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INTRODUCTION who presented with soft tissue necrosis were subjected
to surgical debridement prior to 6 sessions of HBO
Snakebite injuries of the extremities are common in therapy. The patients were followed up for the effects and
India, among those involved in farming and outdoor complications of the treatment.
activities. There are approximately 400 poisonous species
among 2,000 species of snakes known worldwide. These RESULTS
species belong to the families of Elapidae, Viperidae,
Of a total 395 patients, 174 patients treated with ASV
Hydrophiidae, and Colubridae. Viper bites are the most with a mortality of 17 posttreatment. Forty-four out of
[1]
common poisonous bites sustained by humans. [2,3] Russell’s the 174 patients were in the pediatric age group [Table 1]. Of
viper (Viperarusselli) is the most common species in the patients referred to our department, 23 presented with
South Asia and considered as an occupational hazard in cellulitis, 7 with compartment syndrome, and 17 for
the farming community. The World Health Organization has the management of soft tissue cover over the extremities.
estimated that approximately 125,000 deaths occur from Of the 47 patients, 30 involved the lower extremity
250,000 poisonous snake bites worldwide every year. India and rest involved the upper extremity. All patients were
alone accounts for 10,000 deaths. [4,5] These snake bites subjected to HBO therapy as an adjunct. Six patients
involve predominantly young, healthy, and the able-bodied required flap cover: cross finger flap (n = 2), anterolateral
working population in rural areas. Children and the elderly thigh free tissue transfer (n = 1), lateral supramalleolar
are most susceptible to mortality. [5,6] Most of these injuries flap (n = 1), groin flap (n = 1), and dorsal metacarpal
involve the extremities. This results in pain and swelling artery flap (n = 1) [Tables 2 and 3]. There was no need
of the bitten region, leading to cellulitis and compartment for fasciotomy among patients who suffered impending
syndrome, in addition to systemic toxicity. The main compartment syndrome.
cause of mortality is the lack of a systematic approach or
protocol for the management of such injuries. The purpose Case 1
of the study is to share our experience of multidisciplinary A 5-year-old boy was admitted with a snakebite injury
approach in the management of snakebite injuries of the to the lower third of his right leg. He presented with
extremities with various treatment modalities including compartment syndrome of the right leg and foot
hyperbaric oxygen (HBO) therapy, surgical debridement, [Figure 1a and b]. HBO therapy was administered
and skin grafting, local or distant flaps to provide a for six sessions following admission. The patient
treatment for effective management of such injuries recovered from the syndrome without any surgical
from a plastic surgeon’s perspective. intervention [Figure 1c].

METHODS Case 2
An 8-year-old boy was admitted with a snakebite injury
All patients who were treated for snakebite injuries in to the dorsum of his right foot. He presented with
our department between October 2012 and October 2013 compartment syndrome and discoloration at the bite
were included in the study. All patients received tetanus site [Figure 2a]. HBO therapy was administered for six
toxoid. The snakebites were assessed by an emergency sessions following admission, and sequential evaluation
physician who classified them into poisonous and was performed [Figure 2b-d]. After demarcation of the
nonpoisonous snakebites clinically. Anti-snake venom (ASV) nonviable tissue, debridement, and skin grafting was
was administered accordingly. Antibiotics, diuretics, and done [Figure 2e].
blood products were administered as indicated. Patients
were initially admitted to the Departments of Medicine Case 3
or Pediatrics. They were only subsequently referred to A 45-year-old male presented with soft tissue loss
the plastic surgery department if cellulitis, compartment measuring 8 cm × 7 cm × 2 cm over the lower third
syndrome or soft tissue loss was suspected. The treatment of his right leg and lateral aspect of his ankle [Figure 3a].
of soft tissue complications was done only after critical Wound debridement was performed, and the resultant
stabilization of the patient. Patients with cellulitis and soft tissue defect was covered with a left anterolateral
compartment syndrome were subjected to HBO therapy. thigh flap [Figure 3b]. Six sessions of HBO therapy was
Administration of HBO therapy was done in a monoplace performed postoperatively.
chamber where a single patient is placed in a chamber
that is then pressurized to 1.8-2.4 atmospheres with DISCUSSION
100% oxygen. HBO therapy was administered in 6 daily
sessions, with each session lasting 90 min. The sessions Snake envenomations have the highest incidence in Asian
were extended according to the clinical progress of the countries resulting in gross morbidity and mortality.
disease judged by the clinician. The daily treatment Males are more commonly affected than females, as they
sessions were extended another week if insufficient are mostly involved in farming and outdoor activities.
softness of the tissue was attained. The regimen for The predominant age group affected is those between 20
[3]
pediatric patients was identical, although parents were and 40 years. The most common symptoms are pain
allowed to accompany the child in the chamber. Patients and swelling of the bitten region. Systemic signs include
60 Plast Aesthet Res || Vol 3 || Issue 2 || Feb 29, 2016