Gupta Prabha Nini, Thomas Jinesh, Francis Preetham Kumar, Shylaja Sajith Vamadevan
Department of Cardiology, Medical College Hospital, Trivandrum, Kerala, India.
BMJ Case Rep. 2014 Oct 23;2014:bcr2013201912. doi: 10.1136/bcr-2013-201912.
'The Big four' are the most poisonous snakes in India, and especially in Kerala. These include the cobra, the viper, the krait and the sea snake. Most of the poisonous snakebites in India occur in Kerala. We believe there are only a few reports of myocardial infarction after snakebites and most of these are viper bites. We believe this is the second case of primary angioplasty for a snakebite. There are at least a few potential issues in performing a primary angioplasty in a snakebite case, namely (1) Is it a thrombus or a spasm? (2) Are the bleeding parameters deranged? Will the patient tolerate tirofiban and other glycoprotein (GB) 2b3a inhibitors? Will he develop dangerous bleeding due to the high dose of heparin needed? Further, would we save the patient from myocardial infarction only to lose him to renal failure, both due to the nephrotoxicity of the venom, the kidney being further damaged by the contrast media used for the angioplasty? We discuss all these issues as they crossed our mind, and hope it will help further treatment in others. We would like to review the available literature on these points and describe a recent case of ours.
“四大毒蛇”是印度毒性最强的蛇类，在喀拉拉邦尤为如此。它们包括眼镜蛇、蝰蛇、金环蛇和海蛇。印度大部分毒蛇咬伤事件都发生在喀拉拉邦。我们认为，蛇咬伤后发生心肌梗死的报告仅有几例，其中大多数是蝰蛇咬伤所致。我们认为这是第二例因蛇咬伤而行急诊经皮冠状动脉介入治疗（primary angioplasty）的病例。在蛇咬伤病例中进行急诊经皮冠状动脉介入治疗至少存在一些潜在问题，即：（1）是血栓还是痉挛？（2）出血参数是否紊乱？患者能否耐受替罗非班和其他糖蛋白（GB）2b3a抑制剂？由于需要高剂量肝素，患者是否会发生危险的出血？此外，由于毒液的肾毒性以及用于血管成形术的造影剂对肾脏的进一步损害，我们是否能使患者免于心肌梗死，却最终因肾衰竭而失去他？我们讨论了所有这些在我们脑海中闪过的问题，并希望这将有助于他人的进一步治疗。我们想回顾一下关于这些问题的现有文献，并描述我们最近遇到的一个病例。
