World J. Surg.
27, 234–240, 2003
DOI: 10.1007/s00268-002-6552-9
Surgical Globetrotting
Snakebites in the Rainforests of Ecuador
Anita D. Praba-Egge, M.D., Ph.D.,1,2 Stephen W. Cone, M.D.,1,2 Omar Araim, M.D.,1,2 Isabel Freire L., M.D.,3
Galo Paida V., M.D.,3 Johnny Escalante T., M.D.,3 Favio Carrera M., M.D.,3 Mirian Chavez R., M.D.,3
Ronald C. Merrell, M.D.,1,2
1
Medical Informatics and Technology Applications Consortium, Virginia Commonwealth University, P.O. Box 980480, 1101 E. Marshall Street,
Richmond, Virginia 23298, USA
2
Department of Surgery, Virginia Commonwealth University, P.O. Box 980480, 1101 E. Marshall Street, Richmond, Virginia 23298, USA
3
Hospital Pio XII, Avenida Domingo Comin y Avenida 12 de Febrero, Sucúa, Morona Santiago, Ecuador
Abstract. Epidemiologic information about snakebites in Ecuador is
scarce. Snakebites are more common in the lowlands east of the Andes, in
the Amazon basin. In the present study, a retrospective review of all (n =
142) snakebite admissions to Hospital Pio XII, a regional health center/
hospital in the canton of Sucúa, Morona Santiago, Ecuador was carried out
between the years of 1996 and 2000. Bites occurred more frequently during
the months of March to May. The largest group of patients were in the 15-
to 49-year-old range (52.5%), and agricultural workers were the most af-
fected of all patients by occupation (> 40%). In most cases of snakebite,
patients could not identify the type of snake that had bitten them. A small
number of patients (n = 60, 42.3%) received some type of treatment prior to
arrival at the hospital. Bites occurred most frequently on the left lower
extremity (31.7%). Typical symptoms included pain and local edema at the
snakebite site; generalized symptoms such as fever, nausea, and vomiting
were less frequent. Most patients (almost 90%) received antivenin during
hospitalization in addition to supportive care. The mean hospital stay was
4.3 days. More than 90% of all 142 patients recovered, about 8% with local
abscesses. Mortality was 2.9% and occurred as a result of complications,
including renal failure, respiratory failure, and disseminated intravascu-
lar coagulation.
There are more than 400 species of snakes in Ecuador, and approxi-
mately 45 of them are venomous [1]. Although snakebites are quite
common in certain regions of the country, epidemiologic informa-
tion about the problem is scarce.
Ecuador, located on the western coast of South America, is bor-
dered by Colombia to the north, Peru to the southeast, and the
Pacific Ocean to the west. The country has three well recognized
regions: the Pacific coast (La Costa), the Andean highlands (La
Sierra), and the eastern lowlands (El Oriente) [2]. Snakebites are
more common in the lowlands east of the Andes, in the Amazon
basin [2, 3]. Four genera of venomous snakes are considered im-
portant in Ecuador (and El Oriente): Bothrops, Bothriopsis, Lache-
sis, and Micrurus [1]. The first three genera are in the family Viperi-
dae (pit vipers). The last genus belongs to the family Elapidae [2].
Correspondence to: S.W. Cone, M.D., Medical Informatics and Technol-
ogy Applications Consortium, Virginia Commonwealth University, P.O.
Box 980480, 1101 E. Marshall Street, Richmond, VA 23298, USA
WORLD
Journal of
SURGERY
© 2003 by the Société
Internationale de Chirurgie
The genus Bothrops (family Viperidae) are commonly known in
English as lanceheads, or fer de lance, because of their distinctive
head shape. In this group are 31 species, mostly distributed in South
America, with a few species in Mexico, on the Caribbean islands of
Saint Lucia, Martinique, and Trinidad, and on the coast of Brazil.
The snakes range in size from 0.5 to 0.7 m up to 2.5 m or greater.
Although Bothrops snakes can climb, they are mainly terrestrial and
primarily inhabit lowlands at elevations of 1500 m or less. They
have the adaptability to live in regions near sea level or cloud for-
ests as well. Because the snakes occupy a wide range of habitats,
including cultivated regions, they are important causes of human
envenomation, responsible for more human morbidity than any
other venomous snake in the New World [2]. Several epidemiologic
studies in Brazil, Colombia, Costa Rica, and Venezuela have found
that Bothrops species are the snakes most frequently responsible
for venomous snakebites [2, 4–8].
