Compartment syndrome following snakebite in a boy: A case report and literature review

Abstract

Introduction and importance

Snake bites represent a significant public health issue worldwide, as venomous snake bites can result in lethal consequences if not treated promptly, including both local and systemic effects. The local symptoms of a snake bite commonly include tissue necrosis, edema, and compartment syndrome (CS). While CS is a rare complication following a snake bite, it may be more pronounced in children who typically have lower total dilution volume. Currently, the administration of anti-snake venom and prompt fasciotomy are the only specific treatments available for CS.

Case presentation

The present report details a case of CS of the right upper extremity in a three-year-old boy who suffered a snake bite on his right hand and was brought to the emergency department of a hospital in northern Iran after a lapse of 14 h.

Clinical discussion

Snakebites frequently occur in the extremities, with about two thirds of them happening in the upper extremities. The skin of the dorsum is extremely thin, there is essentially little subcutaneous fat tissue, and there are numerous superficial veins in this area, particularly the hand.

Conclusions

Following snake bites, the use of proximal tourniquets should be avoided, and the public's awareness of this need should be encouraged through health education. The prognosis for recovery following fasciotomy and the significance of follow-up and rehabilitation should also be explained to patients.

Highlights

• •Snakebites frequently occur in the extremities.
• •Compartment syndrome is a rare complication following a snake bite.
• •Administration of anti-snake venom and prompt fasciotomy are the effective ways of CS treatment.

1. Introduction

Snakebite is a special type of injury that occurs all over the world, especially in rural areas. The injected venom causes a wide range of toxic effects, from local tissue damage to multi-organ failure, depending on the species of snake. Particularly in children and the elderly, the venom can lead to both local and/or systemic complications that can cause death in six to 6 h. In fact, due to their lower total dilution volume, children are affected by the same amount of venom more severely than adults [1].

The management of local symptoms is challenging, especially in cases of soft tissue necrosis and compartment syndrome (CS), despite the fact that antivenom is effective in preventing or reducing the systemic consequences. Local envenomation manifestations include excruciating pain and the appearance of immovable, tensely swollen, cold, and seemingly pulseless extremities. Clinically, this combination of cytotoxic symptoms could be mistaken for concurrently developing CS [2].

CS causes hypoxia and acidosis due to the vicious cycle of edema, which further increases capillary permeability and fluid extravasation. As a result, the closed fascial compartment's volume increases, impairing circulation and resulting in irreversible damage to the muscles and nerves. CS following a viper snake bite is uncommon [3]^, [4].

The Viperidae (vipers) family includes the majority of the snake species. Its venom has hemorrhagic and cytotoxic effects. The cytotoxic effects lead to early diffuse edema, local tissue necrosis, and hypotension as a result of vascular endothelial damage. Its systemic effects cause coagulopathy and hemorrhage [5]. Serial monitoring of local effects is essential for the early identification of CS, which results in tissue damage from increasing pressure in the limbs. Since there are no specific recommendations for threshold compartment pressure and fasciotomy, the diagnosis of acute CS is made by clinical judgment [6]. Herein, we describe a three-year-old boy following a snake bite, who by his parents was brought with the symptoms ecchymosis, and cyanosis of the right upper extremity to the emergency department (ED) of the hospital in the northern of Iran and was given fasciotomy by the diagnosis of CS. The work has been reported in line with the SCARE 2020 criteria [7].

2. Presentation of case

On April 28, 2022, a three-year-old boy, who resided with his parents in a mountainous area of northern Iran, was bitten by a snake on the dorsal surface of his right hand, specifically in the web between the fourth and fifth fingers. Regrettably, an hour after the incident, the swelling progressed and blood started to leak from the bite site. As a result, his parents resorted to traditional treatments, such as incision of the bitten site, application of ice packs, and tying the elbow area tightly with a ligature or tourniquet before taking him to the hospital (see Fig. 1A and B). Fourteen hours after being bitten, the child was admitted to the pediatric emergency room of a hospital in northern Iran. He exhibited severe swelling, ecchymosis, and cyanosis of the hand.

Fig. 1.

A: Shown two fang marks on the dorsal surface of his right hand in the web between the fourth and fifth fingers. B: The site where the right elbow closed with a tourniquet (cord). C, D: Fasciotomy of forearm, carpal tunnel and dorsal surface of the right hand. E: Right hand fasciotomy site repair.

