When is surgery indicated for treatment of snakebites?

Updated: Apr 09, 2021
  • Author: Spencer Greene, MD, MS, FACEP, FACMT, FAAEM; Chief Editor: Joe Alcock, MD, MS  more...
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Although surgeons are often involved in the management of snake envenomation in the United States, it is essential to recognize that snakebites are a medical, not surgical, condition. Excision of the bite site was once recommended, but it is now understood that this is a disfiguring procedure that does not confer any survival benefit.

Compartment syndrome is an exceptionally uncommon complication from crotalid envenomation, and prophylactic fasciotomies are no longer recommended. Animal studies prove that morbidity and mortality are increased following prophylactic fasciotomy when compared with antivenom therapy. [68, 69, 70] In a review of 99 publications evaluating the efficacy of fasciotomy in animals and humans, the author could not identify any situation in which surgical intervention was beneficial. [71] An expert panel consisting of trauma surgeons and medical toxicologists also concluded that prophylactic fasciotomy was not beneficial and was possibly harmful. [50] The same authors concluded that even in the exceptionally rare case of confirmed compartment syndrome, the initial treatment should be additional doses of antivenom, not fasciotomy. The rationale, supported by animal studies, is that elevated compartment pressure represents a severe envenomation but is not the cause of the morbidity. Rather, it is the venom that is causing the damage, and neutralizing the venom is the definitive treatment. [72] Fasciotomy should only be considered in those patients with persistently elevated compartment pressures despite adequate antivenom therapy.

Delayed surgical intervention following envenomation is indicated when there is full-thickness necrosis requiring amputation. Premature surgery must be avoided, however, because many patients with superficial necrosis recover fully if managed with conservative wound care.

Coral snake envenomations are not characterized by tissue injury and do not require surgical intervention.

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