The genus Bothriopsis (family Viperidae), commonly known as
forest pit vipers, has eight species with a wide range of sizes.
Their common name (forest pit viper) makes reference to the for-
est habitat of the snakes. Six species of Bothriopsis have been docu-
mented in Ecuador. [2]. Of the six, two are found in the lowland
rainforest: Bothriopsis bilineata and B. taeniata. Unlike the terres-
trial range of Bothrops snakes, these two Bothriopsis species are ar-
boreal.
Lachesis muta is commonly known as the bushmaster [2]. The
species is distributed in lower Central America and northern South
America. It is the largest of the New World venomous snakes and
reportedly the longest viper in the world. Lengths of more than 3.6
m have been reported. It is a viviparous snake, with crepuscular and
nocturnal activity. Its habitat is the tropical rainforest and lower
montane wet forests, but the snake is terrestrial. A subspecies, L. m.
muta, also lives in Ecuador.
The genus Micrurus (family Elapidae), more commonly known
as coral snakes, are represented by at least 53 species that inhabit
regions from the southwestern United States to central Argentina
(with Mexico, Central America, and most of South America in-
cluded) [2]. Similar to Bothrops, Micrurus can live in a wide variety
of habitats (even the desert). There are a few species in the El Ori-
Praba-Egge et al.: Snakebites in Ecuador
Fig. 1. Three regions of Ecuador, showing the location of Sucúa.
ente region of Ecuador: M. filiformis, M. hemprichii, M. karl-
schmidti, M. lansdorfii, M. leminiscatus, and M. petersi.
The human population in El Oriente of Ecuador is mostly indig-
enous and relies to a great degree on agriculture (crops and live-
stock) for its livelihood. Encounters with snakes are an accepted
hazard of the life style here. The Amazon basin also attracts inter-
national visitors, such as eco-tourists, missionaries, and relief work-
ers. For travelers, snake advisories are extremely relevant.
The present study was undertaken in one region of El Oriente in
the province of Morona Santiago, Ecuador. The snakebite inci-
dence is higher in this particular region of the province than in
other regions. The purpose of the study was to obtain an epidemio-
logic profile of the persons affected by snakebites in the region. The
specific aims were to determine the people (gender, age group, oc-
cupation) at high risk for snakebites, the most common signs and
symptoms of snakebites, the prevalence of prehospital treatment,
the treatments given in hospital, and the success rate for treating
snakebite.
Methods
Study Period, Site, Population
A retrospective review of all snakebite admissions to Hospital Pio
XII was carried out. The hospital serves a surrounding community
of about 19,500 people [9] scattered over a radius of 50 miles. It is
located in Sucúa, a rural town in the province of Morona Santiago,
which sits in the Andean foothills/Amazonian basin (Fig. 1). All
patients diagnosed with snake envenomation between the months
of January 1996 and December 2000 were included in the review.
These data were used to determine the incidence of snakebites be-
tween 1996 and 2000.
235
Table 1. Snakebite-related questions.
What type of snake?
Any prehospital treatment?
Pattern of snakebite?
Location of bite?
Diagnosis, Clinical Assessment, Treatment
Patients were diagnosed with snakebite on the basis of their clinical
history and physical examination. Retrospective data analysis in-
cluded compilation and analysis of patient demographic informa-
tion, clinical history (with specific snakebite-related questions)
(Table 1), pertinent local or systemic symptoms and physical find-
ings, laboratory results (bleeding times), descriptions of treatment,
and outcomes during follow-up.
Patients were hospitalized or observed after an initial clinical
evaluation in Hospital Pio XII. Routine treatment consisted of
various antivenins that were locally available (Table 2), analgesics,
tetanus prophylaxis and toxoid administration, antihistamines, an-
tibiotics, steroids and H2-blockers. Unstable patients were trans-
ferred to larger medical centers for definitive care as required.
