Pediatric Viper Envenomation Complicated by Compartment Syndrome

Snake envenomations can cause both severe systemic and local complications. Acute compartment syndrome (ACS) is a rare but severe limb-threatening complication. Due to limited communicability and anticipated envenomation-related swelling, it is often subtle and difficult to diagnose in pediatric populations. A previously healthy three-year-old female presented one hour after sustaining a bite to the dorsum of her left foot by a saw-scaled viper (Echinus carinatus). A common viperidae in the region of Oman, it is responsible for a significant amount of annual envenomations leading to coagulopathy. Upon admission, the patient developed rapid swelling of the left foot and profound coagulopathy. The antivenom therapy (EQUINE Serum, Ministry of National Guard, Health Affairs, KSA) was initiated within 90 minutes of envenomation. Serial Doppler ultrasounds were performed with a change from triphasic to monophasic flow and ultimately, barely detectable dorsalis pedis arterial waveforms. Capillary refill time was delayed at 4-5 seconds (normal <2 s). Due to clinical concern for acute compartment syndrome (ACS), an emergent fasciotomy was performed within three hours of admission. Intraoperatively, arterial perfusion improved significantly. Postoperatively, the wounds were left open with regular dressing changes. The patient was found to have healing through secondary intention. This case highlights a potential yet rare complication of envenomation-induced compartment syndrome in a pediatric patient. Early recognition, surgical decompression, and careful postoperative wound care can prevent limb loss and preserve function.