Predictors of the development of post-snakebite compartment syndrome

Compartment syndrome of arm secondary to snake bite on hand: a case report

Introduction

Snake bites pose a significant common public health concern, with more prevalence in rural areas. Compartment syndrome (CS) is one of the rare and severe manifestations of snake bite wherein venom-induced swelling within a closed anatomical compartment leads to increased pressure, which may result in ischemic damage to nerves and muscle. Antisnake venom and prompt fasciotomy is recommended for management of CS secondary to snake bite.

Case details

Here, the authors report a case of 47-year-old female with Green Pit Viper bite on the left hand. Upon arrival to hospital, initial resuscitation measures were initiated. Six hours following the bite, there was severe pain on passive stretch and paresthesia. Ten vials of antisnake venom administration along with fasciotomy of hand and arm resulted in notable alleviation of pain and swelling. Eighteen pints of blood was transfused for coagulopathy and low hemoglobin. After continued care of wound and intensive physiotherapy, functional limb could be achieved.

Discussion

Snake bite envenomation is one of the biggest hidden health crises with case fatality rate of 7.8% in the southern plains of Nepal. As in our case, snake bites commonly affect upper extremities, accounting for around two third of all cases. CS must be differentiated from acute swelling, which sometimes may be difficult. Surgical decompression is indicated in presence of signs and symptoms of CS, in case of resource limited setting.

Conclusion

Multidisciplinary and prompt management with initial resuscitation, ASV administration, fasciotomy, and rehabilitative measures can save both life and limb in such cases.

A Nationwide Study on the Risks of Complications and Healthcare Costs of Snakebite Envenomation in Taiwan

In Taiwan, six medically important venomous snakes, Trimeresurus stejnegeri stejnegeri, Protobothrops mucrosquamatus, Deinagkistrodon acutus, Daboia siamensis, Naja atra, and Bungarus multicinctus, are found. However, comprehensive research on the complications and associated healthcare costs of snakebite envenomation (SBE) is lacking. We retrospectively analyzed pertinent information from the Taiwan National Health Insurance Research Database dated January 2002 to December 2014. We investigated the risk factors for complications and their impact on healthcare costs. Among the 12,542 patients with SBE, those from N. atra or B. multicinctus were more likely to experience wound infections and neurological complications than were those from T. s. stejnegeri or P. mucrosquamatus. In addition, being female, being elderly, and having a Charlson Comorbidity Index equal to or greater than 3 points were associated with an increased likelihood of wound infections and psychological complications. The annual national economic burden averaged US$1,083,624, with an average healthcare cost of US$1,129 per SBE. Snakebite envenomations from N. atra or B. multicinctus, as well as various complications, resulted in significantly higher costs. It is crucial to comprehend the risk factors for complications and their role in increasing expenses to provide insight for tailored healthcare interventions, mitigate complications, and reduce the economic burdens associated with SBEs.

A Guide to the Clinical Management of Vipera Snakebite in Italy

The genus Vipera encompasses most species of medically significant venomous snakes of Europe, with Italy harbouring four of them. Envenomation by European vipers can result in severe consequences, but underreporting and the absence of standardised clinical protocols hinder effective snakebite management. This study provides an updated, detailed set of guidelines for the management and treatment of Vipera snakebite tailored for Italian clinicians. It includes taxonomic keys for snake identification, insights into viper venom composition, and recommendations for clinical management. Emphasis is placed on quick and reliable identification of medically relevant snake species, along with appropriate first aid measures. Criteria for antivenom administration are outlined, as well as indications on managing potential side effects. While the protocol is specific to Italy, its methodology can potentially be adapted for other European countries, depending on local resources. The promotion of comprehensive data collection and collaboration among Poison Control Centres is advocated to optimise envenomation management protocols and improve the reporting of epidemiological data concerning snakebite at the country level.

Acute compartment syndrome and fasciotomy after a viper bite in Italy: a case report

BACKGROUND

Bites caused by European vipers are rare medical emergencies but can occasionally cause life-threatening complications. Viper venom causes local symptoms, which can be accompanied by systemic manifestations in severe cases. The local effects of snakebites include edema and, more rarely, necrosis and compartment syndrome. The consequences of envenomation are often more pronounced in children due to their smaller body size.

CASE PRESENTATION

We present the case of a 6-year-old girl who experienced multiple viper bites in the lower limb in northwest Italy. The girl received supportive care but progressed to develop compartment syndrome that required emergency fasciotomy. The patient's condition improved promptly after surgical decompression and administration of antivenom, but full recovery required prolonged hospitalization and rehabilitation.

CONCLUSIONS

This case highlights the importance of obtaining a timely assessment of the severity of viper envenomation without delaying the administration of antivenom in most serious cases. The presence of multiple bite marks on the patient is one factor that may help to predict the clinical severity of snakebites and anticipate symptom progression.