Results
During the 4-year study period 142 patients were assessed for
snakebites. The resulting incidence for snakebites ranged from 0 to
7 cases each month and 22 to 38 cases each year (Figs. 2, 3). The
number of snakebites fell annually between 1996 and 2000. Con-
sidering that the most recent population estimate for Sucúa is
19,400 persons, the incidence of snakebite may be calculated as 150
per 100,000 persons. Bites occurred more frequently during the
rainy season months of March, April, and May. Within the jurisdic-
tion of the hospital, patients from the two cantons Sucúa and
Logrono (which together make up region 6 of the province) had the
highest incidence of snakebite among the 142 patients (frequency:
59.2% + 19.7% = 78.9%) (Fig. 1).
The 142 patients consisted of 68 women (47.9%) and 74 men
(52.1%) with a mean age of 27 ± 18 years (range 2–89 years). The
largest group of patients (by age group) were in the 15- to 49-year-
old range (52.5%) (Fig. 4). Agricultural workers were the most af-
fected of all patients studied: More than 40% of the 142 snakebite
victims were farmers (Fig. 5). The other two large populations af-
fected were students and homemakers: 24% and 22% of all pa-
tients, respectively. Other snakebite victims included preschoolers,
ranchers, infants, a teacher, a day laborer, and a mason.
In most cases of snakebite (101/142, 70%), patients could not
identify the type of snake that had bitten them (Fig. 6). In the 30%
of cases where the snakes were identified, they were reported by
their common names. Table 3 lists the common and scientific
names of the snakes identified by patients in the present study and
the frequencies with which they were identified. In an ideal situa-
tion, the snake was captured and brought to the hospital (Fig. 7).
The most commonly identified snake was of the Bothrops genus
(Fig. 8).
A small number of patients (n = 60, 42.3%) received some type
of treatment prior to arriving at the hospital. Of the patients who
reported prehospital intervention, most described the use of tour-
niquets (37/60, > 60%). Other prehospital treatments were alcohol
and pepa de aguacate, alcohol alone, curare, alcohol with Kerex
236
Table 2. Antivenins used for treatment.a
Colombian INS
Colombian LP
Leopolda Izquieta Perez
Brazilian
Mexican
INS: Instituto Nacional de Salud; LP: Laboratorios Probiol.
a
All antivenins are polyvalent. Different antivenins were used accord-
ing to the local protocol at different periods during the study.
Fig. 2. Annual incidence of snakebites in Sucúa.
Fig. 3. Monthly incidence of snakebites in Sucúa.
(kerosene available in Ecuador) and pepa de aguacate, suction, in-
cision, topical application of urine, or other substances (Table 4).
Pepa de aguacate is a local medicinal preparation made using ma-
terial taken from the inside of avocado pits; this material is then
mixed with water or liquor and given to the patient to drink. The
use of prehospital treatments did not result in more complications.
Bites occurred on upper and lower extremities at similar fre-
quencies (48.6% vs. 50.7%). One patient was bitten on the trunk.
Patients were bitten more often on the left (58.5%) than on the
right (40.8%), with most injuries occurring on the left lower ex-
tremity (31.7%) followed by the left upper extremity (26.8%) (Fig.
9). Farmers were observed to have more upper extremity bites
(72.1% upper extremity bites vs. 26.2% lower extremity bites vs.
1.6% trunk bites—of all agricultural bites). Lower extremity bites
predominated in patients with other occupations.
More than 95% of patients reported intense pain at the bite site,
World J. Surg. Vol. 27, No. 2, February 2003
Fig. 4. Age distribution of snakebite patients.
Fig. 5. Occupations of snakebite patients.
making it the most common symptom among snakebite patients.
Other local findings included swelling, ecchymosis, inflammation,
and necrosis (Table 5). Generalized symptoms and signs occurred
much less frequently than local indices (Table 5). Among general-
ized complaints, patients reported fever and nausea/vomiting most
commonly.
The average time to treatment was 4.6 ± 0.7 hours (median 2
hours, mode [most common time to treatment] 1 hour, range 0–72
hours) after being bitten. At the hospital, most patients (127/142,
89.4%) were treated with antiserum. Several antisera were used as
infusions; all were polyvalent (Table 2). On average, patients re-
ceived 3.4 ± 2.8 vials (range 0–19 vials), although patients receiving
the Mexican polyvalent antivenin required more vials than those
receiving other types of antivenin. After 1999, use of other antiven-
ins (Brazilian, Ecuadorian, Colombian—all listed in Table 2) was
initiated. Adverse reactions to antivenin (allergic reactions, tachy-
cardia, sweating, vomiting) were reported in 8 of the 127 (6.3%)
patients who received such treatment.
