Venomous snakebite in Thailand. II: Clinical experience.

We reviewed a total of 2,525 snakebite patients in Bangkok. Of these, 1,415 were bitten by venomous snakes, 91 by neurotoxic snakes of genus Naja or Bungarus and 1,324 by snakes of family Viperidae or Crotalidae. Seventy-one percent of bites were on the lower extremity. There were two fatal cobra bites; both patients were dead on arrival at the hospital. Bites from vipers caused morbidity but no deaths. Species-specific antivenins are effective in reversing respiratory failure from cobra bites and coagulopathies from bites by Viperidae and Crotalidae snakes. However, early respiratory and wound care will save lives even in the absence of specific cobra and krait antivenin. Care of a snakebite victim should consist of immobilization and bandaging of the bitten limb with elastic bandages during transport to the hospital, early surgical debridement of necrotic tissue, appropriate infusion of antivenin, aggressive respiratory support, management of shock and infection, and peritoneal dialysis or hemodialysis. Incision of bite wounds, suctioning, application of ice, and tourniquets are of no proven value and may be dangerous. All snakebite victims in southeast Asia should survive if they receive early competent care.

Dog-bite injuries at a Bangkok teaching hospital.

Thailand has a large domestic and stray dog population and Buddhist cultural beliefs encourage feeding and protection of stray animals. Dog bites are common injuries encountered in emergency rooms throughout the country. A prospective study of such bites seen at a teaching hospital in Bangkok revealed that: (1) dog bites represent 5.3% of injuries seen in the emergency room; (2) the majority occur on the street, are inflicated by stray dogs and are interpreted by the victim as unprovoked. Children and teenagers account for 55% of the victims. The lower extremities (54%) and upper extremities (20%) were the most common sites for bites. 9% of patients were bitten on the face or head. In addition to pain, risk of infection (approximately 13%) and the significant cost of caring for these injuries, victims often experienced prolonged anxiety because of to the generally known risk of rabies in Thailand. Due to the high cost of imported immune globulins and vaccines, rabies exposures are not always managed optimally in Asia.

Is injection of contaminated animal bite wounds with rabies immune globulin a safe practice?

In Asia, it is still controversial whether it is safe to inject a contaminated animal bite wound with a foreign protein such as equine or human rabies immune globulin, even though this is recommended by the World Health Organization. A prospective study of 114 severe animal bite wounds which were injected with equine or human rabies immune globulin revealed an overall incidence of gross infection of 11.4%. No matched control group of patients bitten by animals whose wounds were not injected with immune globulin could be studied in this environment with a high prevalence of canine rabies. The incidence of wound infection in lacerations inflicted by sharp objects and sutured under local anaesthesia was therefore studied prospectively in 100 Thai patients from a similar socio-economic milieu; it was found to be 13%. Wound infection was more common in animal bites and lacerations of the lower extremities. It is concluded that injecting a properly cleansed bite wound with equine or human rabies immune globulin is a safe practice and should be performed whenever there is a possibility that the biting animal might have rabies.

Surgical management of an epidemic of penile amputations in Siam.

Thailand recently experienced an epidemic of penile amputations. These were usually performed by angry wives on philandering husbands. This outbreak appeared to have been fueled by graphic press reports and fortunately seems to have abated. A technique for reanastomosis of the amputated penile segment was first described by McRoberts et al [5] in 1968. It was modified further so that it can be performed in any general hospital with an acceptable result. Experience with this procedure in 18 patients has been described.