"I can't imagine what fasciotomy does to those poor nerves and blood vessels in fingers that have been butchered!"
"The finger is essentially a very small compartment. Because of the small diameter, the elastic limit of the skin is rapidly reached. Because of this limited capacity to swell and the complexity of the structures within the finger, even a small area of tissue loss and scar may result in functional deficits. The finger is the most common area of persistant complaints from patients with crotaline snake bite.
Unfortunately there are no practical methods to measure compartment pressure in the finger. Therefore, the diagnosis of compartment sysndrome in the finger must be made on clinical grounds. The tense, blue or pale envenomated finger with absent or poor capillary refill is the one instance in which it seems reasonable to open the "comparment" on clinical grounds alone. This process has been termed digit dermtomy, THIS PROCEDURE CONSISTS OF A LONGITUDINAL INCISION THROUGH THE SKIN ONLY. THIS SHOULD ALWAYS BE PERFORMED ON THE MEDIAL OR LATERAL ASPECT OF THE DIGIT TO EXTEND FROM THE WEB TO THE MID PORTION OF THE DISTAL PHALANX. USING A SHALLOW INCISION AND SPREADING THE SKIN WITH A HEMOSTAT AVOIDS INJURY TO THE UNDERLYING NEUROMUSCULAR BUNDLE." Hall, E.L. (2000)(upercase to high light the procedure, I'm not shouting lol)
I'm all against the general use of fasciotomy(therefore agreeing with what you say), 99.9% are most probably uncalled for. But when people like Prof D. Warrell have protocols as what to do in raised compartment pressure and when to perform a fasciotomy, then the dangers must be there. I personally take his word as gospel, if he informed me that I needed the procedure, I would not hesitate.
Unfortunately in the US you have advocates in this procedure, the strongest being Glass, T.G. (1971) "Snakebite". Hosp Med Vol 3 PP 31-55.
Two needed procedures were: Watt, C.H. (1985) "Treatment of poisonous snakebite with emphisis on digit dertomy" South Med Journal Vol 78 PP 694-699
and Pennell, T.E.et al (1987) "The management of snake and spider bites in the southeastern US" AM Surg Vol 53 PP 198-204
The main danger is digits, and Watts has great success rate in patients keeping their fingers and having full range of movement after.
The importance of having written protocols with you can't be stressed enough, with your views and or management on compartment pressures. Who's to say you have your whits about you to discuss procedures after you have been bitten?
This is my protocols, cut and paste at your own risk!(anyone in general)
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.
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."
ecks cheek::