Patients also received other treatments at the hospital, including
analgesics, antibiotics, and antitetanus prophylaxis (more than
90% of patients). A small number of patients also received antihis-
tamines, corticosteroids, and H2-blockers. Steroids and antihista-
mines were used in cases of antivenin reactions.
Laboratory examinations were limited to the determination of
Praba-Egge et al.: Snakebites in Ecuador 237

Fig. 6. Types of snakes identified

by snakebite patients.

Table 3. Known snakes identified by victims.

Common name Scientific name No. of species
Moash/macanche Bothrops atrox 21
Equis Bothrops brazili 17
Sobrecama Bothrops asper 1
Lora Bothriopsis bilineata 1
Coral Micrurus species 1

bleeding times. This test was performed on 93 patients, with abnor-

mal results (> 10 minutes) noted in 76 (81.7%) of these individuals.
On average, patients had inpatient stays of 4.3 ± 3.9 days. Three
patients were observed as outpatients rather than being hospital-
ized. Patients without complications stayed an average of 3.7 ± 2.6
days versus 12.3 ± 7.4 days for patients who suffered complications
such as an abscess or necrosis. The maximum stay was 30 days.
Most patients (n = 131, 92%) recovered from their injuries.
Eleven (8.4%) of these patients developed abscesses (Fig. 10) that Fig. 7. Snake “perpetrator” caught and brought to hospital.
required local drainage and wound care. Seven patients (5%) had
to be transferred to a larger medical center for more definitive care.
Four patients (2.9%) died as a result of snakebite-related compli-
cases per 100,000 inhabitants (depending on a particular region)
cations: renal failure (n = 1), respiratory failure (n = 1), and dis-
[8].
seminated intravascular coagulopathy (DIC) (n = 2).
That the number of snakebites fell in Sucúa between 1996 and
2000 may be a result of better preventive methods, such as the use
Discussion of tall rubber boots by the local population, particularly men. The
consistent rise in snakebites every April and May coincides with the
Although surveys on poisonous snakebites in the United States, rainy season in Sucúa. Changes in temperature and habitat may
Brazil, Colombia, Costa Rica, Venezuela, and several countries in stimulate snakes, making them more active and more likely to cross
Africa and Asia have been carried out, there are few published epi- paths with people. In North America, snakes are more active dur-
demiologic data on snakebites in Ecuador. The incidence of 150 ing warmer months of the year, resulting in a higher frequency of
snakebites per 100,000 persons in Sucúa attests to the danger of snakebites during those periods [10]. The rainy season may also
such injury in this particular region. In comparison, a 10-year ret- result in less visibility for humans (more vegetation, more mud) and
rospective analysis in Costa Rica revealed an incidence of 20 to 30 more accidental encounters as snakes seek higher ground, condi-
238 World J. Surg. Vol. 27, No. 2, February 2003

Table 5. Local signs and symptoms reported by patients.

Sign/symptom Frequency (%)
Intense pain 137 (95.1%)
Swelling 121 (85.2%)
Ecchymosis 45 (31.7%)
Inflammation 36 (25.4%)
Necrosis 1 (0.7%)

Fig. 8. Distribution of snakes (species) identified.

Table 4. Prehospital treatment (n = 60).

Treatment Frequency
Tourniquet 37 (62.9%)
Alcohol/pepa de aguacate 10 (17%)
Alcohol 9 (15.3%)
Curare 7 (11.9%)
Alcohol/kerex (kerosene)/pepa de aguacate 6 (10.2%)
Suction 6 (10.2%)
Incision 4 (6.8%) Fig. 10. Healing leg with drained abscess site after snakebite.
