Rattlesnake Bite (Sensitive) The right one

[MegF]

I know this is old but I have to comment. Fasciotomy's are not recommended in bites of any kind. While there is a lot of swelling and the arm may appear to have compartment syndrome, rarely do pressures actually cause a problem. The surgery itself actually damages far more than the bite or subsequent necrosis. If you are ever bitten by a crotalus of any type....DO NOT LET THEM DO A FASCIOTOMY!!!!

[Jen]

I have to just elaborate slightly - do not let them do a faciotomy WITHOUT MEASURING COMPARTMENT PRESSURES. As MegF says, the arm may appear to have a compartment syndrome but does not. That being said, probably about 1% of these bites do actually require facsiotomy & doing one can be limb saving. I agree totally that if your doctor recommends a fasciotomy, do not allow it UNLESS you have proven compartment syndrome which is exceptionally rare. We measure pressures by inserting a needle into the affected area & obtaining an actual pressure reading.

[WW]

There is some experimental evidence that, in the case of a snake bite, a fasciotomy does not even help when intracompartmental pressures are elevated... There is a pretty good chance that 75% of the trauma that guy went through was caused by the medics, not the snake.

[Jen]

Hi WW. I think I know the exact study you are referring to. Is it “Fasciotomy Worsens the Amount of Myonecrosis in a Porcine Model of Crotaline Envenomation” by DA Tanen, DC Danish et al; Ann Emerg Med. 2004;44:99-104?

There are a few important points about this study:
1) It is an animal study. Pigs are as close as possible to people, but they are still pigs
2) The authors performed the fasciotomy immediately following injection of the venom. They did not wait for the development of raised intra-compartmental pressures
3) There was more myonecrosis following fasciotomy. This does not actually surprise me as during fasciotomy, scalpels & diathermy (electric current) are applied to the tissues so there will definitely be tissue damage. A fasciotomy is not innocuous. The important issue is whether this microscopic increased myonecrosis is actually clinically relevant.
This study would have been of way more benefit if the authors had actually waited for raised compartmental pressures, done a fasciotomy on half the subjects and not done on the other half & THEN examined the muscle microscopically. In my opinion, the results would have been more relevant. This study is also quite old (2004) and unfortunately there has been no follow up study.

Don’t get me wrong – I am not a fan of fasciotomies. I do believe that they are truly the last resort and should be reserved for a limb saving procedure. I do also feel that because of idiotic cowboy doctors & multiple horror stories, snake keepers have become “anti-fasciotomy” to the extreme.

[Pieter89]

This is what a reputable doctor told me about this: (you guy are welcome to criticise etc.)

In many cases doctors in South Africa do not have the correct equipment to measure the compartment pressures. The worst that happens with a fasciotomy (done correctly) is scarring and some trauma when seeing the limb.

That study, as already mentioned, is not of much worth and fact is, even if there is only a 5% chance of the procedure being limb-saving I'll still rather have it done than having a 5% chance of losing a limb...

BUT the doctor must have some amount of experience with fasciotomies... and fasciotomies should never be done without swelling and some monitoring beforehand.

[bubblesharp]

I think the biggest problem when a person is in hospital with a severe bite is that the patient is in so much pain and fear of life and limb, that the relevant questions are not asked. Most ok's are given in fear as the doctor can blow it out of proportion when explaining it to the patient and the family, due to the doctor not having the necessary experience with treating snake bites etc.

So you lie in bed and are told that if this is not done soon you may loose your arm, from Fear all reasoning leaves the room and an emotional decision is made to go ahead. unless you have seen the pictures of fasciotomities you will not know what damage could possibly be caused by the doctor. when the average person on the street go to a hospital for a life saving treatment, as in the case of a snake bite, it is assumed that the doctor is the expert and that there is no time to be wasted and the doctor needs to do what is necessary.

Not everyone that is bitten by a snake, keeps snakes and in most cases such a person will have no background or knowledge as to what procedures will or will not work. what the doctor says is what needs to be done and finished.

[Pieter89]

I think it is important for doctors to undergo more training on this or have someone to call in case of a bite. Although many people go to doctors for the best treatment doctors can only do as much as they are taught and act according to their experience. With the time frame being so small in the case of many snake bites, it is impossible to refer to another doctor. The doctor does only what comes to mind. There are not many snake bites and treating them is a speciality practice. In many cases I do appreciate the difficult situation a doctor is in when treating a snake bite victim.