Predictors of the development of post-snakebite compartment syndrome Chih-Po Hsu1, Jung-Fang Chuang, Yu-Pao Hsu, Shang-Yu Wang, Chih-Yuan Fu, Kuo-Ching Yuan, Chih-Hao Chen, Shih-Ching Kang and Chien-An Liao* 林口長庚醫院外傷急症外科

Introduction Snakebites remains a public health problem worldwide,ranging from symptomless to life threatening Systemic : well controlled by widespread use of antivenom with acceptable prognosis Loco-regional tissue injury commonly results in pain, blistering, and bruising., rare and lethal condition : compartment syndrome Limited reports concerning post-snakebite compartment syndrome (PSCS) and there is a lack of consensus regarding the diagnosis and management of PSCS.

Introduction When compartment syndrome happens, surgical intervention with fasciotomy is always needed with variable monitoring times that costs medical burden and diagnosing dilemma We present our experience with the management of snakebites at a trauma center, identifying factors associated with the development of PSCS in snakebite patients and analyzed the prognosis of these patients 一旦產生了腔室症候群 多數的病人都需要接受手術治療 最重要的是fasicotomy 而且這些病人通常需要時間不一的觀察時間 曠日費時 也耗費了許多醫療資源以及診斷的困難 現今確診腔室症候群的方法為直接量取腔室內的壓力 一般以30mmhg當作基準 不過我們醫院是比較不一樣的 是以專科醫師臨床懷疑為主

Materials and methods Retrospectively reviewed CGMH trauma database: demographic data; trauma mechanism; prehospital, medical, perioperative, and hospital course; follow-up information; and information regarding complications March 2009 to December 2012 The dataset was further limited by age to include patients over 18 years old and younger than 80 years old

Treatment protocol Identifying species Six common venomous snakes :the Taiwan Habu, bamboo viper ,Russell’s pit viper, Taiwan cobra (Naja naja atra), Taiwan banded krait and sharp-nosed pit viper Asymptomatic patient: discharge after 6h observation, Symptomatic patient: monitoring at least 24hours, receiving adequate antivenom intravenously with a recommended dosage according to the species Admission if progress symptoms noted If can’t identify the species, both antivenom is used 龜殼花 赤尾青竹絲 鎖鏈蛇 眼鏡蛇 雨傘節 百步蛇 沒有症狀的病人我們會讓他在急診觀察六小時後再回家 如果是神經毒如雨傘節的話則會觀察一天 有症狀的病人我們會投與毒蛇血清並且留觀24小時再回家 如果症狀變嚴重的話則會考慮 住院治療 antihistamines, corticosteroids, and antibiotic agents may needed

Treatment Diagnosing PSCS: pain, paresthesia, pallor, paralysis, poikilothermia and pulselessness. One P, considering, two P will establish the diagnosis Fasciotomy is indicated if PSCS is diagnosed in the distal limbs In the present study, we excluded patients who visited the ED more than 72 h after the snakebite episode or who were lost to follow-up at our institution 在此強調我們醫院診斷腔室症候群的方法 是以臨床為主！

Statistical analysis SPSS Pearson’s χ2 test and Fisher’s exact test Student’s t-test and the Mann–Whitney U test. Levene’s test logistic regres- sion.

Results 這邊有提到 在沒有腔室症候群的病人中居然有三個是鎖鏈蛇的蛇毒 原則上鎖鏈蛇的蛇毒血清在台灣西部是沒有的 不過我們還是用混合著的給他使用！！ 原因雖然台灣西部幾乎沒有鎖鏈蛇 但病人還是堅持倍鎖鏈蛇咬傷

Results

Results

Discusssion The mortality of snakebite had decreased, the management of morbidity had became important Compartment syndrome is lethal and may require limb amputation! Hypotheses for PSCS. Snake venom forms enzymatically active proteins after being injected into the human body. Deposition of venom into subcutaneous tissue, a poison-induced capillary leak may induce extravasation of plasma and erythrocytes, resulting in edema and ecchymosis

Discussion The incidence of PSCS was rare in previous reports (0.20-1.36 %) but was 6.6 % in the current study. This higher incidence may be related to the predominance of cytotoxic snakes in Taiwan

Discussion Although snake species are playing important roles in PSCS, but there are several factors that had impact on the formation of PSCS. Species is not the only predicting factor! By the same time, identifying snake is not easy to accomplish at the moment of been bitten ! Other convenient factors should be used for predicting!

Discussion Clinical signs are often late signs for compartment syndrome! It is always sign of ischemia change In our study, WBC and AST maybe used as predicting factors! These two factors are implying the tissue damage is happening

Discussion The necessary duration of observation for symptomatic snakebite patients is controversial. In some studies, the authors suggested that symptomatic cases should be monitored for a minimum of 24 h In the present study, all patients with compartment syndrome developed the condition between 1.4 and 39.7 h after ED arrival. Additionally, 22.2 % of patients (2/9) developed compartment syndrome after more than 24 h. In our department, to exclude the possibility of compartment syndrome, patients are observed for local effects at least 48 h after admission.

Limitation Retrospective analyzing The number of snakebite is Taiwan has decreased in recent years making the case of this study is not enough The WBC and AST should not be used as the only decision making tools for compartment syndrome it’s used for us to evaluating those at high risks of developing compartment syndrome

Conclusion WBC and AST maybe used as risk factors for post snake-bite compartment syndrome At least 48 hours of observation is needed for monitoring compartment syndrome for those symptomatic patients!

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