Without prompt surgical treatment, it may lead to nerve damage and muscle death. Edema of the soft tissue within the compartment further raises the intra-compartment pressure, which compromises venous and lymphatic drainage of the injured area. Pressure, if further increased in a reinforcing vicious cycle, can compromise arteriole perfusion, leading to further tissue ischemia [ 12 ].
The normal mean interstitial tissue pressure is near zero mm Hg in non-contracting muscle. If this pressure becomes elevated to 30 mm Hg or more, small vessels in the tissue become compressed, which leads to reduced nutrient blood flow i.
Of particular importance is the difference between compartment pressure and diastolic blood pressure; where diastolic blood pressure exceeds compartment pressure by less than 30 mm Hg it is considered an emergency [ 13 ].
The compartment pressure measurement can be helpful in the assessment of the patient. Untreated compartment syndrome mediated ischemia of the muscles and nerves lead to eventual irreversible damage and death of the tissues within the compartment and as a long term result Volkmann's contracture.
We report the case of a year-old healthy male tourist no relevant medical history , who was bitten in the right hand by an adder during a getaway at the countryside of Denmark. Initial treatment was performed in a local county hospital in Denmark with analgesia and bandage.
Due to persistent swelling and beginning lymphangitis, the patient was transferred next day to our University Hospital close to his residence. At the time of admission the main symptoms were significant swelling of the right hand, forearm and upper arm with lymphangitis up to the axilla.
The patient suffered from pain at a visual analogue scale around 7 Scale The patient reported beginning paresthesia of the median nerve. The palpation of the upper extremity revealed a hard swelling with a beginning compartment syndrome Figure 1. Laboratory tests showed a leucocytosis and elevated CRP with a body temperature of The Antivenom type European Viper Venon Antivenom was immediately ordered and administered intravenous under ICU-conditions according to the guideline protocol, which recommend the early treatment within 48 hours.
No complications occurred. Only a few hours after admission of the patient in our hospital before arrival of Antivenom the surgical intervention with local incision of the loge of Guyon, the carpal canal, forearm and upper arm was performed Figure 2. Intraoperatively, necrotic muscle tissue and hemorrhagic spots occurred. Long term follow up 1 year showed sufficient wound healing, also the nerval function recovered completely with a full range of motion of all digits.
He had returned to all previous activities and considered his hand and arm to be normal. Figure 3 shows a picture of the wound status 2 weeks post-op.
Snake venom poisoning is a medical emergency requiring immediate attention. Bites from poisonous European snakes can lead to local tissue damage and systemic symptoms [ 2 ]. The effects of envenoming are unpredictable and therefore victims should be referred to hospital for monitoring. Treatment has two components: firstly correction of the systemic hemodynamic, respiratory and hematological disturbances and secondly administration of specific antivenom [ 14 ].
Envenomation of a limb can lead to cutaneous necrosis, compartment syndrome and even necrotising fascitis [ 9 ]. Early diagnosis and prompt treatment is needed to prevent these complications.
Immediately after an adder bite, the bite site should be immobilized to delay the spread of the venom [ 15 ]. In case of a compartment syndrome, which can affects the whole upper extremity beside the carpal canal, the complete decompression of all compressed structures is ultimatively necessary in order to avoid further tissue damage and late sequalae [ 11 ].
Therefore we recommend that the classical signs and symptoms of compartment syndrome serve as indication for surgical decompression. Patients should be monitored for at least 24 hours with measurement of blood pressure, heart-, and respiratory rate as well as lab tests including white blood cell count, serum creatine kinase and bicarbonate. It is recommended that victims also should have an ECG twice daily if hypotension persists [ 8 ].
Reactions to antivenom are very rare; however, victims with allergic histories are at increased risk of developing severe antivenom reactions [ 8 ].
A Sheep-fab-fragment antivenom, which is less allergenic than other antivenoms, should be employed in case of severe symptoms. The risk of reactions with currently available antivenoms for use in bites by European vipers is very low [ 10 , 17 ]. One study reported that in cases of severe envenoming the median duration of hospital admission was reduced from 10 days to 5 days in those receiving antivenom [ 18 ].
The overall mortality resulting from adder bites is very low and less common now than in the past, where for example in Sweden between and there were 24 reported deaths [ 7 ]. Any victim of snakebite presenting to a general practitioner or hospital for treatment in northern Europe can be assumed to have been bitten by the adder V. The Forestry Commission of England describes them as perfect miniatures of adult snakes.
They are sometimes born during hibernation, so they are born with excess fat stores to help them through their first winter. Adders reach sexual maturity between 3 and 4 years of age. They can live for up to 15 years in the wild, according to the ADW. According to the Forestry Commission of England, no one has died of an adder bite in Britain in more than 20 years. Though they are venomous, they are not aggressive, and when threatened only use their venom as a last resort.
Humans are most likely to be bitten if they step on or try to pick up an adder. Adders "have relatively moderate venom, not highly lethal," said Savitzky. They are, however, "unpleasant and could cause potentially serious medical issues. Though they are usually not lethal, that doesn't mean that they don't deserve treatment. Sometimes called African adders, puff adders Bitis arietans are members of the viper family. That is certainly true for the puff adder, which is more venomous and dangerous than its European relatives.
Puff adders average about 3 feet 1 meter in length and have stout bodies. They have light brown, gray, and black markings with a distinctive chevron pattern, according to the Sabi Sabi Game Reserve in South Africa. Their coloring makes for effective camouflage. Like most vipers, their heads have a triangular shape and are distinct from their necks. Males are larger than females.
Like other vipers, puff adders have hinged fangs through which venom is injected into prey. Puff adders are widespread throughout Africa, Savitzky said. They live in most of sub-Saharan Africa except the rainforests in west and central Africa. Puff adders are found across the Red Sea in the southwest corner of Saudi Arabia, Yemen, and in in the southwest corner of Oman. Puff adders primarily live in rocky savannahs, though they are found almost everywhere in Africa except deserts and rainforests.
A primary reason they bite so many people is that they are highly adaptable snakes and often live in developed places, according to the Sabi Sabi Game Reserve. Puff adders are out both during the day and at night, though they are more active at night, according to Perry's Bridge Reptile Park in South Africa.
Because of their stocky bodies, they are relatively slow-moving snakes. They rely on their camouflage for protection rather than their ability to move quickly. Puff adders move in a straight line, like a caterpillar, rather than in the side-to-side slithering motion of most snakes. Puff adders are known for their aggressive temperament, though Savitzky says that might be overstated.
Part of that reputation may come from the relative frequency of humans stepping on puff adders. Because they are slow and heavily camouflaged, it is possible for people to unintentionally get close to the snakes and step on them.
When threatened, puff adders inflate their upper bodies and hiss. This habit as given rise to their common name. For more detail and up-to-date information on death adder snakes, covered at species level, visit www. The information on this page will not be regularly updated, because regular updated information can be obtained from the main toxinology website, listed above.
For more detailed information on death adders, including distribution maps and photos, use the Clinical Toxinology Resources Website at www. Death adders are highly venomous and are found in most of mainland Australia, but not on southern offshore islands, including Tasmania. They are also found in New Guinea and a few islands of western Indonesia.
As with other venomous snakes causing snakebite in humans, death adders have complex venoms with many components. Only the most important clinically are mentioned here. Although the risk of Adder bites is quite low, it is advisable to be cautious at this time of year, especially in areas where the snakes are known to be present. These can include sand dunes, moorland and woodland edges.
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