Lemon 2 (3.4%)
Application of urine 1 (1.7%)
A small number of patients could identify the type of snake re-
sponsible for their bites in this study. The reasons for this may be
multifactorial. First, local people may not know the names of the
snakes: Many snakes in Latin America are simply called a colubrid
(the word refers to any snake with several enlarged teeth on the
posterior ends of the maxillae) [2]. Second, knowledge about Ec-
uadorian herpetofauna is incomplete [2]. Given the conditions of
the rainforest and the dense vegetation found even in well culti-
vated fields, visualizing any snake is a challenge. Finally, many in-
dividuals want to distance themselves from a snake immediately
after being bitten rather than pursue it and examine it closely.
(Their first priority may not be identification.)
Some of the patients (42.3%) received prehospital treatment fol-
lowing their snakebite. Tourniquets were the prehospital treatment
used most often (about 63% of the time) among these patients. The
purpose of the tourniquet is probably to prevent the spread of
venom [11]. The use of tourniquets among the snakebite victims in
the current study is higher than the rate found in a similar study
completed in Arizona (USA) [11]. Although the patients who used
Fig. 9. Location of snakebites. RLE: right lower extremity; LLE: left lower
extremity; LUE: left upper extremity; RUE: right upper extremity. tourniquets in Sucúa did not suffer a higher complication rate, this
technique and other first-aid-type treatments, such as incision and
tions that could contribute to the higher number of bites during the suction, are probably detrimental to the patients [11]. Immobiliza-
period. tion with splints and nonocclusive wrapping of affected limbs are
The finding that the typical snakebite patient fits the profile of a the current first aid recommendations for snakebite victims [12].
farmer between the ages of 15 and 49 was not surprising. First, the The use of medicinal plants (aguacate) as early treatment for
largest proportion of the population in Sucúa is 15 to 49 years old snakebites was noted in the present study and may occur more com-
(representing 8905/19,400, 45.9%) [9]. Second, the nature of farm- monly in other regions of the Ecuadorian Amazon (Jose Yankur,
ing (i.e., outdoor labor) places these individuals at higher risk for personal communication). On a global scale, hundreds of plants
encountering snakes. Rural farmers working in primitive condi- have been described for use in snakebites [13]. In Colombia, a se-
tions (i.e., less cultivated grounds with little or no machinery) are ries of studies have been undertaken to document the many indig-
most likely to be bitten by snakes [2, 11]. enous plants used by traditional healers for treating snakebites [6,
Praba-Egge et al.: Snakebites in Ecuador
13, 14]. These studies have shown that 12 of 74 ethanolic extracts of
plants used by curanderos (traditional healers) are active in treating
the lethal effects of intraperitoneal Bothrops atrox venom injections
in mice; 7 of these 12 plants demonstrated 100% neutralization of
the snake venom, and the other 5 showed partial neutralization
(45–80%) [13]. The ability of the plants to neutralize the hemor-
rhagic effects of the same venom was also demonstrated, with 31 of
75 plant extracts having some neutralizing capacity in Bothrops
atrox-injected mice [14].
Bothrops is the genus that causes most of the snakebites in Latin
America [2, 4–6, 8, 15]. Mortality without treatment is reported to
be 7%, with treatment, it is 0.5% to 0.3% [2]. The snakes that were
most recognized in the current study were Bothriopsis and Bothrops.
The local effects most commonly associated with Bothrops enven-
omations (pain, edema, ecchymosis, inflammation and necrosis at
the bite site [6, 7]) were the same ones most frequently noted in the
current study. Generalized symptoms were described much less
frequently (10–15% vs. 90%) by patients. A similar trend is found in
the literature, although bleeding tendencies (with subsequent gin-
gival hemorrhages, for example) and symptomatic nausea and
vomiting are documented [2, 6].
The location of snakebites seems to vary according to the sur-
roundings. Historically, most bites occur on the legs and feet [2].
One study in Venezuela documented more of snakebites on the
upper extremities than the lower extremities [7]. In the current re-
view, bite location was evenly divided between upper and lower
extremities. The finding that most bites occurred on left-sided ex-
tremities may be attributed to the working habits of the local farm-
ers. The right hand may be used to wield and swing tools (ma-
chetes), distancing the right hand from the ground (and from
snakes). The finding that farmers specifically were bitten more
commonly on upper extremities may also be a function of labor
practices. Agricultural workers typically kneel down when planting
or harvesting so their upper extremities are low to the ground and
vulnerable to terrestrial snakes. To harvest crops, the worker may
use the left hand to hold up the crop and the right hand to cut it. In
this scenario, the upper extremities are again close to the ground,
and the left hand is exposed and closer to the snake than the right
hand (which may be swinging in and out of biting range). The find-
ing that farmers specifically were bitten more commonly on upper
extremities may also be due to their routine use of tall, thick rubber
boots. The knee-level boots are worn for a variety of reasons, in-
cluding protection against lower extremity exposure to snakebites.
