Reference Work Entry

Clinical Toxinology in Asia Pacific and Africa

Volume 2 of the series Toxinology pp 23-52

Date:

Management of Snake Envenomation in Taiwan

  • Yan-Chiao MaoAffiliated withDivision of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General HospitalDivision of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General HospitalInstitute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University Email author 
  • , Dong-Zong HungAffiliated withDivision of Toxicology, Trauma and Emergency Center, China Medical University HospitalGraduate Institute of Clinical Medical Science, China Medical University

Abstract

There are six venomous snakes of medical importance in Taiwan: three crotalids, Trimeresurus (Viridovipera) stejnegeri, Protobothrops mucrosquamatus, and Deinagkistrodon acutus; one viperid, Daboia russelli siamensis; and two elapids, Naja atra and Bungarus multicinctus. In the prehospital settings, there is no role for incision and suction, electrotherapy, and cryotherapy for snakebite wounds. Routine use of a constriction band or pressure immobilization device is not indicated. The Taiwan government produces four types of equine-derived antivenoms to treat the above-noted snakebites, namely, bivalent antivenom for T. stejnegeri and P. mucrosquamatus, bivalent antivenom for N. atra and B. multicinctus, and two monovalent antivenoms for D. acutus and D. r. siamensis, respectively. These antivenoms are F(ab′)2 fragment in the lyophilized form containing 2,000 units per vial (or at least 1,000 Tanaka units). The Taiwan Poison Control Center formulated a flowchart for the management of six major venomous snakebites based on animal studies, clinical observation, and expert opinion in 1999. The recommended dosage of relevant antivenoms is 1–2 vials for T. stejnegeri snakebites, 2–4 vials for P. mucrosquamatus, 2–4 vials for D. acutus, 2–4 vials for D. r. siamensis, 6–10 vials for N. atra, and 2–4 vials for B. multicinctus. The use of antibiotics is suggested when secondary wound infection has developed, whereas surgical indications include wound necrosis, abscess formation, distal limb gangrenous change, necrotizing fasciitis, or, in rare cases, compartment syndrome. Further studies on the severity assessment (e.g., severity score), risk factors for the development of severe disease, optimal dosing of antivenom, effect of prophylactic antibiotics, and timing of surgery in cases of venomous snakebites in Taiwan are warranted.