent venous and lymphatic drainage is appropriate, every 15 ~ 30min relax tourniquet 1 ~ 2min, with the system of rescue conditions after the cessation of tie, the best. The role of tourniquet in 2h. 3, treatment of wounds (1) snake bites can be used at flushing water, cold water, tea, soap and water, saline solution, Potassium Permanganate 1:5000 3% peroxide or 0.02% Furacilin Solution washing. Then bind the wound with 2% saline wet gauze. If bitten by Trimeresurus or for Agkistrodon acutus, iron head snake, first pull out the residual fangs, available 5% EDTA solution, can inhibit the proteolytic activity of snake venom, prevent local ring die. (2) burn the wound, this method can destroy snake venom, But do not burn with acid, iodine and so on. (3) to open the wound detoxification snake bites 24h will be local disinfection teeth marks as the center is "ten" to cut the skin 1 to 2cm or two for cutting coherent tooth marks, not deep subcutaneous tissue, lymph outflow is appropriate to. If the local blisters, you can make a small "ten" - shaped incision around it in order to facilitate detoxification. If bite hands and feet, then between fingers and toes with coarse needle acupuncture detoxification. But bite the 24h, do not go to the law, feasible puncture drainage, natural outflow of venom. (4) to absorb the venom suction device, absorb the local poison milk cupping or aspirator in snakebite. (5) apply to snake wound around the snake wound skin proximal 2cm with a circle of snake, but not with the wound. (6) partial closure, with 0.25% procaine plus dexamethasone, 5mg, swelling of the injured limb 3 to 4cm above, or in the tourniquet above the ring closed. (7) local soft tissue surrounding the bite with ice or cold water. (two) detoxification treatment tablets 1, oral Sheyao antidote Shanghai, Guangzhou, Jiangxi, Fujian, Yunnan and other places of production, 2, application of anti venom serum this product is divided into monovalent and polyvalent antivenom. (1): the selection of the drug before refining Agkistrodon hyalys Antivenin for allergic test, in order to prevent the process of drug allergy, can be given oral chlorpheniramine allergy medicine, intravenous infusion of dexamethasone 2 ~ 5mg, and then to the refining of Agkistrodon hyalys Antivenin (8000 units) 10ml plus saline 20ml intravenous administration. If the snake bites 2h, you can also consider around 5ml of the anti venom serum around the wound. Allergy test: take the snake venom serum 0.1ml plus physiological saline 1. 9ml after mixing, 0.1ml injects, observed 10min, Pichugin diameter of less than 2cm, no redness and pseudopods for skin test negative. (2) refined wubushe venom serum with this medicine before the need for allergy test, negative to refined Agkistrodon acutus venom serum (16000 units) 20 ~ 30ml plus saline 40 ~ 50ml intravenous administration. If the skin test positive or suspicious positive, can try to antivenom 1 ~ 2ml or 200mg plus hydrocortisone and dexamethasone in 5 ~ 10mg in glucose 500ml slow intravenous drip, 20 ~ 30 drops per minute, close observation of the adverse reaction, if without any discomfort or abnormal side effects, then gradually anti venom treatment the amount of serum need intravenous drip infusion, while given antihistamine drugs. 3, people in the treatment of fresh herbs Oldenlandia, seven leaf flower, Lobelia chinensis, Herba Violae, nitidine and several kinds of Chinese herbal medicine, desirable abluent after smashed juice, every time 50ml, daily 3 ~ 4 times oral. 4, the use of neostigmine to combat the venom of nerve venom, to help the body as soon as possible to restore and reduce mortality. (three) symptomatic, support treatment 1, oxygen inhalation generally high concentration of oxygen, nasal tube oxygen can be. In 2, coagulation disorders and DIC in addition to the early use of antivenom to terminate the systemic poisoning, no other drugs. Condensate protein or fresh blood and blood components, a small amount of intravenous infusion, has a certain effect, but a large number of such products will sometimes aggravate the condition. 3, the principle of infusion is to measure out. Excessive infusion may aggravate the symptoms of poisoning and lead to acute failure of heart, lung and kidney. Vitamin C 500mg may be added to the infusion, Can also be added vitamin B1100mg and / or vitamin K110mg, intramuscular injection, 2/d. Infusion of liquid can also be added ATP, coenzyme A and so on. 4, prevention of infection with penicillin based, but also depending on the condition of the disease, while using other antibiotics. 5, the prevention of tetanus use Tetanus Antitoxin, first allergy test, no allergies, a intramuscular injection of 1500U, you can. 6, respiratory failure treatment of respiratory paralysis caused by neurotoxicity and respiratory paralysis caused by neuromuscular paralysis, breathing machine ventilation is quite effective, often 8 ~ 30h or more. But not to use PEEP as well, so as not to aggravate heart failure. 7, acute renal failure in the early to give antivenom and general support therapy, peritoneal dialysis or hemodialysis have good effect. 8, acute myocardial membrane gap syndrome, blood circulation and mixed poisonous snake bite limb, often due to severe edema of the limbs pressure muscles, and the syndrome, should be timely diagnosis, early decompression. When the syndrome is formed, the pressure in the gap often exceeds 3.93kPa (40cmH2O). 9 intracranial hemorrhage, including brain parenchyma, subarachnoid space and epidural hematoma, is worse after recovery. Hemostasis or evacuation of hematoma. 10, endocrine damage, some snake bites can appear anterior pituitary or adrenal damage, causing hormone deficiency, timely use of hormones is necessary. 11, shock input low molecular dextran, expansion of blood capacity, may be appropriate to use booster drugs, such as dopamine, such as hydroxylamine. People with acidosis can be corrected by 4% to 5% sodium bicarbonate. 12, heart failure and respiratory arrest, cardiac failure can use digitalis drugs, such as small dose of hair glucoside C, cardiac arrest, cardiopulmonary resuscitation treatment. 13 、 other therapies in recent years, foreign use of electric shock local treatment. The 9V battery produces a voltage of 25kV and a current of less than 1mA, which can reduce or prevent the symptoms of systemic poisoning during the partial discharge of the bite, once every 10s. 14, the treatment should disable central inhibition and muscle relaxation drugs such as morphine, chlorpromazine, barbiturates, diphenhydramine, curare, succinylcholine; with anticoagulants such as heparin, sodium citrate, dicoumarin.