Is there a role for fasciotomy in Crotalinae envenomations in North America?

CONTEXT

The local effects of Crotalinae envenomation can cause significant tissue destruction, pain, paresthesias, and deformity of the limb, which mimic findings of compartment syndrome, despite rare subfascial penetration of the fangs. Complicating this are the various techniques and ideas about what determines compartment syndrome combined with the fact that elevated intracompartmental pressures have been documented after Crotalinae envenomation, without clear evidence of compartment syndrome or tissue hypoperfusion.

OBJECTIVE

The purpose of this review is to evaluate the North American literature to provide an evidenced-based conclusion about the indications for fasciotomy in Crotalinae envenomations.

METHODS

The search was conducted with studies published only in the English language. The search included all human and animal publications, regardless of the format of study. The Cochrane Central Register, MEDLINE/ Pub Med, Scopus, and Biological Science databases were searched. Citations from all the articles were also cross-referenced if they were pertinent to the review. Major toxicology and emergency medicine and surgical textbooks were also referenced. Abstracts from the North American Congress of Clinical Toxicology, Poisonidex®, and personal articles were also scanned to complete the process, resulting in a total of 640 sources. Papers were excluded if they were duplicates, non-North American, involved excisional therapy, or did not discuss fasciotomy. This left 99 publications applicable to our study.

FINDINGS

No randomized controlled trials, 8 animal experiments, 1 human prospective observational study, 24 retrospective reviews, 32 review articles, 10 case reports, 15 textbooks references, 2 abstracts, and 7 editorials were included in the analysis. Controlled animal experiments show that crotaline Fab antivenin reduces intracompartmental pressure and increases tissue perfusion, while fasciotomy either has no beneficial effect or worsens myonecrosis. The case reports and opinions supporting fasciotomy come from the surgical literature and precede the modern crotaline Fab antivenin.

CONCLUSION

The current evidence does not support the use of fasciotomy or dermotomy following Crotalinae envenomation with elevated intracompartmental pressures. At present, early and adequate administration of crotaline Fab antivenin is the treatment of choice. Fasciotomy cannot be recommended until further well-designed investigations are completed.