Stiletto Snake Bite -Atractaspis bibroni

[Johnny]

A buddy of mine daughter was stabbed by a Stileto on monday last week, on the finger. In was night time & the dog was barking at the snake, so she thought she would pick it up & throw it in the bush. (NOT KNOWING WHAT IT WAS!) Her arm was swolen up to the shoulder. The swelling has now gone down & is limited to the finger. The doctors are planning to debride tomorrow & do a skin graft some time next week.

[WW]

A buddy of mine daughter was stabbed by a Stileto on monday last week, on the finger. In was night time & the dog was barking at the snake, so she thought she would pick it up & throw it in the bush. (NOT KNOWING WHAT IT WAS!) Her arm was swolen up to the shoulder. The swelling has now gone down & is limited to the finger. The doctors are planning to debride tomorrow & do a skin graft some time next week.

Why do they want to debride and do a skin graft? Is there dead flesh there? If all there is is swelling, then it should be left alone. Obviously it's hard to judge from the description...

[Johnny]

Necrosis.

[Bushviper]

Johnny necrosis from a Stiletto snake is usually confined to the skin and operations are normally not required. Is there any chance we could get some photos of the bite.

Skin grafts will not take at this stage. It WILL have to be repeated at a later stage.

[toxinologist]

I'm sorry but if these are really photos of a patient bitten by an A. bibronii, then my advice to that patient is to HIRE A LAWYER and SUE both the doctor and the hospital for criminal negligence.

There is no way on earth that this limb would ever have satisfied the clinical criteria for a diagnosis of compartment syndrome that necessitated that degree of butchery. And I am sure there would be many expert witnesses available to testify to the fact.

It is time that SA doctors got out the 1960's and dragged themselves into the 21st Century's second decade.

Cheers


David

[Maverick]

I'm not a medical person,but after watching http://dsc.discovery.com/videos/i-was-b ... nakes.html I was wondering if the action was justified? But then again,the guy in the video was bitten 3 times.
Scary. I've often picked up snakes I've thought were harmless...House and Water snakes etc ,but after reading about the Stiletto,I've gained a whole new repect on snakes!

[WW]

I don't think that documentary tells us anything about the value of fasciotomy - the only thing it tells us (most impressively!) is that getting bitten by a stiletto can be a majorly bad idea. A good point actually, since, until seeing that doco, the books had led me to think of A. bibronii as a week-end wrecker rather than a potential life wrecker. However, there is absolutely no evidence whatsoever that earlier surgical intervention would have helped that stiletto bite patient. I agree entirely with David re the original photo that started this thread.

[toxinologist]

I've discussed this case with with two very experienced colleagues of mine, and we are all in agreement that this is a badly botched job. There are a couple of important clinical observations that can be made about the photos at the origin of this thread:

1. The bite is to the right index finger, the pulp space of the finger itself would be the compartment most at risk in a bite like this, however, it is clear from the photographs that neither the bitten finger, or those next to it, nor the hand itself are swollen to any significant extent, and the colour indicates that circulation to the hand and fingers is reasonable. Why on earth would you open up the limb remote to the injury without actually dealing with the compartments that were that most at risk in the first place??
2. The incisions are jagged and haphazard, not straight, and are incorrectly located. The upper and lower arm incisions do not connect (they should in a correctly performed full limb length fasciotomy), and such as they are visible in these photographs these incisions qualify neither as a fasciotomy or an escarotomy.
3. The environment appears to be a normal ward bed - hardly an acceptably sterile environment.
4. The fascial compartments are not even incised - if a compartment pressure sufficient to justify fasciotomy had been present - this procedure would not have decompressed the compartments.
5. The visible muscle appears to be perfectly healthy and is not ischaemic.
6. While the subcutaneous fat has caused a reasonable amount of skin separation, there is not sufficient to indicate a pathological degree of tension.

In other words, this particular procedure should never have been performed.

Cheers


David

[Bushviper]

David thanks for pointing this out to the point that somebody might be able to use this in a malpractice case. I know we have certain attorneys that do take on cases like this on a no-win no-fee basis.

[Stilleto]

The photo's shown are a week after the bite, the swelling was extreme to the point that the skin was shining and the arm could no longer bend, as well as the swelling spreading down the side of my body. It was swollen from the fingers right up beyond the shoulder and down to the lats. The decision to do a fasciotomy was not a reckless one. Many authorities were contacted with regards to it and the decision to save the arm was made. I know, because it is my arm, and months down the line, i have a fully functional arm and hand thanks to the research and excellent work from the team that included specialists, surgeons and a professor. There are many comments on this forum regarding the procedure, but they are all from individuals. The amount of specialists involved in the decisions made here was enormous and countrywide. Despite what everyone thinks they know about the stilleto, the fact is that very little is known about the venom of this snake, and that is the opinions of the profetionals that work with the snake, eg. tygerburg and pure venom. The fact that its the one snake on earth that can not be handled safely or milked makes the research of its venom very incomplete. The venom of the Stilleto can not be compared to the Night adder which is very mild in comparison to the Stilleto.

[froot]

Thanks and welcome Stiletto.
Glad to hear you've had a full recovery, that's the main thing at the end of the day. I still believe though that you could've recovered with much less discomfort.
How long after the bite were those photos taken?
Did suffer any secondary infections?
How are the wounds looking now? Care to share some photos?

[WW]

The photo's shown are a week after the bite, the swelling was extreme to the point that the skin was shining and the arm could no longer bend, as well as the swelling spreading down the side of my body. It was swollen from the fingers right up beyond the shoulder and down to the lats. The decision to do a fasciotomy was not a reckless one. Many authorities were contacted with regards to it and the decision to save the arm was made. I know, because it is my arm, and months down the line, i have a fully functional arm and hand thanks to the research and excellent work from the team that included specialists, surgeons and a professor. There are many comments on this forum regarding the procedure, but they are all from individuals. The amount of specialists involved in the decisions made here was enormous and countrywide. Despite what everyone thinks they know about the stilleto, the fact is that very little is known about the venom of this snake, and that is the opinions of the profetionals that work with the snake, eg. tygerburg and pure venom. The fact that its the one snake on earth that can not be handled safely or milked makes the research of its venom very incomplete. The venom of the Stilleto can not be compared to the Night adder which is very mild in comparison to the Stilleto.

Glad you have retained full limb function. I understand entirely why you are attributing your positive outcome to the treatment received. However, from a purely scientific point of view, all that has been shown is that neither the incisions nor the venom caused you to lose limb function, not that the incisions are what saved your arm.

Irrespective of the identity of the venom, there is only one indication for fasciotomy, and that is elevated pressure within the muscle compartments that stops blood going in, and/or leads to nerve damage. That pressure needs to me measured directly - severe, tight swelling is not evidence of compartment syndrome. Even if intracompartmental pressure is elevated, there is some published evidence that in snakebite cases, fasciotomy does not in fact improve the final outcome. Moreover, incising the skin without incising the muscle fascia (the connective tissue sheaths that house and constrain the individual muscle compartments, potentially leading to compartment syndrome) does not constitute a fasciotomy, and would not have achieved anything.

I can imagine that it might have relieved the pain from the swelling and the stretching of the skin, but that's about it. However, swelling of the extent you describe is not that unusual from many viper bites, and medical opinion in general is strongly against fasciotomy in most cases, unless there really are elevated intracompartmental pressures (which is actually quite rare).