However, local farmers do not wear long sleeves or gloves as com-
monly, which may explain in part the higher incidence of upper
extremity bites in the present study.
The time period between snakebite and presentation to the
health center/hospital ranged widely, with the average time being
about 4.5 hours. A 10-year retrospective study of snakebite victims
admitted to a regional trauma center in Georgia revealed an aver-
age time of 3 hours between snakebite and antivenin administra-
tion [16]. In Ecuador few rural residents have easy access to trans-
portation. Remote locations and difficult travel conditions
(geography, climate) may make transportation of victims difficult,
accounting for the wide range in time interval and possibly the use
of prehospital treatments [6].
Coagulopathy, with resultant bleeding, is a known effect of Bo-
throps venoms [6]. Snake venom contains a number of proteolytic
enzymes (L-aminooxidase) and procoagulant venom factors that
may contribute to coagulopathies [12]. The proteolytic enzymes
239
may cause fibrin degradation and subsequent hypofibrinogenemia
[17]. Examination of blood taken from 18 patients bitten by Bo-
throps asper revealed alterations in their fibrinogen levels and the
levels of multiple coagulation factors [17]. Most of the patients (>
80%) who were tested (93/142) in the current review were found to
have some degree of coagulopathy (bleeding time > 10 minutes).
In a previous study of Bothrops victims in Venezuela (n = 60),
blood clotting was abnormal in 55% of all patients [7]. Physical
findings such as gingival and cutaneous hemorrhages are attribut-
able to the coagulation disturbances.
Hospital stays averaged 4 days, but a difference of approximately
10 days was found between patients with and without complications
(abscess or necrosis). The finding that 8.4% of patients developed
abscesses is comparable to similar retrospective analyses of snake-
bite victims undertaken in 60 Bothrops-bitten Venezuelan patients
(abscess rate of 6%) [7] and in 80 Costa Rican children (abscess
rate of 11.35%) [8]. Abscess development was not associated with
prehospital treatments (tourniquets), the use of antibiotics, or the
interval between the bite and presentation to the hospital. The
Costa Rican study showed that hypofibrinogenemia (fibrinogen
levels < 100 g/dl) and a prothrombin time of < 2% were risk factors
for development of an abscess [8].
Most patients in the present study (92%) had a good outcome.
The patients who were transferred to another hospital required
specialized care (intensive care admission or surgery) or an anti-
venin that was unavailable at our hospital. Mortality was 2.9% in
the current study, comparable to the Costa Rican snakebite analy-
sis (mortality 2.6%) [8], although in the Venezuelan investigation
zero mortality was found among 60 patients [7]. The latter study
had half the population of patients as the present one, and the
sample size might contribute to the finding of such low mortality. In
one of the patients from the current review, the interval between
snakebite and presentation was more than 24 hours, which may
have contributed to the poor outcome. Among the causes of death,
renal failure and DIC have been documented to occur after Bo-
throps envenomation [7, 8].
Compared to other areas in the world where snakes such as co-
bras or mambas live, mortality due to snakebites in Ecuador is quite
low (St. L. Crute, personal communication). It is important to note
that some snakebite victims may never present to the hospital. Lo-
cal tradition may honor the concept of fated events, and patients
choose not to seek medical attention. Patients may also seek only
the treatment of traditional healers. Considering these possibili-
ties, recovery and mortality rates may be skewed.
Conclusions
The retrospective review suggests that male farmers age 15 to 49
are at highest risk for snakebites in Sucúa. Prehospital treatments
are common, and antivenin is used frequently. Most patients re-
cover from their injuries after a few days of hospitalization, al-
though development of an abscess increases the recovery time.