Ultrasound-guided selective peripheral nerve block for the snakebite pain management in the emergency department: Our experience

Envenomation from snakebites (SBs) is a significant public health hazard globally. The venomous SB is associated with moderate-to-severe pain. Weak opioids such as tramadol or acetaminophen are commonly used for pain management but often provide inadequate analgesia. We hereby report our experience of using ultrasound-guided selective superficial peroneal, sural, and saphenous nerve blocks for pain management following SBs in nine patients. The selective peripheral nerve blocks are achieved with a small amount of local anesthesia and without loss of motor functions.

Neurological and neuro-ophthalmological manifestations of snake bite: a systematic review

Objective

Snakebites, a major health concern in developing countries, affect rural farming communities. Venom, primarily neurotoxin, injected during a snake bite disrupts the nervous system, causing symptoms like muscle weakness, paralysis, altered sensation, and coordination issues. This review focuses on evaluating neurological and neuro-ophthalmological manifestations associated with snakebites.

Methods

A database search was conducted in EMBASE and PubMed for studies published from 2000 to 2023. The investigation centered on examining neurological and neuro-ophthalmological symptoms and signs, treatment approaches, treatment outcomes, and long-term complications of snake bites.

Results

Neurological and neuro-ophthalmological symptoms were common in both neurotoxic and hemotoxic snake bites, especially in neurotoxic cases. Ptosis was a prevalent manifestation across various snake bites, along with respiratory paralysis, limb weakness, dysphasia, and visual disturbances in some instances. However, most patients improved without residual neurological symptoms after treatment.

Conclusions

Understanding patterns of neurological manifestations contributes valuable insights for the comprehensive management of snakebite.

Long-term health manifestations of hump-nosed pit viper (Genus: Hypnale) bites

INTRODUCTION

The hump-nosed pit viper (Genus: Hypnale) is a highly medically significant snake in Sri Lanka, responsible for the majority of venomous snakebites (22-77%). They are found throughout Sri Lanka and the Western Ghats region of India. The venom can lead to two types of effects: acute and long-term. Acutely, bites often result in local symptoms, with less common systemic effects such as acute kidney injury, venom-induced consumption coagulopathy, and thrombotic microangiopathy.

METHODS

We conducted a prospective observational study at Teaching Hospital Ratnapura, Sri Lanka, spanning six years, starting in June 2015. Patients bitten by hump-nosed pit vipers were followed up for two years, with assessments every three months to identify long-term effects. Data was gathered through interviewer-administered questionnaires.

RESULTS

Out of 728 patients bitten by hump-nosed pit vipers, 22 (3%) were lost to follow-up. Forty-four (6.2%) experienced long-term effects, including chronic kidney disease (24; 3.4%), chronic wounds (five; 0.7%), amputations (five; 0.7%), fasciotomy-related wounds (four; 0.6%), and psychological illnesses (four; 0.6%). There were nine (1.3%) deaths in this group. Among those with chronic effects, 27 (61%) were males, and 17 (39%) were females, with ages ranging from 29 to 82 years (mean 57.6 years). The time it took to diagnose acute kidney injury from the snakebite was 18 h (interquartile range: 15-23.5 h), while the time to diagnose chronic kidney disease was 69 days (interquartile range: 64-74.75 days). In these patients, the estimated glomerular filtration rate was 29.3 mL/min/1.73 m2 (interquartile range: 14-50.75 mL/min/1.73 m2). Among the patients who did not develop long-term complications (662; 91%) 660 (90.7%) experienced local effects, and 82 (11.3%) developed systemic manifestations, including acute kidney injury in 60 (8%) and coagulopathy in 35 (5%).

CONCLUSION

Following hump-nosed pit viper bites, a subset of patients may experience long-term health complications, including chronic kidney disease, chronic ulcers, amputations, fasciotomy-related wounds, and psychological illnesses, with chronic kidney disease being the most frequently observed among these manifestations.

Compartment Syndrome Secondary to Bothrops spp. Envenomation in Triângulo Mineiro, Region, Minas Gerais, Brazil

BACKGROUND

Snakebite is a neglected global health problem with high morbidity. We describe compartment syndrome (CS) cases related to snakebites by Bothrops spp.

METHODS

The medical records of patients admitted with snakebites envenomation were reviewed.

RESULTS

Of 47 patients with Bothrops spp. envenomation (4 male; mean age: 42 years), 7 (15%) developed CS. The mean time to antivenom administration was 9.5 hours. The time to fasciotomy was variable. Seven patients developed infection and four had acute kidney injury.

CONCLUSIONS

The incidence of CS is higher than that reported previously. This may be due to the clinical severity and long delay before administering antivenom.