Upon admission, the patient presented with several physical characteristics indicative of their condition. These included a Glasgow coma scale score of 15 out of 15, a body temperature of 37.7 °C, a heart rate of 110 beats per minute, a blood pressure of 87/56 mm Hg, and an oxygen saturation of 98 %. Furthermore, a local examination revealed two fang marks on the dorsal surface of the patient's right hand, located in the web between the fourth and fifth fingers, as well as significant edema in the patient's right upper limb. The edema extended to the hand and forearm, accompanied by pallor, bruising, and tenderness (see Fig. 1A and B). The capillaries in the fingers were delayed in filling, and the distal pulses were feeble. Both active and passive movements of the fingers elicited pain in the patient. Due to the child's irritability and fear, it was challenging to assess for hypoesthesia or paraesthesia. The envenomation severity was determined to be grade III and IV.

After establishing venous access, an infusion of dextrose saline (D/S 0.9 %) was immediately initiated, and local wound washing was performed. The patient's laboratory findings were within the normal range (see Table 1), and his urine analysis was also normal. An electrocardiogram revealed sinus tachycardia. The patient's condition improved following the initial dose of fluid replacement and after administrating 10 polyvalent vials of anti-snake venom (Razi Institute, Iran). In comparison to the left upper extremity, the radial pulse of the right upper extremity was feeble, and the forearm and fingers exhibited pallor, coldness, ecchymosis, and cyanosis.

Table 1.

Baseline laboratory results.

Parameter	Initial value	Reference value	Unit
Na	139	135–145	mEq/L
K	5.3	3.5–5	mEq/L
BUN	18	3–23	mg/dL
Cr	0.6	0.6–1.2	mg/dL
Ca	8.1	8.5–10.5	mg/dL
Mg	2.1	1.7–2.2	mg/dL
P	3.3	2.5–4.5	mg/dL
BS	150	<140	mg/dL
AST	110	10–40	IU/L
ALT	58	˂45	IU/L
ALP	250	80–306	IU/L
CPK	1646	0.3–1.2	mg/dL
Hb	12	12–16	g/dL
WBC	13 × 103	4000–1000	mm3
Plt	220 × 103	145,000–450,000	mm3
PT	14	11–13	s
PTT	35	19–36	s
INR	1.3	1–1.3	Ratio

Abbreviations: BS: blood sugar, Cr: creatinine, BUN: blood urea nitrogen, Hb: hemoglobin CPK: creatine phosphokinase, AST: aspartate aminotransferase, ALT: alanine aminotransferase, ALP: alkaline phosphatase.

The determination of significant stretch pain on passive finger extension was challenging due to the distressed state of the child who was crying. Moreover, the absence of suitable equipment led to the non-performance of intra-compartmental pressure (ICP) measurement. However, clinical signs such as pallor, pulselessness, pain, color change in the fingers, ecchymosis, cyanosis, and increased swelling in the affected area were utilized to confirm the diagnosis of CS and indicated the need for fasciotomy. In addition to the administration of five units of anti-snake venom, an urgent request for orthopedic surgery was made, and the patient was promptly transferred to the operating room for the fasciotomy procedure.

The surgical procedure involved the administration of general anesthesia, during which a fasciotomy was executed through incisions made on the dorsum of the hand, the carpal tunnel, and the volar aspect of the right forearm, as illustrated in Fig. 1C and D. The swollen muscles in the forearm exhibited individual dusky patches, which were subsequently removed. Post-surgery, the patient was transferred to the pediatric intensive care unit, and ceftriaxone (50 mg/kg/day) and clindamycin (15 mg/kg every 8 h) were initiated as antibiotic treatments.

Subsequent to 12 h' post-surgery, notable improvements were observed in both the general health issues and CS of the patient. Following one week of recovery, the postoperative pain and swelling diminished, and the patient underwent secondary wound repair, as depicted in Fig. 1E. The patient was subsequently transferred to the general pediatric ward, where a rehabilitation program was initiated to prevent intervention-induced adherence and retraction. The patient was discharged from the hospital in good general condition after a hospital stay of 12 days. A three-month postoperative follow-up confirmed that the patient had achieved a complete and functional recovery.

Written informed consent was obtained from the patient's parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. This study was conducted according to the Declaration of Helsinki Principles. The study is registered with the research registry, and the UIN is research registry 8506 https://www.researchregistry.com/register-now#home/registrationdetails/637f37efe50fd70021842f73/.

3. Discussion

Snakebites frequently occur in the extremities, with about two thirds of them happening in the upper extremities, as in the case of our patient. The skin of the dorsum is extremely thin, there is essentially little subcutaneous fat tissue, and there are numerous superficial veins in this area, particularly the hand. Because of the extensive vascular network on the palmar surface of the hand, snakebites to the hand are more likely to cause systemic venom distribution. Furthermore, in the upper hand, essential tissues, including joints, nerves, and tendons, are very superficial. As a result, treating snakebite on the hand at an early stage is essential since it is more urgent than treating snakebite elsewhere [2]. Our research has shown that antivenom administration and timely fasciotomy reduce edema and peripheral ischemia and result in excellent functional outcomes.

