title: Can surgical need in patients withNaja atra(Taiwan or Chinese cobra) envenomation be predicted in the emergency department?
abstract: OBJECTIVE
  To investigate the clinical predictors and the aetiologies for surgery in patients withNaja atra(Taiwan or Chinese cobra) envenomation.
  
  
  METHODS
  This case series was conducted in the only tertiary care centre in eastern Taiwan. Patients who presented to the emergency department withNaja atrabite between January 2008 and September 2014 were included. Clinical information was collected and compared between surgical and non-surgical patients.
  
  
  RESULTS
  A total of 28 patients withNaja atraenvenomation presented to the emergency department during the study period. Of these, 60.7% (n=17) required surgery. Necrotising fasciitis (76.5%) was the main finding in surgery. Comparisons between surgical and non-surgical patients showed skin ecchymosis (odds ratio=34.36; 95% confidence interval, 2.20-536.08; P=0.012) and a high total dose of antivenin (≥6 vials; odds ratio=14.59; 95% confidence interval, 1.10-192.72; P=0.042) to be the most significant predictors of surgery. The rate of bacterial isolation from the surgical wound was 88.2%.Morganella morganii(76.5%),Enterococcus faecalis(58.8%), andBacteroides fragilis(29.4%) were the most common pathogens involved. Bacterial susceptibility testing indicated that combined broad-spectrum antibiotics were needed to cover mixed aerobic and anaerobic bacterial infection.
  
  
  CONCLUSIONS
  Patients withNaja atraenvenomation who present with skin ecchymosis or the need for a high dose of antivenin may require early surgical assessment. Combined broad-spectrum antibiotics are mandatory.
authors: Department of Emergency Medicine, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan; Department of Emergency Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.
authors: H Y
authors: HY
authors: Su
authors: Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.
authors: M J
authors: MJ
authors: Wang
authors: Department of Public Health, Tzu Chi University, Hualien, Taiwan.
authors: Y H
authors: YH
authors: Li
authors: Department of Family Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.
authors: C N
authors: CN
authors: Tang
authors: Department of Emergency Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan; Department of Sports Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.
authors: M J
authors: MJ
authors: Tsai
mesh_terms: D000818:Animals; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D000997:Antivenins / Q000008:administration & dosage*; D001424:Bacterial Infections / Q000453:epidemiology / Q000382:microbiology; D004438:Ecchymosis / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D004546:Elapid Venoms / Q000633:toxicity*; D004636:Emergency Service, Hospital; D019115:Fasciitis, Necrotizing / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D000073176:Naja naja; D012189:Retrospective Studies; D012909:Snake Bites / Q000150:complications / Q000601:surgery* / Q000628:therapy; D013624:Taiwan
chemical_list: D000900:Anti-Bacterial Agents; D000997:Antivenins; D004546:Elapid Venoms
keywords: Emergency service, hospital; Snake bites; Surgical procedures, operative