Prediction of Compartment Syndrome after Protobothrops mucrosquamatus Snakebite by Diastolic Retrograde Arterial Flow: A Case Report

Post-snakebite compartment syndrome (PSCS) is an uncommon but dangerous condition. Compartment syndrome-like symptoms after snakebite by Protobothrops mucrosquamatus (P. mucrosquamatus) are not effective in guiding fasciotomy. Objective evaluation of intracompartmental pressure measurements in patients with suspected PSCS is recommended. However, there is a lack of consensus regarding PSCS and indications for surgical intervention, including the threshold value of chamber pressure. In addition, intracompartmental pressure measurements may not be readily available in all emergency service settings. Measuring intracompartmental pressure in all snakebite patients for early diagnosis of PSCS is impractical. Therefore, identifying risk factors, continuous real-time monitoring tools, and predictive factors for PSCS are important. Sonography has proved useful in identifying the location and extension of edema after a snakebite. In this study, we attempted to use point-of-care ultrasound to manage PSCS in real-time. Here, we describe a rare case of snakebite from P. mucrosquamatus. PSCS was considered as diastolic retrograde arterial flow (DRAF) was noted in the affected limb with a cobblestone-like appearance in the subcutaneous area, indicating that the target artery was compressed. The DRAF sign requires physicians to aggressively administer antivenom to salvage the limb. The patient was administered 31 vials of P. mucrosquamatus antivenom, and fasciotomy was not performed. DRAF is an early sign of the prediction of PSCS.

Snakebite envenomation in children: An ongoing burden in Morocco

Introduction

Snakebites are a leading cause of mortality and permanent disabilities especially among children in tropical countries and rural areas such as Morocco. Thus, a nationwide management protocol including specific antivenom therapy along with prevention strategies was implemented to reduce the overall snakebites morbimortality.

Patients and methods

Our retrospective study aimed to describe the clinical aspects of snakebite envenomation before and after the implementation of this protocol in children admitted to the pediatric intensive care unit (PICU) in Marrakesh-Morocco for a period of 11 years.

Results

A total of 75 cases were included and were mostly male (70%) with a mean age of 10 years old. Most envenomations were mild or severe (75%) and often occurred during outdoor activities in limb extremities. Altered hemostasis frequently occurred in 67% of cases but was rarely associated with severe exteriorized hemorrhage. Moderate anemia and PNN- predominant leukocytosis were often observed at admission (52.2% and 58%) but quickly tended to normalize before 48 h. Local symptoms were the main dread as they quickly evolve to a compartment syndrome and necrosis in the absence of antivenom therapy. Fasciotomy was performed in 33% of cases while 5 children required limb amputation. Antivenom administration (n = 39) was statistically significant for rapid improvement in hemostasis disorders, reduced blood transfusions and fasciotomy for compartment syndrome as well as a shortened length of stay in PICU. The onset of acute kidney injury was observed in 18 cases but restored in most patients within 48 h (77%). Five children died of which only two had received delayed antivenom immunotherapy due to its unavailability and deferred hospital admission.

Conclusion

The advent of specific serotherapy has made it possible to optimize the management of patients and to prevent and treat local and systemic complications thus improving the overall prognosis; nevertheless, primary prevention remains the key to reducing snakebites morbimortality.

•

Snakebites are a leading cause of mortality and permanent disabilities especially among children.

•

Morocco represents a hot spot in northern Africa for venomous snakes where there is a wide variety of species.

•

The clinical presentation is widely variable and may rapidly evolve in time.

•

Snakebites are eminently preventable and manageable through community awareness and unified therapeutic action.

•

The inaccessibility to healthcare structures and the occasional availability of immunotherapy continue to be the main limitation.

The development of surgical risk score and evaluation of necrotizing soft tissue infection in 161 Naja atra envenomed patients

BACKGROUND

Naja atra bites cause wound necrosis, secondary infection, and necrotizing soft tissue infection (NSTI) requiring repetitive surgeries. Little information is known about the predictors for surgery after these bites.

MATERIALS AND METHODS

We retrospectively evaluated 161 patients envenomed by N. atra, 80 of whom underwent surgery because of wound necrosis and infection. We compared the patients' variables between surgical and non-surgical groups. To construct a surgical risk score, we converted the regression coefficients of the significant factors in the multivariate logistic regression into integers. We also examined the deep tissue cultures and pathological findings of the debrided tissue.

RESULTS

A lower limb as the bite site, a ≥3 swelling grade, bullae or blister formation, gastrointestinal (GI) effects, and fever were significantly associated with surgery in the multivariate logistic regression analysis. The surgical risk scores for these variables were 1, 1, 2, 1, and 2, respectively. At a ≥3-point cutoff value, the model has 71.8% sensitivity and 88.5% specificity for predicting surgery, with an area under the receiver operating characteristic curve of 0.88. The histopathological examinations of the debrided tissues supported the diagnosis of snakebite-induced NSTI. Twelve bacterial species were isolated during the initial surgery and eleven during subsequent surgeries.

DISCUSSION AND CONCLUSIONS

From the clinical perspective, swelling, bullae or blister formation, GI effects, and fever appeared quickly after the bite and before surgery. The predictive value of these factors for surgery was acceptable, with a ≥3-point risk score. The common laboratory parameters did not always predict the outcomes of N. atra bites without proper wound examination. Our study supported the diagnosis of NSTI and demonstrated the changes in bacteriology during the surgeries, which can have therapeutic implications for N. atra bites.

