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Can Steel Heal a Compartment Syndrome Caused by Rattlesnake Venom?
Richard C. Dart, MD, PhD
From the Rocky Mountain Poison and Drug Center, Denver Health Authority, and the Division of Emergency Medicine, University of Colorado Health Sciences Center, Denver, CO.
See related article, p. 99.
[Ann Emerg Med. 2004;44:105-107.]
Compartment syndrome is a feared complication of a rattlesnake bite. It is often followed by severe compartmental muscle necrosis, resulting in dysfunction of an extremity. Other types of compartment syndromes appear to be the result of increased compartment pressure. If the pressure is relieved promptly, the detrimental effects are reduced. Because fasciotomy is a common treatment for other causes of compartment syndrome, it is reasonable to consider it for the management of compartment syndrome induced by snake venom. Indeed, some practitioners have advocated for early fasciotomy in nearly all victims of rattlesnake envenomation.1 Few published studies have addressed the issue of increased compartment pressure induced by snake venom. The few reports (all retrospective) in human beings have reported good outcomes after surgical or nonsurgical approaches.2-4 Animal studies have yielded mixed results. Grace and Omer5 injected Western diamondback (Crotalus atrox) venom into the hind leg of rabbits. Unfortunately, this did not produce an increase in compartment pressure. They reported that extremity swelling was reduced in rabbits treated with antivenom alone, antivenom plus steroids, or fasciotomy alone. Histologic sections showed severe muscular necrosis in all groups. Stewart et al6 performed a similar experiment with C atrox venom in rabbits, but also tested long-term muscle function. Experimental groups included venom alone, venom plus antivenom, venom plus fasciotomy, venom plus antivenom and fasciotomy, and controls. The
Copyright Ó 2004 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2004.03.013
mean compartment pressure for all animals increased after venom injection from 3 mm Hg to 30 mm Hg. Nine weeks after envenomation, they found that the limb muscles had reduced ability to generate tension in all groups that received venom when compared with a nonenvenomated group; however, the group treated with antivenom alone was statistically superior to all other groups injected with venom. The fasciotomy technique used by Stewart et al involved both decompression and the debridement of ‘‘clinically nonviable tissue,’’ the usual technique reported for venom-induced compartment syndromes.1 Therefore, the reduced muscle performance could theoretically be caused by necrosis or the debridement of potentially viable tissue. Garﬁn et al7,8 studied the hind limb in a dog model using southern Paciﬁc rattlesnake (C viridis helleri) venom. Venom injected into the anterolateral compartment increased the intracompartmental pressure from a mean of 4 mm Hg to 44 mm Hg at 4 hours and 80 mm Hg at 24 hours after injection. They reported that a small dose of antivenom failed to reduce compartment pressure, but a large dose successfully reduced compartment pressure.7 Using the same model, Garﬁn et al8 found that fasciotomy performed before venom injection successfully reduced the intracompartmental pressure, but did not reduce muscle necrosis. The results of Tanen et al9,10 extend these animal studies substantially. First, they performed their study using the established methodology of a clinical trial. In many animal trials, the principles developed for clinical trials are not applied.11 Tanen et al9 randomized animals to an experimental group, and the investigators were blinded to the use of antivenom. They were unable to blind the use of fasciotomy, but the pathologist evaluating the biopsies was blinded. These techniques allow bias to be distributed evenly among groups, unlike the many reports where animals are tested in groups.9 Tanen et al9,10 were able to demonstrate that venom injection produced intracompartmental pressures above 30 mm Hg. The ﬁrst report from Tanen et al9 found that injection of C atrox venom into the anterior compartment reduced the compartmental perfusion pressure from about 54 mm Hg to 32 mm Hg. The administration of antivenom 1 hour after venom injection into the anterior leg compartment improved perfusion pressure
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A snake in the clinical grass: late compartment syndrome in a child bitten by an adder. The Rocky Mountain Poison and Drug Center receives funding from Fougera.10 Proponents of fasciotomy must demonstrate improved functional outcome using appropriate research design in the study of venom-induced compartment syndrome.6. a surgeon assesses the patient at this stage. the extent of myonecrosis appeared worse in the animals that received fasciotomy. the patient is treated with both mannitol (1 g/kg) and antivenom (4–6 vials of Crotalidae polyvalent immune Fab [ovine]) immediately. This practice is supported currently only by animal data and case reports. neither prevention of increased compartment pressure nor relief of established compartment syndrome with fasciotomy has been demonstrated to improve muscle injury in animals. Although such research is difﬁcult to accomplish because of variability in clinical severity and difﬁculty in the assessment of functional outcome. Management of suspected compartment syndrome in victims of crotaline snakebite. One approach involves (1) rapid infusion of additional antivenom. fasciotomy should be considered. it is the only information that will answer the question. et al. attempt to address functional