红脖游蛇咬伤引起严重中毒的临床观察报告

Clinic Report on the Severe Toxicosis caused by Snakebite of Rhabdophis subminiatus

目的 为了观察红脖游蛇（Rhabdophis subminiatus）咬伤的临床表现，探明其中毒引起出血的机制．方法 对2001-2005年我科诊治的7例红脖游蛇咬伤病人。采取临床观察结合实验室检查：试管法凝血时间（coagulation time）、PT、APTT、TT、纤维蛋白原浓度（Fibrinogen．Fib）和纤维蛋白降解产物含量（3P和D-二聚体）测定等实验检查的血液学研究。并采用自行设计方法治疗;蛇咬伤伤口局部消毒后给予点状加压止血（绝对不能切开．已经切口的需把伤口缝合后再止血）。全身治疗主要有（1）根据需要输注全血或血浆；（2）止血抗纤溶药：止血敏维生素K，止血芳酸．止血环酸；（3）654—2加地塞米松静脉点滴防治全身炎症反应综合症（SIRS）；（4）口服中草药蛇药；（5）扰感染；（6）抗休克和治疗MODS等对症处理。结果 7例病人就诊时全部有伤口出血难止，全身严重出血倾向，其中1例头颅CT检查发现有脑出血，2例出现了休克、急性肾功能衰竭．全部患者进行血液学检查试管法凝血时间均明显延长．普通试管里血液未能凝固IPT、APTT和TT均延长．纤维蛋白原明显减少，基本检测不出，3P阳性和D-二聚体增加。呈脱纤维蛋白原血症状态。脑出血患者因元手术指征．保守治疗病情稳定后自动出院，1例急性肾功能衰竭患者因无法人工肾治疗而自动出院（后证实死亡）．其余5例痊愈出院．结论 提示该蛇咬伤可引起患者体内凝血系统被激活而继发纤溶亢进完全脱纤维蛋白状态的DIC样血液学改变．如不及时治疗，可引起严重合并症，甚至死亡．

Objective To observed the clinic manifest and clarify the toxic characteristics in the hematological disturbances evoked by Rhabdophis subminiatus snakebite. Methods We observed the clinic symptom and measured the Cruor Time, PT, APTT, TT, Fibrinogen （Fib）and 3P or D-Dimer in seven of all the patients from 2001 to 2005. We treated the patients with the methods that designed. Results The wound bleeding and hemorrhage tendency was present in all patients. Cruor Time, PT, APTT and TT was prolong,Fibrinogen was decreased to undetectable, and 3P or D-Dimer was increased in all the patients. Head CT was finding the cerebral hemorrhage in one of the patients. Acute renal failure was caused by bleeding shock after some days of snakebite when two severe patients come to emergency. Conclusion After Rhabdophis subrniniatusbite, the coagulate system may activity and occurred the defibrinogenation and DIC-like hematological disturbances. If treatment of bleeding is not on time, the patient can be developed to severity or death.