Venomous Snakebites: Treatment Considerations and the Emergency Department Nurse Practitioners'/Providers' Priorities of Care

In the United States, 7,000-8,000 people are bitten by a venomous snake each year, out of which approximately 5 die. Although common practice is to treat any and all victims of envenomation with repeated doses of antivenom, this approach is not without its risks. The gold standard for treating venomous snakebites with severe symptoms is antivenom. Although a standardized approach to treating envenomation is needed, it cannot be developed without first delineating current practices. This article discusses the ways in which advanced practice emergency nurses should manage bites from a variety of venomous snakes. It is divided into 4 main sections: (1) the types of venomous snakes found in the United States, their habitat, and the effects of their venom; (2) priorities of care in treating venomous snakebites; (3) preparation and administration of antivenom; and (4) other considerations for the advanced practice emergency department nurse.

Challenges in the Management of an Echis coloratus Adult Snakebite Victim at a Tertiary Care Hospital: A Case Report

Patient: Male, 18-year-old

Final Diagnosis: Snakebite envenomation

Symptoms: Coagulopathy

Medication:—

Clinical Procedure: Anti snake venom

Specialty: General and Internal Medicine • Toxicology • Tropical Medicine

Massive cutaneous complications due to snakebite: A case report and literature review

Wound infections due to snake bites such as cellulitis and necrotizing fasciitis, although not common, are seen in snake bites and if left untreated can cause serious complications.

Snake Bite Management: A Scoping Review of the Literature

Background:

Around the world, snake bite envenomation remains an underreported human health hazard. Envenomation can cause local and systemic complications, especially when there is a lack of antivenom availability. Although there are established guidelines regarding snake bite management acute care, there is a paucity of data regarding surgical intervention and the plastic surgeon’s role treating this unique patient population.

Methods:

A review was conducted identifying relevant published articles involving snake bite management and treatment in PubMed and EMBASE.

Results:

One hundred ten articles were identified and 77 met inclusion criteria. Snake bite envenomation can result in complications that are dependent upon a variety of variables. The literature has shown the best field treatment to be timely transportation to the nearest medical facility, along with antivenom administration. The cytotoxic, hemotoxic, and neurotoxic effects of venom can cause a variety of local soft tissue and systemic complications. Surgical interventions such as fasciotomies, wound debridements, skin grafts, and tissue flaps may be necessary in these patients to optimize functional and aesthetic outcomes. Disparities in access to care in resource limited settings are discussed.

Conclusions:

Global health disparities and insufficient antivenom distribution create an inequality of care in snake bite patients. Plastic surgeons have an important role in managing acute and chronic complications of snake bite envenomations that can lead to improved patient outcomes.

Wound Infections from Taiwan Cobra (Naja atra) Bites: Determining Bacteriology, Antibiotic Susceptibility, and the Use of Antibiotics-A Cobra BITE Study

Wound necrosis and secondary infection are common complications after Naja atra bites. Clinical tools to evaluate the infection risk after Taiwan cobra bites are lacking. In this Cobra BITE study, we investigated the prevalence of wound infection, bacteriology, and corresponding antibiotic usage in patients presenting with Taiwan cobra snakebites. Patients with wound infection lacking tissue necrosis were included in developing Cobra BITE score utilizing univariate and multiple logistic regression, as patients with wound necrosis require antibiotics for infection treatment. 8,295,497 emergency department visits occurred in the span of this study, with 195 of those patients being diagnosed as having cobra bites. Of these patients, 23 had wound necrosis, and 30 had wound infection, resulting in a wound infection rate of 27.2% (53/195). Enterococcus faecalis and Morganella morganii were the main bacteria identified in the culture report regardless of whether patients’ wounds had necrosis. As per our Cobra BITE score, the three factors predicting secondary wound infection after cobra bites are hospital admission, a white blood cell count (in 103/µL) × by neu-trophil-lymphocyte ratio value of ≥114.23, and the use of antivenin medication. The area under the receiver operating characteristic curve for the Cobra BITE score system was 0.88; ideal sensitivity and specificity were 0.89 and 0.76. This scoring system enables the assessment of wound infections after N. atra bites, and it could be modified and improved in the future for other Naja spp. bites.

The role of a point-of-care ultrasound protocol in facilitating clinical decisions for snakebite envenomation in Taiwan: a pilot study

BACKGROUND

The incidence of acute compartment syndrome (ACS) following snakebite envenomation may be seriously overestimated in Taiwan. Snakebite-induced ACS is difficult to determine solely by clinical examination. Snakebite patients previously underwent surgical intervention based on speculation and general clinical examinations suggesting ACS presentations instead of direct intracompartmental pressure (IP) measurement prior to fasciotomy. Point-of-care ultrasound (POCUS) is a relatively widely available noninvasive tool. This study aimed to evaluate snakebite-envenomated patients for the presence of subcutaneous edema and diastolic retrograde arterial flow (DRAF).

MATERIALS AND METHODS

Snakebite patients were prospectively recruited between 2017 and 2019. All patients were examined with POCUS to locate edema and directly visualize and measure the arterial flow in the compressed artery. The presence of DRAF in the compressed artery is suggestive of ACS development because when compartment space restriction occurs, increased retrograde arterial flow is observed in the artery.