outcome. In fact. Future evaluations of venominduced compartment syndrome must emphasize outcome.8 If compartment pressure is an important component of the pathogenesis of this injury.10 did not Figure. It remains unknown whether additional doses of antivenom speciﬁcally for increased compartment pressure are useful. This creates the discouraging possibility that injury caused by venom inside of a compartment is not amenable to either surgical or antivenom treatment. Hayes C. the data available indicate that surgical steel is not likely to improve the outcome of venom-induced compartment syndrome. For compartment syndrome following trauma and related conditions. However. Denver. CO 80204. the reduction in pressure was not associated with improved histologic appearance of the muscle. several measurements are needed to establish the pressure accurately. the central factor is likely to be direct venom effects on the tissue and not solely the resulting increase in compartment pressure. Br J Plastic Surg. the pathophysiology appears to hinge on increased pressure. Reprints not available from the author. Ingleﬁeld CJ. This ﬁnding is similar to that of Grace and Omer.10 have found that the administration of antivenom improved perfusion pressure within the compartment. If the compartment pressure is elevated above 30 mm Hg. depending on local practices. PhD. For venom-induced compartment syndrome. In short. 2002. as expected. Dart. 2.8 Thus.C O M P A R T M E N T S Y N D R O M E A N D R A T T L E S N A K E V E N O M Dart substantially. Physical examination may be misleading because crotaline snake venom causes pain and swelling that simulates the effects of compartment syndrome.org. MC 0180. 303-739-1100.7. JAMA.8. In several cases over a 15-year period. early fasciotomy should eliminate this factor. Tanen et al9. Two studies in other animal models have suggested that the relatively early administration of antivenom does improve functional outcome.5 as well as that of Garﬁn et al. another patient developed an anterior leg compartment pressure of 110 mm Hg after a C atrox bite. Glass TG.235:2513-2515. I have witnessed the intracompartmental pressure decrease from 45 or 50 mm Hg to below 30 mm Hg after the combined use of antivenom and mannitol. Often. The risks and beneﬁts should be explained to the patient. In animals. E-mail rdart@rmpdc. Patients suspected of increased compartment pressure should have intracompartmental pressure monitoring performed. Fasciotomy was averted in a few cases. In contrast. a pharmaceutical company that makes antivenom. In their 2 reports. but we have no idea whether these patients had improved outcomes. 1976. Address for correspondence: Richard C. Tanen et al10 report that immediate fasciotomy prevented an increase in compartment pressure. The patient with compartment syndrome from snake venom is almost certain to require antivenom for other manifestations of the venom. If the pressure remains elevated and the clinical consensus is that intracompartment ischemia is present.6. Cawrse NH. 3. 1.6.55: 434-435. Antivenom is often used in victims of rattlesnake envenomation. fax 303-739-1443. the jury is still out on the efﬁcacy of antivenom in the treatment of venom-induced compartment syndrome. Rocky Mountain Poison and Drug Center. which decreased only to 90 mm Hg after this treatment. (2) attempting to decrease the ﬂuid in the compartment by administering mannitol. but failed to improve histologic appearance. However. Typically. REFERENCES 1. and (3) performing fasciotomy if the intracompartmental pressure remains elevated (Figure). 2. MD. 4. many physicians have adopted the ‘‘kitchen sink’’ approach of attempting several treatments in a last ditch effort to reduce injury. Early debridement in pit viper bites.9 Given the remaining uncertainties and the dismal prospects for a patient with elevated compartment pressure after snakebite. In this issue of Annals. Tanen et al9. 1 0 6 ANNALS OF EMERGENCY MEDICINE 44:2 AUGUST 2004 . 777 Bannock Street. and consent should be obtained.
Barish RA. Reporting of animal research methods: Are rigorous study methods reported? [abstract] J Toxicol Clin Toxicol. 1998. Crotalidae polyvalent immune fab antivenom limits the decrease in perfusion pressure of the anterior leg compartment in a porcine crotaline envenomation model.22:177-182. 6. Gold BS. 1980.36:490. Ann Emerg Med. et al. Am J Surg.23:677680. Toxicon. Rosen PB. Page CP.35:86-88. Antivenin and fasciotomy/ debridement in the treatment of the severe rattlesnake bite. Rattlesnake bites and surgical decompression: results using a laboratory model. 2003. et al. 5. Dart RC. Omer GE. Clark RF. 44:99-104. Heard K.C O M P A R T M E N T S Y N D R O M E A N D R A T T L E S N A K E V E N O M Dart 3. Schwesinger WH. Garﬁn SR. Resolution of compartment syndrome after rattlesnake envenomation utilizing non-invasive measures. Castilonia RR. Fasciotomy worsens the amount of myonecrosis in a porcine model of crotaline envenomation. AUGUST 2004 44:2 ANNALS OF EMERGENCY MEDICINE 1 0 7 . Mubarak SJ. 1989. 9. 11. Ann Emerg Med. 8.5:168-177.158:543547.24:285288. 1984. Grice GA. Tanen DA. Leiva JI. Tanen DA. Toxicon. Garﬁn SR. 10. 2003. Ann Emerg Med. 4. J Hand Surg. Delayed antivenom treatment for a patient after envenomation by Crotalus atrox. The management of upper extremity pit viper wounds. Stewart RM. Ross CP. 2004. Castilonia RR. Mubarak SJ. Dart RC. The effect of antivenin on intramuscular pressure elevations induced by rattlesnake venom. 2000. et al. et al. J Emerg Med. 7. et al. Danish DC. 1985.41:384-390. Danish DC. Grace TG. Yip L.
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