Rattlesnake bites in children: Antivenin treatment and surgical indications

Background: Orthopaedic surgeons working in the Americas may be consulted in the care of patients bitten by venomous rattlesnakes (genus Crotalus), particularly with regard to the possibilities of compartment syndrome and soft-tissue destruction. Despite considerable evidence regarding the safety and efficacy of antivenin in the treatment of rattlesnake bites in adults, controversy persists regarding the roles of antivenin and surgery in the treatment of rattlesnake envenomations in children. Our hypothesis is that aggressive use of antivenin is just as effective and safe for children as it is for adults. Methods: We retrospectively reviewed the charts of twenty-four consecutive patients who had been managed at our hospital because of a bite from a western diamond back rattlesnake. Nineteen of the twenty-four patients had been envenomated. The uniformity of collected data was facilitated by the use of an intensive-care-unit protocol during the ten-year period that was reviewed. A questionnaire was developed for long-term follow-up. Results: Aggressive use of polyvalent equine antivenin safely prevented the need for surgery in sixteen of the nineteen envenomated patients. Of the three patients who had surgical treatment, two were managed with limited soft-tissue debridement and one was managed with a fasciotomy of the leg because of a compartment syndrome that occurred when adequate antivenin was withheld. No serious adverse effects were noted in association with the antivenin, and no functional impairments were noted at the time of discharge. Conclusion: Antivenin, rather than surgery, is the proper initial treatment of severe rattlesnake envenomations in children.