RESULTS

Twenty-seven snakebite patients were analyzed. Seventeen patients (63%) were bitten by Crotalinae snakes, seven (26%) by Colubridae, one (4%) by Elapidae, and two (7%) had unidentified snakebites. All Crotalinae bit patients received antivenom, had subcutaneous edema and lacked DRAF in a POCUS examination series.

DISCUSSION

POCUS facilitates clinical decisions for snakebite envenomation. We also highlighted that the anatomic site of the snakebite is an important factor affecting the prognosis of the wounds. There were limitations of this study, including a small number of patients and no comparison with the generally accepted invasive evaluation for ACS.

CONCLUSIONS

We are unable to state that POCUS is a valid surrogate measurement of ACS from this study but see this as a starting point to develop further research in this area. Further study will be needed to better define the utility of POCUS in patients envenomated by snakes throughout the world.

Delayed Splenic Rupture: A Rare Complication of Snakebites

Bites by venomous snakes can cause fatal systemic and coagulation disorders. Rare complications, such as compartment syndrome and hemoperitoneum, may also require surgical intervention. Here, we describe our experience with an unusual case of snakebite-induced delayed splenic rupture. A 54-y-old male with no specific medical history visited a local hospital for a bite by an unidentified snake. He had been bitten on the left thumb and was administered antivenom. He was discharged from the local hospital after 3 d when his symptoms had improved. However, he revisited our emergency medical center 2 d later, reporting dizziness with diaphoresis. Focused abdominal ultrasonography and computed tomography revealed large amounts of intraperitoneal fluid collection and hemoperitoneum with splenic rupture, respectively. The patient underwent immediate blood transfusion and received antivenom treatment in our emergency department and, subsequently, emergency splenectomy. Histopathologic findings at the time of surgery revealed multifocal lacerations on the external surface of the spleen, with fresh hemorrhage. He recovered 7 d after surgery without any complication.

Envenomation by Trimeresurus stejnegeri stejnegeri: clinical manifestations, treatment and associated factors for wound necrosis

Background

Trimeresurus stejnegeri stejnegeri bite induces tissue swelling, pain, thrombocytopenia, rhabdomyolysis, and acute renal failure. However, the incidence of coagulopathy, factors associated with wound necrosis, and the appropriate management of this condition have not been well characterized yet.

Materials

This study included patients bitten by T. s. stejnegeri that were admitted to the study hospitals from 2001 to 2016. Patient characteristics, laboratory data, and management approaches were compared in victims with and without wound necrosis.

Results

A total of 185 patients were evaluated: three patients (1.6%) were asymptomatic; whereas tissue swelling and pain, local ecchymosis, wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and renal impairment were present in 182, 53, 13, 15, 10, 1, and 3 patients, respectively. One patient died from coagulopathy and hemorrhagic shock. Antivenom was administered to all envenomed patients at a median time of 1.8 h after the bite. The median total dose of antivenom was five vials. Chi-square analysis showed that bitten fingers, using cold packs during first aid, presence of bullae or blisters, lymphangitis or lymphadenitis, local numbness and suspected infection to be significantly associated with wound necrosis. After adjustment using a multivariate logistic regression model, only cold packs as first aid, bulla or blister formation, and wound infection remained significant.

Conclusions

The main effects of T. s. stejnegeri envenomation are tissue swelling, pain, and local ecchymosis. We do not recommend the use of cold packs during first aid to reduce wound pain, as this may be a risk factor for wound necrosis. In addition, patients with bulla or blister formation should be carefully examined for subsequent wound necrosis. Antiplatelet use may worsen systemic bleeding. No severe rhabdomyolysis or renal failure was observed in this large case series, we therefore considered that they were not prominent effects of T. s. stejnegeri bite.

Upper limb compartment syndrome after a viper bite in a child: A case report

The occurrence of compartment syndrome after a viper bite is a rare phenomenon and its treatment remains controversial. We report the case of an 11-year-old boy who developed compartment syndrome of the right upper limb following a viper bite. Decompression by fasciotomy was performed urgently with a good outcome. Surgical decompression for compartment syndrome following a viper bite is not a common treatment according to the literature. Fast access to care and antivenom administration seem to be effective at treating the compartment syndrome without recourse to fasciotomy.

Clinical manifestations and treatments of Protobothrops mucrosquamatus bite and associated factors for wound necrosis and subsequent debridement and finger or toe amputation surgery

INTRODUCTION

Protobothrops mucrosquamatus bite induces wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and acute renal failure. The severity of the hematological derangements and associated factors for wound necrosis and subsequent surgery and the appropriate management of these conditions have not been well characterized. Although severe renal failure requiring hemodialysis has been reported following P. mucrosquamatus bite, the culprit snake may be erroneously classified.

MATERIALS AND METHODS

A total of 186 patients with P. mucrosquamatus bites were retrospectively evaluated. They were categorized into group 1 (patients receiving debridement or finger/toe amputation) and group 2 (all other patients) to identify the associated factors for surgery. Characteristic data were compared between groups 1 and 2 and between definite and suspected cases.

