Algorithmic approach to the prevention of unnecessary fasciotomy in extremity snake bite

Türkmen, Arif; Temel, Metin

doi:10.1016/j.injury.2016.10.023

Cited by 22 publications

(25 citation statements)

References 27 publications

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“…Local cytotoxicity from V. berus envenoming can result in marked soft tissue oedema but seldom if ever results in compartment syndrome. Both ultrasound and compartmental pressure assessment have been strongly advocated to distinguish extra fascial from subfascial oedema, thus limiting surgical intervention where possible [32][33][34].…”

Section: Clinical Complication Frequencymentioning

confidence: 99%

Moderate-to-severe Vipera berus envenoming requiring ViperaTAb antivenom therapy in the UK

Lamb

Stewart

Warrell

et al. 2021

Clinical Toxicology

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Background: Bites by the European adder (Vipera berus) in the UK are uncommon but potentially life threatening, and can be associated with marked limb swelling and disability. Following an interruption in Zagreb Imunolo ski zavod antivenom supply around 2012, the UK changed its national choice of antivenom for Vipera berus to ViperaTAb, an ovine Fab monospecific antivenom. In the absence of randomised controlled trials, we established an audit to review its use in clinical practice. Methods: A prospective audit of ViperaTAb use was conducted from March 2016 until November 2020 by the UK National Poison Information Service (NPIS). Users of the NPIS online toxicology database, TOXBASE, considering the use of antivenom for V. berus envenoming were invited to discuss the case with the on-call clinical toxicology consultant. Information was collected prospectively on indications, administration, adverse reactions and outcome of patients administered ViperaTAb antivenom. Results: One hundred and seventy patients were administered ViperaTAb antivenom over five years. One hundred and thirty-two were adults and 38 children (median age and range: 38, 2-87 years). Bites occurred across the UK, but most commonly in coastal regions of Wales and of SouthWest and East England. Median time to presentation was 2.1 (IQR 1.5-4.0) h and to antivenom administration from presentation was 2.0 (IQR 0.9-3.6) h. A minority of patients presented to hospital more than 12 h after being bitten (n ¼ 19, 11.2%) or received antivenom more than 12 h after presenting to hospital (n ¼ 17, 10.0%). Features of systemic envenoming were present in 64/170 (37.6%) patients, including 23 (13.5%) with anaphylaxis and 26 (15.3%) with hypotension (nine with both). Clinician assessment considered the initial antivenom to have been effective in 122/169 (72.2%) patients. Repeated dosing was common, occurring in 55/169 (32.5%), predominantly due to persisting or worsening local effects (46/51, 90.2%). There were three cases of probable early adverse reaction. No deaths occurred during the study. Complications of envenoming were rare but included four patients that underwent surgery, three patients each with acute kidney injury, mild coagulopathy, or thrombocytopenia (one severe). The median duration of hospital stay was 43.7 (IQR 22.5-66.5) h, longer for children than adults (52.5 vs 41.3 h). Conclusion: ViperaTAb antivenom appears to be effective and safe and should be administered as soon as possible for patients meeting clinical criteria. Patients require close observation following antivenom to detect adverse reactions and progression or recurrence of envenoming. Close collaboration with expert NPIS consultant advice can help optimise antivenom timing, ensure repeated dosing is given appropriately, and avoid unnecessary surgical intervention. All hospitals, particularly those located in areas of relatively high incidence, should stock sufficient antivenom available at short notice, 24 h a day.

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Section: Clinical Complication Frequencymentioning

confidence: 99%

Moderate-to-severe Vipera berus envenoming requiring ViperaTAb antivenom therapy in the UK

Lamb

Stewart

Warrell

et al. 2021

Clinical Toxicology

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“…This is the surgical attempt to alleviate intracompartmental pressure [ 147 , 148 ], a technique entirely appropriate in crushing injuries that produce extreme swelling and dramatic rises in intracompartmental pressure [ 149 ]. Medical practitioners unfamiliar with snakebite may view swelling as needing fasciotomies to reduce compartmental pressure due to their lack of the knowledge necessary to discern that the pathology of snakebite-induced subdermal swelling is radically different from the deep tissue swelling produced by traumatic injuries [ 150 , 151 , 152 , 153 , 154 , 155 ]. However, typically, the decision to send the patient to surgery for a fasciotomy is taken without the advisory tests to measure the intracompartmental pressure.…”

Section: Issues and Controversies In Modern Medical Carementioning

confidence: 99%

Snakebite: When the Human Touch Becomes a Bad Touch

Fry

2018

Toxins

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Many issues and complications in treating snakebite are a result of poor human social, economic and clinical intervention and management. As such, there is scope for significant improvements for reducing incidence and increasing patient outcomes. Snakes do not target humans as prey, but as our dwellings and farms expand ever farther and climate change increases snake activity periods, accidental encounters with snakes seeking water and prey increase drastically. Despite its long history, the snakebite crisis is neglected, ignored, underestimated and fundamentally misunderstood. Tens of thousands of lives are lost to snakebites each year and hundreds of thousands of people will survive with some form of permanent damage and reduced work capacity. These numbers are well recognized as being gross underestimations due to poor to non-existent record keeping in some of the most affected areas. These underestimations complicate achieving the proper recognition of snakebite’s socioeconomic impact and thus securing foreign aid to help alleviate this global crisis. Antivenoms are expensive and hospitals are few and far between, leaving people to seek help from traditional healers or use other forms of ineffective treatment. In some cases, cheaper, inappropriately manufactured antivenom from other regions is used despite no evidence for their efficacy, with often robust data demonstrating they are woefully ineffective in neutralizing many venoms for which they are marketed for. Inappropriate first-aid and treatments include cutting the wound, tourniquets, electrical shock, immersion in ice water, and use of ineffective herbal remedies by traditional healers. Even in the developed world, there are fundamental controversies including fasciotomy, pressure bandages, antivenom dosage, premedication such as adrenalin, and lack of antivenom for exotic snakebites in the pet trade. This review explores the myriad of human-origin factors that influence the trajectory of global snakebite causes and treatment failures and illustrate that snakebite is as much a sociological and economic problem as it is a medical one. Reducing the incidence and frequency of such controllable factors are therefore realistic targets to help alleviate the global snakebite burden as incremental improvements across several areas will have a strong cumulative effect.

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“…Eine Immobilisierung der betroffenen Extremität und der umgehende Transport in ein Krankenhaus sind indiziert, im Zweifel kann die Giftnotrufzentrale wertvolle Hilfestellung geben [68]. Fälle von Kompartmentsyndromen nach Schlangenbissen sind keine Seltenheit; bestehen hier diagnostische Schwierigkeiten, können die intrakompartimentelle Druckmessung und eigens entwickelte Algorithmen Abhilfe schaffen [69,70].…”

Section: Bisse Und Toxineunclassified