A Sadly Well Earned Fasciotomy

This section will help you get first aid treatment protocols incase of an envenomation. This includes indigenous and exotic reptiles. Please do not use this forum for photo sharing, etc.

A Sadly Well Earned Fasciotomy

Postby Jen » Wed Nov 30, 2011 5:44 pm

Today I had a 5 year old child presenting with a snake bite on the right foot 36 hours ago. He was booked in theatre for a fasciotomy.

On examination of the child, he had severe swelling of the leg up to the mid-thigh level. He was in severe pain. The leg felt very tense & His pulses were impalpable. I was able to detect a very faint arterial pulse with the use of a saturation probe (a monitoring device used to detect oxygen level in the blood). He had a tachycardia (fast heart rate) and a temperature – typical of the inflammatory response to the venom (known as SIRS)

The bite site itself was unremarkable – no bleeding or blistering. His blood results showed an abnormal clotting profile – his INR was 2.0 (double the normal) indicating that he has a coagulopathy. However, there was no bleeding from IV puncture sites, his gums, his nose or any other sites.

The snake was described as “black” but that was the sum total of the description. There was no parent present to give any further information. The patient had the clinical syndrome of progressive swelling plus coagulopathy. The possible culprit could be a puff adder, but the lack of local skin changes was against this. Snake bite is treated syndromically, however, so the identity is immaterial.

The surgeons wanted to do an immediate fasciotomy. I managed to convince them of an alternative management plan.

We induced anaesthesia in the child and secured his airway with an endotracheal tube. Then, I gave him a pre-treatment dose of intramuscular adrenalin (dosage based on the paper by Silva et al entitled “Low-Dose Adrenaline, Promethazine, and Hydrocortisone in the Prevention of Acute Adverse Reactions to Antivenom following Snakebite: A Randomised, Double-Blind, Placebo-Controlled Trial” www.plosmedicine.org May 2011 | Volume 8 | Issue 5)

We gave him some plasma to counteract the clotting abnormality. We then administered 5 vials of polyvalent antivenom over 30 minutes. During this time, there was no change in his heart rate, blood pressure or airway pressure (i.e. no bronchospasm) – he had no signs of allergy or anaphylaxis. We gave him co-treatment of hydrocortisone 10mcg/kg and promethazine 6.25mg.

We then measured his compartmental pressures directly via a needle attached to an electronic transducer. Unfortunately, the pressures inside his compartments were very high. The pressures inside his muscles exceeded his diastolic blood pressure. This was confirmation that he did indeed have a compartment syndrome. Had we waited for loss of the arterial pulsation (which would have been inevitable given the pressure), we would have missed the boat to salvage the limb.

We made a decision to proceed with the fasciotomy. This was very sad but I do not regret the decision.
The antivenom will still help with his pain and will prevent further swelling of the limb. It will also help to treat the coagulopathy.

I will keep you informed of his progress.
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Re: A Sadly Well Earned Fasciotomy

Postby Fooble » Wed Nov 30, 2011 5:57 pm

Well done Jen!
I think the medical field needs another 50+ people like you! Who have the insight to manage bites.
Hope your patient comes out in the best way possible.
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Re: A Sadly Well Earned Fasciotomy

Postby Bushviper » Wed Nov 30, 2011 6:21 pm

Well done Jen. I can see you tried to avoid it but in this case you had no choice. Did the pressure revert to normal after the fasciotomy?

As you say the snake was not important however this one has me baffled. How long after the bite was the patient treated by you? A puff adder should have shown some signs of blistering etc but possibly this was still too early. A Spitting cobra should not have caused the coagulopathy that you reported.

For a serious bite like this you could have given at least another 4 vials however if it was many hours after the bite it is speculative if the antivenom can get to the swollen areas and neutralise the venom anyway.

I am sure the patient will recover quickly and with proper wound care they should only have a decent scar to brag about than possibly not having that limb (or his life).

Did you get any photographs?

I am so glad we have someone like you who is interested in snake bites so that you are able to expand the knowledge amongst the doctors in your region.
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Re: A Sadly Well Earned Fasciotomy

Postby Bushviper » Wed Nov 30, 2011 6:25 pm

Sorry I see you said 36 hours ago. Now I have less money on a Puff adder.

The antivenom will help with the bleeding but it is too late to prevent any necrosis. That damage has been done.

Its a pity we cannot get an Elisa test for venoms so that we know exactly what we are working with.
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Re: A Sadly Well Earned Fasciotomy

Postby Smeegle » Thu Dec 01, 2011 8:17 am

Fooble wrote:Well done Jen!
I think the medical field needs another 50+ people like you! Who have the insight to manage bites.
Hope your patient comes out in the best way possible.


For sure! Exactly why Jen is my hero!
One of the most tragic things I know about human nature is that all of us tend to put off living. We are all dreaming of some magical rose garden over the horizon instead of enjoying the roses that are blooming outside our windows today.
- Dale Carnegie
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Re: A Sadly Well Earned Fasciotomy

Postby Rishaad » Thu Dec 01, 2011 8:19 am

Shame, poor kid. We are all very lucky to have people like you, Arno and others who really take an interest in snake bite treatment. Kudos...
And God has Created every animal from water, of them are some creeping on their bellies, some walk on two legs, and some on four. God Creates what He wills, for sure God has Power over all things. (Noble Quran 24:45)

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Re: A Sadly Well Earned Fasciotomy

Postby Jen » Sat Dec 03, 2011 11:23 am

Hi everyone
Just an update for those of you who have been following the story:
The little guy is doing really well. His blood results have normalised and the swelling is minimal. He is a little sore (as to be expected) but is coping well. When I visited him yesterday he was out of bed being exercised by the physio.
The plan is to close the wounds some time early next week.
I'll keep you posted.
1.1.0 Epicrates cenchria cenchria
1.1.0 Corallus hortulanus
1.1.0 Heterodon nasicus
1.1.0 Trimeresurus puniceus
2.2.0 Trimeresurus albolabris
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Re: A Sadly Well Earned Fasciotomy

Postby Bushviper » Sat Dec 03, 2011 7:28 pm

Thats good to hear.
It is easier to ask for forgiveness than permission.

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Re: A Sadly Well Earned Fasciotomy

Postby Warren Klein » Sun Dec 04, 2011 9:44 am

Thanks for sharing Jen, like the other guys have said, it is good to know there are people in the medical field in SA who have a genuine interest in snake bite treatment. Hope I never have to see you under those circumstances.
An inaccurate naturalist is a pest and a danger, forever perpetuating illogical deductions and landing later naturalists in trouble. Damm and blast them all to hell in the most painful way. C.J.P. Ionides
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