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Snakes: Controversies


Fasciotomy of the affected limb for suspected compartment syndrome has been a controversial aspect of treatment for crotaline envenomation. Sub-fascial envenomation is unusual and true compartment syndrome is usually not present when intracompartmental pressures are invasively monitored. In addition, a recent porcine study supports previous clinical experience that fasciotomy is unlikely to be beneficial for the treatment of crotaline bites and may actually worsen outcome. Based on this evidence, fasciotomy cannot be routinely recommended. Rapid administration of CroFab® antivenom and elevation of the involved extremity is more likely to improve the local swelling. Fasciotomy should not be undertaken unless intracompartmental pressures are invasively monitored and documented to be persistently elevated despite antivenom treatment, and myonecrosis is considered imminent.45

Electroshock Therapy

Electroshock therapy has been proposed in a case report to prevent further toxicity resulting from rattlesnake envenomation. There are no human trials to support this modality of treatment. It was theorized that proteins in the venom would be denatured and inactivated by the electricity. However, this treatment would likely injure the patient's tissues as well. This dangerous therapy cannot be recommended.6

Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy has been proposed to limit rattlesnake venom-induced myonecrosis and to promote healing in mouse models. In one case report, antivenom, mannitol, and hyperbaric oxygen were used in treating compartment syndrome and were deemed effective because they prevented fasciotomy. It is difficult to ascertain whether the hyperbaric oxygen therapy alone or the combination of therapies prevented the compartment syndrome from worsening. There have been no human trials demonstrating significant improvement in outcome with this treatment.46,47

Pressure Immobilization

Pressure immobilization has been used in Australia in the prehospital treatment of snakebites. The technique involves wrapping the entire extremity, starting at the bite site with an elastic or compressive bandage and immobilizing it with a splint in order to slow the systemic spread of the venom. For North American snake envenomations, two porcine model studies of this treatment have shown promise in increasing survival after envenomation. One study involving subcutaneous injection of Eastern Coral Snake venom showed significantly prolonged survival times with pressure immobilization. This is not surprising since the pressure immobilization technique originated in Australia where most venomous snake species are elapids. The other study involving intramuscular injection of Eastern Diamondback Rattlesnake venom demonstrated that the pressure immobilization group had longer survival times and decreased local swelling. However, higher intracompartamental pressures were documented. There have been no human data confirming these animal findings and, at this time, there are no official recommendations regarding the use of pressure immobilization for the prehospital treatment of crotaline snakebites.48-50

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