Some public health recommendations are appropriate based on
the findings. First, prevention of snakebites includes the use of pro-
tective clothing and shoes; the use of long sleeves and long gloves
can prevent some injuries, particularly in agricultural workers. Sec-
ond, public education with regard to first aid treatments (immobi-
lization, splints, compressive but not constrictive dressings) should
continue. Finally, research into snake venom and neutralization as
well as research into new modes of treatment (medicinal plants)
240
should continue. Historically, botanical collections of explorers and
ethnobotany have played important roles in drug development
[18]. Tropical rainforests offer great potential for discovering new
drugs; and studying the plants already used by people indigenous to
the rainforests is an efficient way to identify plants with bioactive
compounds [19]. In fact, in a remote region of Ecuador the indig-
enous people may have a potentially beneficial treatment for
snakebites that remains largely untapped.
Résumé. Les données épidémiologiques concernant les morsures de
serpent en Equateur sont rares. Les morsures de serpent sont plus
fréquentes dans les plaines basses vers l’est des Andes dans le bassin
amazonien. Dans cette étude, on a revu rétrospectivement toutes les
admissions pour morsure de serpent (n = 142) à l’hôpital Pio XII, un
centre régional dans le canton de Sucúa, Morona Santiago, Equateur, entre
les années 1996 et 2000. Il y avait plus de morsures pendant les mois de
mars-mai. La plupart de victimes avaient entre 15–49 ans (52.5%),
principalement des ouvriers agricoles (> 40%). Dans la plupart des cas, les
patients ne pouvaient pas identifier le type de serpent qui les avait mordu.
Une minorité de patients (n = 60, 42.3%) avaient reçu un traitement avant
d’arriver à l’hôpital. Les morsures intéressaient surtout l’extrémité
inférieure gauche (31.7%). Les symptômes typiques comprenaient la
douleur et l’œdème au niveau de la morsure; les signes et symptômes
généralisés tels la fièvre, les nausées et les vomissements étaient beaucoup
moins fréquents. La plupart des patients (presque 90%) ont reçu un sérum
antivenimeux pendant l’hospitalisation en plus d’un traitement
d’entretien. La durée moyenne du séjour a été de 4.3 jours. Plus de 90% des
142 patients ont récupéré, avec environ 8% d’abcès locaux. La mortalité a
été de 2.9%, essentiellement en rapport avec des complications comprenant
l’insuffisance rénale, l’insuffisance respiratoire et la coagulation
intravasculaire disséminée.
Resumen. La información epidemiológica sobre la mordedura de ofidios
en Ecuador es escasa. Las mordeduras por ofidios son más frecuentes en
las tierras bajas al este de los Andes, en la cuenca Amazónica. Se efectúa un
estudio retrospectivo (n = 142) de pacientes ingresados de 1996 al 2000,
por mordeduras de serpientes, en el Hospital Pío XII, un centro de salud
regional situado en la ciudad de Sucúa, Morona Santiago, Ecuador. Las
mordeduras se produjeron con más frecuencia entre los meses de marzo a
mayo. La mayoría de los pacientes (52.5%) tenían edades comprendidas
entre los 15–49 años y más del 40% eran labradores. En la mayoría de los
casos, los pacientes no pudieron identificar la especie de ofidio que les
había mordido. Algunos pacientes (n = 60, 42.3%) recibieron algún tipo de
tratamiento antes de llegar al hospital. La mordedura se localizó con más
frecuencia en el miembro inferior izquierdo (31.7%), apareciendo los
síntomas locales típicos: dolor y edema. Sintomatología general como
fiebre, nauseas y vómitos fue menos frecuente. A la mayoría de los
pacientes (alrededor del 90%) se les administró durante su hospitalización
antivenin junto con otras medidas terapéuticas. La hospitalización media
fue 4.3 días. Más del 90% de los 142 pacientes se recuperaron; cerca del 8%
desarrollaron un absceso local. La mortalidad fue del 2.9% debida a
complicaciones tales como: fracaso renal, respiratorio o coagulopatía
intravascular diseminada.
