Suspected Acute Compartment Syndrome Following Snakebite Envenomation: A Fatal Case Highlighting the Conflict Between Life-Saving Resuscitation and Limb-Saving Fasciotomy.

Acute compartment syndrome (ACS) is a rare but devastating potential complication of snake envenomation. Distinguishing suspected ACS from venom-induced pseudo-compartment syndrome remains a major clinical challenge, as unnecessary fasciotomy in a coagulopathic patient carries substantial risks, whereas delayed decompression may result in irreversible ischemic injury. We report the case of a 68-year-old man admitted 48 hours after a snakebite with massive progressive swelling of the left upper limb, profound metabolic acidosis, severe consumptive coagulopathy, and refractory shock. Surgical decompression was strongly considered due to high clinical suspicion of ACS; however, emergency fasciotomy could not be safely performed owing to severe hemodynamic instability and uncorrected coagulopathy. Despite aggressive resuscitation, antivenom administration, and hemostatic support, the patient rapidly deteriorated and developed refractory cardiac arrest, culminating in death 90 minutes after admission in the setting of overwhelming systemic envenomation. This case highlights both the diagnostic uncertainty surrounding ACS without access to intracompartmental pressure monitoring and the critical therapeutic dilemma of managing severe local complications alongside life-threatening systemic toxicity.