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<< Diagnosis And Management Of North American Snake And Scorpion Envenomations

Controversies

Alternative Treatment

Several studies have addressed specific techniques used in the care of snake envenomations and have shown that many of the devices and techniques traditionally used in care of snake envenomations were either of no benefit or were, in fact, harmful. Incisions, suction devices, packing in ice (cryotherapy), application of heat, and even application of electrical shocks have all historically been used to treat snake envenomations. While the application of a stun-gun or "gasoline engine spark plugs" to a patient may be intriguing, there is no clinical benefit, and a handful of case studies show the danger of this therapy, even in controlled settings.50 As discussed in detail above, little role remains for any field treatment beyond immobilization, reassurance, and rapid transport.

 Fasciotomy

Once considered part of the primary treatment of snake envenomations, fasciotomy is the other controversial issue that has yet to be addressed in this discussion. Good clinical data from animal studies have shown that in snake envenomations, rabbits that receive fasciotomy (with or without antivenom) have poorer outcomes than those treated with antivenom alone.51-52 The signs and symptoms of a significant envenomation closely mimic the symptoms of compartment syndrome and it is clinically impossible to establish the difference without direct measurement of compartment pressures.53 Even in the cases where compartment pressures exceed 30 to 40mm Hg, additional antivenom administration (four to six vials) has been shown to reduce compartment pressures, avoiding an unnecessary and disfiguring fasciotomy. Fasciotomy should only be considered in the extraordinarily rare cases where additional antivenom doses have failed to reduce measured pressures.

In the authors' opinion, given the "assess, treat, reassess, treat" management strategy, and the scheduled dosing nature of current management, a medical ICU service may be more appropriate than a surgical service. Clearly, in the rare case of true elevated compartment pressures, a consultation to orthopedics or surgery is warranted. That said, snake envenomations present such a complex interaction of multisystem toxicologic effects that the determination of the best admission service should be handled on a caseby- case and hospital-by-hospital basis.

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Last Modified: 08/17/2017
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