Acknowledgments
We thank Dr. Edgar Rodas and the staff at Fundacion Cinterandes
in Cuenca, Ecuador for their support of this project. The Funda-
cion was instrumental in setting up communications between Rich-
mond and Sucúa and in securing the transfer of data between the
two locations. Thanks also go to Dr. Rodas for reviewing the manu-
World J. Surg. Vol. 27, No. 2, February 2003
script. Special thanks go to Stephen L. Crute, an amateur herpe-
tologist in the Division of Research, Department of Surgery, Vir-
ginia Commonwealth University, School of Medicine for reviewing
this manuscript and for his thoughtful comments. This work was
funded in part by a grant from NASA.
References
1. Rumbea JG, Freire AL, Sandoval LN, et al. Guia operativa para el
manejo de accidents ofidicos. Bol. Epidemiol. 1999;3:2–13
2. Campbell JA, Lamar WW. The Venomous Reptiles of Latin America.
Ithaca, NY, Comstock Publishing, 1989;440
3. Theakston RDG, Laing GD, Fielding CM, et al. Treatment of snake
bites by Bothrops species and Lachesis muta in Ecuador: laboratory
screening of candidate antivenoms. Trans. R. Soc. Trop. Med. Hyg.
1995;89:550–554
4. De Carvalho MA, Nogueira FN. [Snakes from the urban area of
Cuiaba, Mato Grosso: ecological aspects and associated snakebites.]
Cad. Saude Publica 1998;14:753–763
5. Li QB. Anisodamine as an effective drug to treat snakebites. J. Nat.
Toxins 1999;8:327–330
6. Otero R, Fonnegra R, Jimenez SL, et al. Snakebites and ethnobotany in
the northwest region of Colombia. I. Traditional use of plants. J. Eth-
nopharmacol. 2000;71:493–504
7. Rodriguez AA, Uzcategui W, Azuaje R, et al. Analisis clinico y epide-
miologico de los accidents por mordeduras de serpientes del genero
Bothrops en Venezuela [A clinical and epidemiological analysis of ac-
cidental bites by snakes of the genus Bothrops in Venezuela]. Rev. Cu-
bana Med. Trop. 2000;52:90–94
8. Saborio P, Gonzalez M, Cambronero M. [Snake bite accidents in chil-
dren in Costa Rica: epidemiology and determination of risk factors in
the development of abscess and necrosis.] Toxicon 1998;36:359–366
9. Evaluacion de la Produccion de Servicios de Salud. Provincia de Mo-
rona Santiago, Ano 1999. Macas, Morona Santiago, Ecuador. Direc-
cion Provincial de Salud de Morona Santiago 1999;112:122
10. Tokish JT, Benjamin J, Walter F. Crotalid envenomation: the southern
Arizona experience. J. Orthop. Trauma 2001;15(1):5–9
11. Buranasin P. Snakebites at Maharat Nakhon Ratchasima Regional
Hospital. Southeast Asian J. Trop. Med. Public Health 1993;24:186–
192
12. Jurkovich GL, Gentilello LM. Envenomation and environmental inju-
ries. In Greenfield LJ, editor, Surgery: Scientific Principles and Prac-
tice, Philadelphia, Lippincott-Raven, 1997;402–406
13. Otero R, Nunez VV, Jimenez SL, et al. Snakebites and ethnobotany in
the northwest region of Colombia. II. Neutralization of lethal and en-
zymatic effects of Bothrops atrox venom. J. Ethnopharmacol. 2000;71:
505–511
14. Otero R, Nunez V, Barona J, et al. Snakebites and ethnobotany in the
northwest region of Colombia. III. Neutralization of the haemorrhagic
effect of Bothrops atrox venom. J. Ethnopharmacol. 2000;73:233–241
15. Yamanouye N, Britto LRG, Carneiro SM, et al. Control of venom pro-
duction and secretion by sympathetic outflow in the snake Bothrops
jaraca. J. Exp. Biol. 1997;200:2547–2556
16. Rudolph R, Neal GE, Williams JS, et al. Snakebite treatment at a
southeastern regional referral center. Am. Surg. 1995;61:767–772
17. Barrantes A, Solis V, Bolanos R. [Alterations in the coagulation
mechanisms of patients bitten by Bothrops asper.] Toxicon. 1985;23:
399–407
18. Heinrich M. Ethnobotany and its role in drug development. Phytother.
Res. 2000;14:479–488
19. Schultes RE. Amazonian ethnobotany and the search for new drugs.
Ciba Found. Symp. 1994;185:106–112