Compartment syndrome after Bothrops jararaca snakebite: monitoring, treatment, and outcome

Objective. To report the outcome of a patient who developed compartment syndrome after Bothrops jararaca snakebite. Case report. A 39-year-old male was admitted 5 h after being bitten on the lower right leg. Physical examination revealed tense swelling, ecchymosis, hypoesthesia, and intense local pain that worsened after passive stretching, limited right foot dorsiflexion, and gingival bleeding. The case was classified as moderate/severe and eight vials of bothropic antivenom (AV) were infused 1 h postadmission. The main laboratory findings upon admission were incoagulable blood (incoagulable PT, aPTT, and INR), thrombocytopenia, serum creatine kinase (CK) of 580 U/L (reference value < 170 U/L), and a serum venom level of 33.7 ng/mL (ELISA; cutoff = 2.3 ng/mL). High anterior compartment pressure (60 mmHg) was identified 8 h post bite, with progressively lower pressures after AV administration and limb elevation (36 mmHg; 19 h post bite). However, moderate pain and limited foot dorsiflexion persisted. In addition, there was a progressive increase in serum CK (6,729 U/L; 45 h post bite), as well as marked edema and hemorrhage of the anterior compartment detected by magnetic resonance imaging (MRI) at 48 h post bite. A fasciotomy done after a further increase in intracompartmental pressure (66 mmHg, 57 h post bite) revealed hemorrhage/necrosis of the anterior tibial muscle that subsequently required partial resection. The patient developed a local infection (day 15 post bite) and a permanent fibular palsy. Conclusion. Compartment syndrome is an unusual but severe complication of snakebites. MRI, in conjunction with subfascial pressure measurements, may be useful in the diagnosis of compartment syndrome after snakebites.