RESULTS

No differences were observed between definite and suspected cases in terms of symptomatology and management. Of the 186 patients, 7 (3.8%) were asymptomatic, 179 (96.2%) experienced tissue swelling and pain, and 107 (57.5%) had local ecchymosis. Coagulopathy, thrombocytopenia, and renal impairment were found in 13 (7%), 19 (10.2%), and 7 (3.8%) patients, respectively. None of the patients required transfusion therapy or hemodialysis. Furthermore, no systemic bleeding or death occurred. Antivenom was administered to all 179 envenomed patients at a median of 1.5 h post-bite. The median total dose of the specific antivenom was 5.5 vials. In multivariate logistic regression analysis, finger as the bite site, bullae and blister formation, and wound infection were significantly associated with wound necrosis; whereas finger as the bite site and bullae and blister formation were related to debridement or finger/toe amputation.

DISCUSSION AND CONCLUSIONS

Protobothrops mucrosquamatus envenomation mainly exerts effects on local tissue. Systemic effects are uncommon and generally nonsevere and transient after the treatment with the specific antivenom. We speculated that severe renal failure requiring hemodialysis is not a typical finding of P. mucrosquamatus envenomation. Patients with finger as the bite site and bullae or blister formation should be carefully examined for wound necrosis, secondary infection, and subsequent surgery. Further evaluations of the efficacy of antivenom against local tissue effects and the effect of selective antibiotics in the management of bite wound infection are urgently required. Although the antivenom manufacturer suggested a skin test prior to use, we believed that it could be omitted because it does not accurately predict the allergic responses.

Effect of Traditional Chinese Medicine on Long-Term Outcomes of Snakebite in Taiwan

Herein, we review the characteristics of the six predominant venomous snakes in Taiwan and the effects of traditional Chinese medicine on the long-term outcomes of snakebite venom. We electronically searched databases, including PubMed, ClinicalKey, China National Knowledge Infrastructure, National Digital Library of Theses and Dissertations in Taiwan, and Airiti Library, from their inception to November 2019 by using the following Medical Subject Headings' keywords: snakebite, long-term, chronic, Chinese medicine, CAM, herb, and Taiwan. The most common long-term effects of snakebite envenomation include "migraine-like syndrome", brain injuries caused by hypoxia or intracranial hemorrhage, and chronic kidney disease. In addition, hypopituitarism is also worth mentioning. Traditional Chinese medicine can potentially be used in a complementary or alternative treatment for these effects, but additional studies are needed.

Naja atra venom-spit ophthalmia in Taiwan: An epidemiological survey from 1990 to 2016

BACKGROUND

Venomous snakebites are common during hot seasons in Taiwan. However, rarely is venom spat directly into the subject's eyes, causing eye injury. Despite being uncommon, analytical data regarding venom-spit ophthalmia in Taiwan have been lacking. This study thus aimed to conduct an epidemiological survey on Naja atra venom-spit ophthalmia in Taiwan during the past decades to improve future care of such patients.

METHODS

Registered records of cases with snake venom injuries at the Taiwan National Poison Control Center from 1990 to 2016 were retrospectively reviewed, enrolling those with records of cobra venom-spit eye injuries and excluding exotic species. Demographic data, clinical symptoms, snake species, ocular conditions, management, and outcomes were recorded and analyzed.

RESULTS

A total of 39 cases suffering from Naja atra venom-spit ophthalmia were enrolled. The overall incidence rate was 1.6 cases per million people from 1990 to 2016. Among the included cases, most were unilaterally injured (82%), male (95%), aged 18 to 59 years (90%), injured during catching (51%), and injured in spring and summer (92%). Ocular symptoms occurred in 90% of the cases, majority of which included ocular pain (90%) and redness (85%). Conjunctivitis (67%) and corneal injury (59%) of involved eyes were common. Immediate water irrigations were done in all cases, most of whom received further topical eye drops, including antibiotics, corticosteroids, and vasoconstrictors. Although topical or intravenous antivenoms were administered in 11 cases, no obviously superior outcome was observed. Most cases (77%) were symptom free after the acute stage.

CONCLUSION

Although Naja atra venom-spit ophthalmia in Taiwan is uncommon, the risk for transient ocular symptoms and corneal/conjunctival injury does exists. Prompt ocular irrigation and professional ophthalmic care after envenomation help prevent serious ocular sequelae. Moreover, superior outcomes were not achieved with the use of antivenom. Nonetheless, further studies are required to clarify the role antivenoms play in venom-spit ophthalmia.

Surgical Considerations for Pediatric Snake Bites in Low- and Middle-Income Countries

BACKGROUND

Snake envenomation is associated with major morbidity especially in low- and middle-income countries and may require fasciotomy. We determined patient factors associated with the need for fasciotomy after venomous snake bites in children located in KwaZulu-Natal, South Africa.

METHODS

Single institutional review of historical data (2012-2017) for children (<18 years) sustaining snake envenomation was performed. Clinical data, management, and outcomes were abstracted. Syndromes after snake bite were classified according to Blaylock nomenclature: progressive painful swelling (PPS), progressive weakness (PW), or bleeding (B), as it is difficult to reliably identify the species of snake after a bite. Comparative and multivariable analyses to determine factors associated with fasciotomy were performed.

