Snakebite management in a pediatric patient: More doubts than certainties

Sanjuan, E.; Álvarez-Baena, L.; Callejo, D.; Romera, A.

doi:10.1016/j.redare.2021.04.001

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Sanjuan, L. Álvarez-Baena, D. Callejo, A. Romera" "autores" => array:4 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Sanjuan" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Álvarez-Baena" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Callejo" ] 3 => array:4 [ "nombre" => "A." "apellidos" => "Romera" "email" => array:1 [ 0 => "andreilla111@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo de una mordedura de ofidio en un paciente pediátrico: más dudas que certezas" ] ] "textoCompleto" => "Snake bites are rare in our setting,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> a factor that complicates decision-making difficult and delays the start of treatment, particularly in paediatric patients.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> We report the case of a child bitten by a viper who developed compartment syndrome that required 2 fasciotomies. As anaesthesiologists and paediatric critical care specialists, we ask ourselves whether the administration of antivenom would have improved management.The patient was a 5-year-old boy weighing 20 kg, with no clinical history, who was bitten by a snake in the thenar space. He was transferred to 2 hospitals before arriving at the Gregorio Marañón General University Hospital in Madrid, where he was admitted 12 h after being bitten. The diagnosis of viper bite, probably from a Vipera latastei or “snub-nosed viper”, was performed correctly in both hospitals, based on the morphology of the bite, the geographic location, and the description provided by the patient. Both hospitals decided to take a conservative approach and transfer the patient to a tertiary hospital. When he finally arrived in our paediatric critical care unit, the patient was in good general condition with haemodynamic and respiratory stability. The affected hand, in addition to the bite mark, was swollen, hot and flushed. The parents reported that these symptoms had increased gradually and spread upwards. The only laboratory abnormality found was leucocytosis of 17,000 μl. The National Institute of Toxicology and Forensic Sciences was contacted by telephone and, following their protocol, antivenom was not administered. The patient was examined by the trauma unit and underwent fasciotomy in the wrist within 1 h of admission, and a second intervention 48 later, both to treat compartment syndrome. The patient was treated with amoxicillin-clavulanate and intravenous corticosteroids. In the first 24 h, mild phlebitis was observed in the forearm, which progressed to the axilla. The pitting oedema reached as far as his wrist. Aside from the initial leucocytosis, which normalized within 8 h of admission, his laboratory parameters (urine sediment, blood count, biochemistry, coagulation, acute phase markers and muscle damage) were normal. He remained stable during his hospital stay and was discharged home 11 days later.Snake bites in Spain are rare, but potentially serious.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Although the patient was treated by a multidisciplinary team, none of the specialists involved—anaesthesiologists, traumatologists and experts in infectious diseases—had experience in snake bites. A comprehensive review of the international literature showed that this pathology can be confusing, given the many different classifications of patient severity and different therapeutic criteria.In terms of the clinical classification, some authors use the Audebert classification or a slightly modified version,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> which divides patients into 4 grades and considers extensive oedema and moderate general symptoms (grade III) to be the determining factors for severity. In our patient, oedema only reached as far as the wrist (although the phlebitis progressed along the arm over the first days) and the leucocytosis lasted only a few hours; both factors suggested mild envenoming.Children and elderly patients are more likely to develop severe envenoming.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The site of the bite in our patient is the most frequently described in Spain.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Although most envenomations are superficial to the fascia and rarely progress to compartment syndrome, bites in the hand are the exception to this rule,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and this has prompted some authors to claim that the anatomical site can be a determining factor in the development of compartment syndrome. Management is similar for all snake species in Spain, so knowing the specific type of viperis is not essential for treatment.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>The most important diagnostic studies are electrocardiography, since toxins can have a direct cardiotoxic effect and cause arrhythmias—particularly supraventricular tachycardia and heart block, and renal function tests for the presence of choluria due to myoglobinuria or haematuria, proteinuria, oliguria or progression to kidney failure.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>In terms of therapy, the affected limb should be immobilized and elevated, but never compressed, and cryotherapy (applied indirectly) and bed rest should be considered. Tourniquets, cutting or sucking the wound are not recommended, and cauterizing the bite area, amputation or applying electric current should be avoided, as should the administration of stimulating drugs or drinks that increase cardiac output and facilitate the spread of venom. Anti-tetanus prophylaxis should be administered if needed, analgesics (not salicylates) should be started. The use of antivenom serum should be considered, with or without intravenous mannitol at 1−2 g/kg/weight.<a class="elsevierStyleCrossRefs" href="#bib0005">1,4</a>There are no randomized clinical trials comparing the benefit of antivenom and the effectiveness of fasciotomy in humans. Although fasciotomy has hitherto been prioritized, more recent studies recommend administering antivenom as first-line treatment, as it is effective and well-tolerated, prevents progression, improves inflammation, and reduces hospital stay.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Early (within 6 h of the bite), rather than late administration of the antivenom serum is more effective, probably because the venom has had less time to act. However, late administration, though less effective, is also useful (even after 24 h).<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Likewise, some authors recommend early administration of antivenom in pregnant women and in patients that already show signs of compartment syndrome.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Our diagnosis of compartment syndrome was made on the basis of clinical criteria, without directly measuring compartment pressure. Some authors recommend performing this measurement to determine whether the oedema is intracompartmental or extracompartmental, and to apply the appropriate treatment in each case,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> since snake venom itself causes muscle necrosis and can mimic compartment syndrome.Furthermore, fasciotomy resolves compartment syndrome, but not muscle necrosis.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Although the administration of antivenom is not without risk—pruritus, urticaria, angioedema, nausea, hypotension or anaphylactic shock—most experts agree that adverse effects are rare.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Some authors advise premedicating with antihistamines and corticosteroids and/or performing a hypersensitivity test. The rate of administration should be reduced or suspended altogether if adverse effects appear, although this is highly unlikely given the low antigenicity of these sera.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The prophylactic use of antibiotics has not been shown to be useful.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Corticosteroids are only indicated in the exceptional case of an allergic reaction to the poison or in the event of a very rare adverse reaction after administration of the serum.We believe that this was a borderline patient as far as antivenom serum is concerned. Factors advising against administration were the time elapsed since the bite and the extent of the lesion; factors in favour were the age of the patient, the location of the bite and the need for fasciotomy. Given our limited experience and the diversity of criteria found in the literature, we cannot establish an unequivocal guideline for action.We recommend always contacting the National Institute of Toxicology and taking their opinion and protocol into account, albeit it bearing in mind that they can be too conservative in some cases.FundingThe authors declare that they have not received funding for this study." "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Sanjuan E, Álvarez-Baena L, Callejo D, Romera A. Manejo de una mordedura de ofidio en un paciente pediátrico: más dudas que certezas. Rev Esp Anestesiol Reanim. 2021;68:304–305." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Envenenamiento por mordedura de serpiente en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Martín-Sierra" 1 => "S. Nogué-Xarau" 2 => "M.A. Pinillos" 3 => "J.M. Rey" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emergencias." 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ISSN: 2341-1929

Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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