Reptile & Amphibian Forums

Here is a couple picks of a atrox X helleri bite.
The snake had good enough aim to get two fingers one with each fang!
The dead tissue was removed.
atrox are tissue destroyers this is still a minimal bite
hospital bills went to 11 thousand with no av!
blood work showed a major drop in clotting ability
that returned in 8 hours.

http://mysite.verizon.net/res06q45/sitebuildercontent/sitebuilderpictures/.pond/2005bites005.jpg.w300h200.jpg
http://mysite.verizon.net/res06q45/sitebuildercontent/sitebuilderpictures/.pond/2005bites.jpg.w560h373.jpg

http://mysite.verizon.net/res06q45/sitebuildercontent/sitebuilderpictures/2005bites2.jpg

http://mysite.verizon.net/res06q45/sitebuildercontent/sitebuilderpictures/.pond/2005bites003.jpg.w560h373.jpg

sorry about the quality of the pics camera is a old one.

Here is my point faciotomy is only a option when the tissue is dead and needs to be removed and thats it.
I contacted several athorities on bites and envenomations to
come to the same conclusions they have .
If you have any problems with this contact WW,and David Warrell

This a quote from WW a few years back

"if the swelling is so bad that a fasciotomy is necessary, then in most cases the underlying muscle is dead anyway - so either the procedure is unnecessary, or useless. Since David is by far the most globally experienced snakebite expert alive, I am inclined to take his views pretty darn seriously."

Cheers,

Wolfgang
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Bud

I'm a great admirer of Prof D. Warrell and base the majoritys of my answers on his work. But even he knows that a times a fasciotomy maybe necessary but he has strict procedures to follow. This is taken directly from on of his documentation:

Compartmental syndromes and fasciotomy
The appearance of an immobile, tensely-swollen, cold and apparently pulseless snake-bitten
limb may suggest to surgeons the possibility of increased intracompartmental pressure,
especially if the digital pulp spaces or the anterior tibial compartment are involved. Swelling
of envenomed muscle within such tight fascial compartments could result in an increase in
tissue pressure above the venous pressure, resulting in ischaemia. However, the classical
signs of an intracompartmental pressure syndrome may be difficult to assess in snake bite
victims.
Clinical features of a compartmental syndrome
• Disproportionately severe pain
• Weakness of intracompartmental muscles
• Pain on passive stretching of intracompartmental muscles
• Hypoaesthesia of areas of skin supplied by nerves running through the compartment
• Obvious tenseness of the compartment on palpation

Detection of arterial pulses by palpation or doppler ultrasound probes, does not exclude
intracompartmental ischaemia. The most reliable test is to measure intracompartmental pressure
directly through a cannula introduced into the compartment and connected to a pressure transducer or
manometer (Annex 5). In orthopaedic practice, intracompartmental pressures exceeding 40 mmHg
(less in children) may carry a risk of ischaemic necrosis (eg Volkmann’s ischaemia or anterior tibial
compartment syndrome). However, fasciotomy should not be contemplated until haemostatic
abnormalities have been corrected, otherwise the patient may bleed to death (Fig 44). Animal
studies have suggested that muscle sufficiently envenomed and swollen to cause intracompartmental
syndromes, may already be irreversibly damaged by the direct effects of the venom. Early
treatment with antivenom remains the best way of preventing irreversible muscle damage..

Criteria for fasciotomy in snake-bitten limbs
haemostatic abnormalities have been corrected (antivenom with or without clotting
factors)
• clinical evidence of an intracompartmental syndrome
• intracompartmental pressure >40 mmHg (in adults)

But I do agree that fasciotomy is carried out all too quickly in cartain areas.
The surgical removal of dead tissue is Debridement.
I hope this helps clarify a little.
John
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"Its no help to hide behind the statement that snake bite accidents are a rarity and that the average Dr seldom or never will treat one. For the bitten patient, it is a matter of life or death, and the rarity of the event is of no interest to him."