Sadeghi et al. described a 65-year-old man who had a diffuse vesiculobullous lesion on the palmar and dorsal surfaces of the left upper extremity and axillary area. Their patient's symptoms have improved after receiving anti-snack venom and broad-spectrum antibiotics without the occurrence of CS [8]. Due to the venom's inclusion of proteases, hyaluronidases, and peptides, snake bite envenomation causes both local and systemic consequences [6]. Death can occur 6 to 60 h after a bite, with 48 % of bites occurring on the feet and 52 % on the hands [5].

Although it may extend over several days, the first 12 h are typically considered crucial for a patient. Pain, edema, lethargy, numbness, tachycardia, ecchymosis, muscular fasciculation, a metallic taste in the mouth, nausea, disorientation, and hemorrhagic diathesis are the most typical clinical manifestations. If the victims are children, they may experience lethargic or semi-conscious symptoms. Local symptoms caused by increased vascular permeability and fluid accumulation increase pressure in the compartment area, resulting in extremity ischemia and amputation [3]^, [9].

The basis of severe envenomation treatment includes the correction of hemodynamic disturbances and the administration of specific antivenom. The immediate fasciotomy is the only effective surgical treatment for CS (compartment release). Decompression aims to restore muscle perfusion within 6 h [5]. ICP measurement may be useful in children who refuse to cooperate during the examination, but the majority of centers lack the necessary equipment. Therefore, when the diagnosis is clinically evident, it is not recommended to measure ICP [4]. The presence of CS is indicated by the inconsistency between the patient's pain and the clinical manifestations.

Fasciotomy is rarely necessary after a snake bite, but it should be considered if clinically significant pressures (>30 mm Hg) persist despite all supportive treatments and adequate anti-snake venom therapy [10]. By following this strategy, limb loss and long-term morbidity can be prevented. Similar to our patient, the immediate administration of the antivenom and timely fasciotomy have been effective in preventing complications and amputation of the hand and were required to resolve the acute episode, which resulted in a satisfactory outcome. The length, depth, and location of the bite; the amount of venom injected; the victim's age and general condition; and the success of early therapy are all factors that can affect the clinical findings of a venomous snakebite [2]^, [9]. Venomous snakebite's significance as an emergency medical issue is greater in children [9]. The first 12 h are often considered critical for a victim, although they may last for many days. The signs and symptoms that are most frequently present include hemorrhagic diathesis, vomiting, edema, weakness, numbness, tingling, tachycardia, ecchymosis, and muscular fasciculation [9]^, [11]. In order to prevent the spread of venom, it is generally agreed that the bite site should be immobilized as follows: Additionally, it is essential to reassure the patient [11]^, [12].

It is essential to remove tight clothes and jewellery, including watches and bracelets, from the bitten extremities to prevent tightening due to swelling [12]. To avoid worsening local damage to the skin and underlying tissues and increasing the rate of venom absorption, manipulation or incision of the bitten site should be avoided in snake bites. Using potassium permanganate and ice packs for cryotherapy is also not recommended to promote local necrosis. It is not recommended to apply a ligature or tourniquet above the bite site, apply light bandages, or attempt to suction or squeeze the poison out of the inoculation site [13]. Unfortunately, in our patient, the parents tightly tied the cord, which resulted in accelerated swelling and pain, ecchymosis, ischemia, and CS.

4. Conclusion

Patients who have suffered snake bites and have been referred to the emergency department require constant and precise monitoring for any developing systemic or local complications, necessitating hospitalization. In the absence of intra-compartmental measuring equipment, all clinicians should be capable of identifying the early symptoms and signs of progressive CS, as timely surgical intervention may preserve the limb. The use of proximal tourniquets should be avoided following snake bites, and public health education programs should be implemented to raise awareness of this need. Patients should be informed of the prognosis for recovery following fasciotomy and the significance of follow-up and rehabilitation.

Patient (parent's) consent

Written informed consent was obtained from the patient's parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

The study was approved by our local ethics committee.

Funding

N/A.

Guarantor

Mohammad Reza Navaeifar.

Research registration number

8506.

CRediT authorship contribution statement

MRN involved in the collecting of samples and data AGh and ZZ involved in writing, editing, and preparing the final version of the manuscript. MS, AZ preparing the draft and submitted of the manuscript. All authors reviewed and approved the final version of the manuscript.

Conflicts of interest

None declared.

Data availability statement

The data are available with the correspondence author and can be achieved on request.