Research

Defining the need for surgical intervention following a snakebite still relies heavily on clinical assessment: The experience in Pietermaritzburg, South Africa

J P Pattinson, V Y Kong, J L Bruce, G V Oosthuizen, W Bekker, G L Laing, D Wood, P Brysiewicz, D L Clarke

Abstract


Background. This audit of snakebites was undertaken to document our experience with snakebite in the western part of KwaZulu-Natal (KZN) Province, South Africa (SA).

Objective. To document our experience with snakebite in the western part of KZN, and to interrogate the data on patients who required some form of surgical intervention.

Methods. A retrospective study was undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, SA. The Hybrid Electronic Medical Registry was reviewed for the 5-year period January 2012 - December 2016. All patients admitted to the service for management of snakebite were included.

Results. The offending snake is rarely identified, and the syndromic approach is now the mainstay of management. Most envenomations seen during the study period were cytotoxic, presenting with painful progressive swelling (PPS). We did not see any purely neurotoxic or haemotoxic envenomations. Antivenom is required for a subset of patients. The indications are essentially PPS that increases by >15 cm over an hour, PPS up to the elbow or knee after 4 hours, PPS of the whole limb after 8 hours, threatened airway, shortness of breath, associated clotting abnormalities and compartment syndrome. If no symptoms have manifested within 1 hour of a snakebite, clinically significant envenomation is unlikely to have occurred. Antivenom is associated with a high rate of anaphylaxis and should only be administered when absolutely indicated, preferably in a high-care setting under continuous monitoring. The need for surgery is less well defined. Urgent surgery is indicated for compartment syndrome of the limb, which is a potentially life- and limb-threatening condition. Its diagnosis is usually made clinically, but this is difficult in snakebites. Morbidity and cost increase dramatically once fasciotomy is required, as evidenced by much longer hospital stay. There is frequently a degree of cross-over between cytotoxicity and haemotoxicity in envenomations that require fasciotomy, which means that fasciotomy may result in catastrophic bleeding and should be preceded by the administration of antivenom, especially in patients with a low platelet count or a high international normalised ratio. Physiological and biochemical markers are unhelpful in assessing the need for fasciotomy. Objective methods include measurement of compartment pressures and ultrasound.

Conclusion. The syndromic management of snakebite is effective and safe. There is a high incidence of anaphylactic reactions to antivenom, and its administration must be closely supervised. In our area we overwhelmingly see cytotoxic snakebites with PPS. Surgery is often needed, and we need to refine our algorithms in terms of deciding on surgery.


Authors' affiliations

J P Pattinson, Department of Surgery, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; General Surgery, Pietermaritzburg Hospital Complex, KwaZulu-Natal, South Africa

V Y Kong, Department of Surgery, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; General Surgery, Pietermaritzburg Hospital Complex, KwaZulu-Natal, South Africa

J L Bruce, General Surgery, Pietermaritzburg Hospital Complex, KwaZulu-Natal, South Africa

G V Oosthuizen, General Surgery, Pietermaritzburg Hospital Complex, KwaZulu-Natal, South Africa

W Bekker, General Surgery, Pietermaritzburg Hospital Complex, KwaZulu-Natal, South Africa

G L Laing, General Surgery, Pietermaritzburg Hospital Complex, KwaZulu-Natal, South Africa

D Wood, Department of Emergency Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

P Brysiewicz, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

D L Clarke, Department of Surgery, Grey’s Hospital and College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

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Keywords

Snakebite; Surgical intervention; South Africa; KwaZulu-Natal; Age; Gender; Outcomes; Syndromic approach

Cite this article

South African Medical Journal 2017;107(12):1082-1085. DOI:10.7196/SAMJ.2017.v107i12.12628

Article History

Date submitted: 2017-11-27
Date published: 2017-11-27

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