RESULTS

There were 72 children; mean age was 7 (±3) years, 59% male. Feet were most commonly affected (n = 27, 38%) followed by legs (n = 18, 25%). Syndromes (according to Blaylock) included PPS (n = 63, 88%), PW (n = 5, 7%), and B (n = 4, 5%). Eighteen patients underwent fasciotomy, and one required above knee amputation. Nine patients received anti-venom. Few patients (15%) received prophylactic beta-lactam antibiotics. Hemoglobin < 11 mg/dL, leukocytosis, INR >1.2, and age-adjusted shock index were associated with fasciotomy. On regression, age-adjusted shock index and hemoglobin concentration < 11 mg/dL, presentation >24 h after snake bite, and INR >1.2 were independently associated with fasciotomy. Model sensitivity was 0.89 and demonstrated good fit.

CONCLUSIONS

Patient factors were associated with the fasciotomy. These factors, coupled with clinical examination, may identify those who need early operative intervention. Improving time to treatment and the appropriate administration of anti-venom will minimize the need for surgery.

LEVEL OF EVIDENCE

III.

Envenomation by a western green mamba (Dendroaspis viridis) - A report of three episodes in Switzerland

The African elapid snake genus Dendroaspis comprises four species, with D. polylepsis the most dangerous of them. D. viridis is believed to cause stronger neurotoxic symptoms than the potentially least toxic of the genus, D. angusticeps, but seems less toxic compared to either of the D. jamesoni species (D. j. jamesoni(TRAILL 1843) and D. j. kaimosae (Loveridge 1936)). We present three episodes of bites byD. viridis in the same patient, sustained on three different occasions, caused by three different and unrelated snakes. While the first bite remained oligosymptomatic with a slight tightness of the throat and speedy resolution of symptoms without specific therapy, episodes two and three resulted in the patient developing massive local swelling. However, the patient showed only minimal neurologic and systemic symptoms such as tightness of the throat and a tingling sensation of the body. Episode two resolved with fasciotomy after compartment syndrome was diagnosed with a measured intracompartmental pressure of 52 mmHg. In episode three, antivenom was administered with good resolution of symptoms. The clinical courses in this patient were remarkable as he displayed mainly local symptoms after three individual bites by a supposedly neurotoxic snake.

Long-term Effects of Snake Envenoming

Long-term effects of envenoming compromise the quality of life of the survivors of snakebite. We searched MEDLINE (from 1946) and EMBASE (from 1947) until October 2018 for clinical literature on the long-term effects of snake envenoming using different combinations of search terms. We classified conditions that last or appear more than six weeks following envenoming as long term or delayed effects of envenoming. Of 257 records identified, 51 articles describe the long-term effects of snake envenoming and were reviewed. Disability due to amputations, deformities, contracture formation, and chronic ulceration, rarely with malignant change, have resulted from local necrosis due to bites mainly from African and Asian cobras, and Central and South American Pit-vipers. Progression of acute kidney injury into chronic renal failure in Russell's viper bites has been reported in several studies from India and Sri Lanka. Neuromuscular toxicity does not appear to result in long-term effects. Endocrine anomalies such as delayed manifestation of hypopituitarism following Russell's viper bites have been reported. Delayed psychological effects such as depressive symptoms, post-traumatic stress disorder and somatisation have been reported. Blindness due to primary and secondary effects of venom is a serious, debilitating effect. In general, the available studies have linked a clinical effect to a snakebite in retrospect, hence lacked accurate snake authentication, details of acute management and baseline data and are unable to provide a detailed picture of clinical epidemiology of the long-term effects of envenoming. In the future, it will be important to follow cohorts of snakebite patients for a longer period of time to understand the true prevalence, severity, clinical progression and risk factors of long-term effects of snake envenoming.

Compartment Syndrome following Bothrops Snakebite Leads to Decompressive Fasciotomies

Snakebite envenoming is a neglected tropical disease with relevant morbidity and mortality. In this report, we illustrate the clinical course of a suspected Bothrops snakebite envenoming of a patient that evidenced severe pain, edema, pallor, regional lymphadenopathy, ecchymosis, myonecrosis, and bullous erythema in the right lower limb, specially around the fang marks. The clinical course progressed to compartment syndrome followed with decompressive fasciotomies to reduce pressure within the affected compartment.

Fasciotomy in compartment syndrome from snakebite

BACKGROUND

Local symptoms and signs of snake envenomation mimic the clinical features of compartment syndrome. It is important to measure the intracompartmental pressure to diagnose compartment syndrome. In this study, we present our experiences of confirming compartment syndrome and performing fasciotomy in snakebite patients based on high intracompartmental pressure findings.

METHODS

The medical records of patients who visited the trauma center of Wonju Severance Christian Hospital from January 2010 to December 2015 for the management of venomous snakebite were retrospectively reviewed. Starting in 2014, fasciotomy was performed in patients with an intracompartmental pressure of more than 40 mmHg in addition to the clinical symptoms of compartment syndrome.

