The role of a point-of-care ultrasound protocol in facilitating clinical decisions for snakebite envenomation in Taiwan: a pilot study

Ho CH 1 , Ismail AK 2 , Liu SH 3 , Tzeng YS 4 , Li LY 5 , Pai FC 6 Show all authors , Hong CW 5 , Mao YC 7 , Chiang LC 8 , Lin CS 9 , Tsai SH 5

Affiliations 

  • 1 Department of Emergency Medicine, Tri-Service General Hospital, Taipei, Taiwan
  • 2 Emergency Medicine, Jalan Yaacob Latif, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
  • 3 Institute of Toxicology, College of Medicine, National Taiwan University, Taipei, Taiwan
  • 4 Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  • 5 Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  • 6 Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
  • 7 Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
  • 8 College of Life Sciences, National Tsing Hua University, Hsinchu, Taiwan
  • 9 Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Division of Cardiology, Department of Internal Medicine, Taipei, Taiwan
Clin Toxicol (Phila), 2021 Sep;59(9):794-800.
PMID: 33605805 DOI: 10.1080/15563650.2021.1881535

Abstract

BACKGROUND: The incidence of acute compartment syndrome (ACS) following snakebite envenomation may be seriously overestimated in Taiwan. Snakebite-induced ACS is difficult to determine solely by clinical examination. Snakebite patients previously underwent surgical intervention based on speculation and general clinical examinations suggesting ACS presentations instead of direct intracompartmental pressure (IP) measurement prior to fasciotomy. Point-of-care ultrasound (POCUS) is a relatively widely available noninvasive tool. This study aimed to evaluate snakebite-envenomated patients for the presence of subcutaneous edema and diastolic retrograde arterial flow (DRAF).

MATERIALS AND METHODS: Snakebite patients were prospectively recruited between 2017 and 2019. All patients were examined with POCUS to locate edema and directly visualize and measure the arterial flow in the compressed artery. The presence of DRAF in the compressed artery is suggestive of ACS development because when compartment space restriction occurs, increased retrograde arterial flow is observed in the artery.

RESULTS: Twenty-seven snakebite patients were analyzed. Seventeen patients (63%) were bitten by Crotalinae snakes, seven (26%) by Colubridae, one (4%) by Elapidae, and two (7%) had unidentified snakebites. All Crotalinae bit patients received antivenom, had subcutaneous edema and lacked DRAF in a POCUS examination series.

DISCUSSION: POCUS facilitates clinical decisions for snakebite envenomation. We also highlighted that the anatomic site of the snakebite is an important factor affecting the prognosis of the wounds. There were limitations of this study, including a small number of patients and no comparison with the generally accepted invasive evaluation for ACS.

CONCLUSIONS: We are unable to state that POCUS is a valid surrogate measurement of ACS from this study but see this as a starting point to develop further research in this area. Further study will be needed to better define the utility of POCUS in patients envenomated by snakes throughout the world.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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