[Toxic necrosis following a bite by Naja nigricollis, a therapeutic challenge]

The surgical approach to snake bite lesions remains controversial. As a rule surgery is not recommended. However, the attitude towards severe local effects of envenoming should be revised and treatment made more aggressive, as our case report illustrates: following envenoming by Naja nigricollis, progressive necrosis jeopardized not only the function but also the survival of the hand. In view of this observation, we believe that a restrictive attitude is debatable. At first, immediately after the bite, splinting of the upper extremity is necessary, the hand being in intrinsic-plus position. Close clinical observation is necessary to detect early necrosis or a compartmental pressure-rise. As soon as pressure rises or local necrosis is suspected, extensive debridement with fasciotomy is recommended, especially in the presence of a venom with well known local toxic effects. Soft tissue coverage necessitates extensive flap surgery, such as the pedicled radialis flap, which appears not only to guarantee skin coverage but, by its excellent blood supply, prevents necrosis and allows for regeneration of underlying tissue. Our case confirms the local cytotoxicity of the venom of Naja nigricollis. Local and general effects of the snake bite must be clearly defined. The local development deserves immediate surgical attention, while the systemic effects need intensive medical care.