Snakebite Related Compartment Syndrome--A Case Report and Literature Review

蛇咬傷導致的腔室症候群──病例報告及文獻回顧

Ting-Ruei Lin(林廷叡)；Shih-Chen Tsai(蔡世楨)；Cheng-Mao Liao(廖晟貿)；Wei-Chen Lin(林威辰)；Chen-Hsiang Kuan(官振翔)

snakebite ； compartment syndrome ； Protobothrops mucrosquamatus ； fasciotomy

臺灣整形外科醫學會雜誌

33卷3期（2024 / 09 / 01）

349 - 358

英文;繁體中文

Background: The pathophysiology of acute compartment syndrome spans a spectrum of causes, from acute traumatic injuries to more insidious etiologies like snake envenomation. This particular cause poses unique clinical challenges due to the complex mechanisms of snake venoms and their potential for rapid progression to severe outcomes. Snake venom can cause a range of systemic and local effects, from coagulopathy, acute kidney injury to tissue necrosis, and soft tissue infections. When venom is deeply injected, it can cause muscle necrosis and elevate compartmental pressure. In cases where compartment syndrome develops, a thorough evaluation is crucial to determine the need for emergent fasciotomy. Intracompartmental pressure might rise to 80mmHg, and CK levels could exceed 7000 U/L. Descriptive studies from Eastern and Northern Taiwan have shown fasciotomy rates of 22.2% and 23.8%, respectively, in patients bitten by P. mucrosquamatus. Aim and Objectives: Herein, we report a case of compartment syndrome secondary to a snakebite by Protobothrops mucrosquamatus. The clinical symptoms and images, intraoperative findings, and follow-up results are described. Materials and Methods: A 67-year-old male bitten at the right dorsal wrist by Protobothrops mucrosquamatus was referred to our hospital. The laboratory test revealed mild thrombocytopenia and declined renal function. Progressive pain and swelling extending to the right upper arm occurred under repeat Antivenin injection (total 4 vials within 6 hours). He denied paresthesia at the affected limb. Intracompartmental pressure measurements were taken and immediate fasciotomy was performed. Intraoperatively, the muscles appeared healthy, and the procedure effectively reduced compartment pressures. Results: Following the fasciotomy, the wound sites were managed with moist dressings to mitigate pressure. Vacuum-Assisted Closure (VAC) therapy was initiated two days post-surgery to facilitate wound decompression and promote healing. By the seventh post-operative day, the patient underwent advanced wound closure, employing both full-thickness and split-thickness skin grafts. During subsequent follow-up visits in the outpatient department, he exhibited complete recovery with no residual symptoms. Conclusion: Snakebite-related compartment syndrome, though rare, is a critical condition that can develop within hours to days following a snakebite. Direct intracompartmental pressure measurement remains essential for diagnosis and evaluation, and early fasciotomy is crucial to prevent irreversible neurovascular damage. Patients receiving timely fasciotomy have been shown to achieve good outcomes, underscoring the importance of prompt and appropriate intervention in such cases.

背景：急性腔室症候群的病理生理學涉及多種成因，包含常見的急性創傷到少見的蛇類咬傷等。蛇毒複雜的致病機轉以及其可能在短時間內造成病況迅速惡化，使得蛇咬傷導致的腔室症候群在臨床診斷及處理評估上更加棘手。蛇的毒液可能對人體產生全身以及局部性的影響，包括凝血功能異常、急性腎損傷、組織壞死、軟組織感染等。蛇毒注入深部組織時，可能造成肌肉壞死及腔室壓力上升。當腔室症候群產生時，仔細的評估對於決定是否需要施行緊急筋膜切開術來說相當重要。蛇咬傷導致的腔室症候群可能讓腔室壓力超過80毫米汞柱以及讓每公升血液中肌酸激酶數值超過7千單位。台灣東部及北部的描述性研究顯示，被龜殼花咬傷患者接受筋膜切開術的機率分別為22.2%以及23.8%。目的及目標：我們報告一例被龜殼花咬傷導致的腔室症候群，並描述臨床症狀及外觀、術中發現、術後追蹤的結果。材料及方法：一名67歲男性患者因為右手腕背側被龜殼花咬傷轉送至本院。抽血檢查顯示輕微血小板低下及輕微腎損傷。病患在接受抗蛇毒血清重複注射下（6小時內注射共4劑血清），右上肢腫脹及疼痛仍然持續惡化。病患並沒有手麻等症狀。在接受右上肢腔室壓力量測後，病患立即接受右手背、前臂筋膜切開術。術中肌肉顏色正常，術後手掌、前臂腔室壓力也都有顯著下降。結果：術後傷口使用濕敷換藥照顧，並於術後第二天安裝負壓引流裝置（VAC）幫助減壓及促進傷口癒合。病患於術後第七天接受前移皮瓣及全層、裂層植皮，於第十四天順利出院。病患在門診追蹤5個月，傷口及功能都恢復良好。結論：蛇咬傷導致的腔室症候群是一種罕見但緊急的併發症。在被蛇咬傷數小時到數天後都有可能發生。直接量測腔室內壓力仍然是診斷及評估此急症的重要工具。及早接受需要的筋膜切開術不只可以避免症狀惡化，造成神經血管永久性傷害；也可以讓病人恢復良好的外觀及功能。