RESULTS

A total of 158 patients with snakebite came to the hospital within 48 hours for treatment. Most patients (110 patients) were bitten at the upper extremities (69.6%). Since 2014, 33 out of 59 patients were suspected to have compartment syndrome, and their intracompartmental pressures were measured. Seventeen of those patients had a high intracompartmental pressure (average, 49.6 mmHg; range, 37-88 mmHg), and fasciotomy was performed.

CONCLUSIONS

In this study, as many as 10.8% of all cases were in need of fasciotomy when compartment syndrome was diagnosed by measuring the intracompartmental pressure. Previously, it was reported that fasciotomy was not required in many cases of compartment syndrome originating from snakebite. However, some patients may develop very severe compartment syndrome, requiring fasciotomy.

Two cases of unidentified acute compartment syndrome

Acute compartment syndrome (ACS) is a surgical emergency that requires urgent fasciotomy to prevent irreversible sequelae. We report two cases of unidentified ACS, which did not result from traumatic injuries such as fractures or crush injury, iatrogenic injury or diseases such as haematological malignancies. Both patients complained of severe pain and swelling of their extremity. No bite marks, blisters or skin necrosis was noted. They also complained of marked symptoms of third cranial nerve injury, including divergent squint and diplopia. The diagnosis of ACS was made following continuous intracompartmental pressure measurement, and both patients underwent urgent fasciotomy with partial incision. Considering the season and location of the injuries, together with the rapid progression of signs and symptoms that included thrombocytopaenia, acute renal failure, rhabdomyolysis and especially that of third cranial nerve injury, we postulate that these two cases may have developed following mamushi (Gloydiusblomhoffii) bites.

Naja atra snakebite in Taiwan

BACKGROUND

Naja atra snakebite is uncommon in Taiwan and causes distinct effects on its victims. Although the Taiwan government produces its own specific antivenom, little information on the management of N. atra snakebite is available.

MATERIALS AND METHODS

We retrospectively evaluated 183 patients admitted to two medical centers. Of these, 45 were identified as definite cases of N. atra snakebite, 86 as suspected cases, and 52 as clinical cases. Demographic data, symptomatology, and management were compared between these case groups.

RESULTS

Symptomatology and management were similar in the three groups. Among the 183 patients, 10 (5.5%) were asymptomatic and nine (4.9%) had transient and partial ptosis or body weakness. The principal effects were local tissue swelling and pain in 173 patients (94.5%), followed by clinically suspected wound infection in 148 (80.9%), skin necrosis in 120 (65.6%), necrotizing soft tissue infection in 77 (42.1%), fever in 59 (32.2%), and gastrointestinal effects in 53 (29%). The median total dose of specific antivenom needed to treat N. atra envenoming was 10 vials. In the envenomed patients, debridement was required in 74 patients (42.8%), fasciotomy/fasciectomy in 46 (26.6%), and finger or toe amputation in seven (4%). The first operation was performed at a median of 3.5 days after the bite.

DISCUSSION AND CONCLUSIONS

Based on these typical manifestations, clinical diagnosis of N. atra snakebites may be feasible and practical. In contrast to other snakes of Elapidae family, N. atra bite did not cause serious neurological effects. Early surgical consultation should be obtained because half of the patients underwent surgery due to infectious complications. Acute compartment syndrome was the surgical indication in rare cases; however, overestimation of the incidence may have occurred. This syndrome should be confirmed by serial intracompartmental pressure monitoring instead of only physical examination, and a sufficient dose of antivenom should be given prior to surgical decompression.

Necrotizing fasciitis following venomous snakebites in a tertiary hospital of southwest Taiwan

BACKGROUND

Necrotizing fasciitis following venomous snakebites is uncommon. The purpose of this study was to describe the initial clinical features of necrotizing fasciitis after snakebites, and to identify the risk factors for patients with cellulitis who later developed necrotizing fasciitis.

METHODS

Sixteen patients with surgically confirmed necrotizing fasciitis and 25 patients diagnosed with cellulitis following snakebites were retrospectively reviewed over a 6-year period. Differences in patient characteristics, clinical presentations, snake species and laboratory data were compared between the necrotizing fasciitis and the cellulitis groups.

RESULTS

None of the 41 patients died after being bitten by a snake. Twenty-nine patients (70.7%) were bitten by a cobra. Enterococcus species and Morganella morganii were the most common pathogens identified in wound cultures. Relative to the cellulitis group, the necrotizing fasciitis group had significantly higher rates of hemorrhagic bullae (p=0.000), patients with underlying chronic disease (p=0.019), white blood cell counts (p=0.035), segmented white cell counts (p=0.02), and days of hospitalization (p=0.001).

CONCLUSIONS

Victims of venomous snakebites should be admitted for close monitoring of secondary wound infections. The risk factors of developing necrotizing fasciitis from cellulitis following snakebites were associated with chronic underlying diseases and leukocytosis (total white blood-cell counts ≥10000cells/mm³ and ≥80% of segmented leukocyte forms). Physicians should be alert to a worsening wound condition after a snakebite, and surgical interventions should be performed for established necrotizing fasciitis with the empirical use of third-generation cephalosporins plus other regimens.