These are the procedures I have in my bite protocols on possible Fasciotomy:

Fasciotomy and Compartment syndrome.
The "old school" method of treating snake bite involved physical surgery. Modern
researchers have since discovered more effective ways to medically manage
envenomations without invasive physical trauma, but because snake bite is such
a rare occurrence, the average doctor will not be up to date in this field and the
average hospital will still be working from treatment protocols that do not take
these recent changes into account. True compartment syndrome is considered
rare in a properly managed envenomation where sufficient antivenom is
administered - but the effects of envenomation may be difficult to distinguish from
compartment syndrome, leading the doctor to perform an inappropriate
fasciotomy.90% of snake bites involve the SUBCUTANEOUS level only,any concern for the swelling that may arise the compartment pressures must be measured and consulted before fasciotomy is to be performed.Through the appropiate treatment and the administration of adequate amount of Anti-venom will help reduce any swelling and also revert any coagulopathy disorders.

It should be noted that fascial compartment syndrome in rattlesnake envenomations is very rare. Limbs may swell significantly, but rarely involve specific fascially bound compartments. If however the logistics of the bite raise a high index of suspicion for Compartment Syndrome, monitoring with a Wick Catheter or appropriate pressure devices may be necessary. Fasciotomy is rarely if ever recommended in these patients.

Yours Sincerely
The patient.

Management of possible compartment syndrome after Crotalid envenomation

1.Determine intracompartmental pressure.

2.If not elevated, continue standard management.

3.If signs of compartment syndrome are present and compartment pressure is > 30mm/hg:
a. Elevate limb
b. Administer mannitol 1 to 2 g/kg IV over 30 minutes.
c. Simultaneously administer additional appropriate (Crotalidae) Antivenin, 10 to 15 vials over 60 minutes.
d. If elevated compartment pressure persists another 60 minutes, consider fasciotomy.

Notes: 1. Elevated compartment pressure is caused by the action of the venom on the tissues, and thus, the most effective treatment is to neutralize the venom, which in many cases will reduce the compartment pressure.

2.This protocol delivers a high osmotic load and should not be used when contraindicated. The protocol must be completed promptly so that, if ever needed, fasciotomy may be performed as early as possible

If the patient arrives to the hospita as quickly as possible and receives the appropriate clinical treatment for snake bite, then complications as above should not arise.

John
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"Its no help to hide behind the statement that snake bite accidents are a rarity and that the average Dr seldom or never will treat one. For the bitten patient, it is a matter of life or death, and the rarity of the event is of no interest to him."

How long after the bite was the patient admitted? Was the lack of AV use due to allergic considerations?
Cheers
Brett

The victim waited a hour to see if he was envenomated enough to
go to the hospital.
He let the ER doc know he wanted to leave after about a hour at the ER.
but he was kept for another eight hours just in case he took a turn for the worse.
Tim F [Deuce] might have some insight why the patient did not require any AV after a envenomation by such a deadly snake.
He was offered it at once when the doc examined the bleeding wounds.
Which bled out for at least 3-4 days!
We don't think it was a IV bite but it hit some capillaries
and took out the nerves.
There was necrosis down to the fiberous digital sheath.
Taking AV when not needed is not only a waste but very expensive and might cause a bad reaction if used again later on .
oh the pics are a week after the bite.

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Bud

>> There was necrosis down to the fiberous digital sheath.
>> Taking AV when not needed is not only a waste but very expensive and might cause a bad reaction if used again later on .

I might be missing something, but while I agree with the second statement, I think the first clearly shows that it was the wrong decision in this case (note that I don't have enough info to say whether this person could have known that at the time.)

Larry,
The damage was done the second the venom was injected then pooled in the abscesses.
as you know fingers are very delicate and damaged
quicker than a solid arm or leg bite.
Also the swelling went no farther than the wrist.
if you had AV standing by ready to go in less than a min.
It was still would not be fast enough to make a difference.
and we all know damage like this is not reversable any way.
so giving AV later would have done nothing.
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Bud

I would have to see the reports. But I'm just a novice, so my guess might not be accurate. There's always a sub-LD dose that might come into play, just enough to really hurt and look bad, but not enough to break the point of no return. I think I just completely forgot what I'm posting on, oops! What's the Q?

That clearly shows the power of SI. That's the worse case with that type of snake. Gettin a hit in the finger, even with strong gamma immunity protection is a risk because of a reduced area with the bite. Not without pain though, but no AV, no death, and a good lookin' hand. To bad I can't say the same for your face!