Introduction:Snake bites are a common medical emergency in many parts of the world, especially in tropical and subtropical regions. Snake bites in children, especially in low-income countries, can cause serious physical and mental harm to children, and considering that the volume of distribution is less than the amount of poison injected in children, neurological and hematological complications and local symptoms may develop faster and more severe, so timely diagnosis and correct treatment are very necessary in them.In older children, according to their ability to provide a history, it is somewhat easy to diagnose snakebite, but in younger children, especially if the snakebite occurred in the absence of the parents, it will be somewhat difficult to diagnose.This article introduces a case of a 4-year-old child, which is a challenge to diagnose snakebite due to the specific location and occurrence of non-specific initial symptoms.Case Presentation:A 4-year-old child was brought to the emergency department with a complaint of sudden severe general weakness and impaired consciousness. The child’s father reported that they rode a motorcycle together from his uncle’s house, and the child was riding behind the motorcycle. At the beginning of the ride, the child’s general condition was completely normal, but a few minutes after riding the motorcycle, the child suddenly became completely weak and lethargic and had a disorder of consciousness. The child was brought to the hospital for this reason.At the beginning of entering the emergency department, the child was immediately evaluated, and the airway and breathing were adequate. The SPO2 was 98%, and the pulses were palpable, but the child had tachycardia with PR: 130 and tachypnea RR: 30, Blood pressure : 90/50 mmhg . The glucometer blood sugar was 108 mg/dL, and the reflexes were normal but decreased. Other examinations were normal but level of consciousness was low and the child was lethargic and DTR in four limbs were decreased 3/5- 4/5. In the laboratory examination, most of the findings were normal, except for the white blood count, which was 15000.There was no symptoms in favour of infection or fever or trauma or previous hospitalization in the child. There was no underlying disease and the child’s growth and development were appropriate. History of drug or chemical use was also negative. The history of convulsions in the family and the child itself was negative.The possibility of poisoning with the exhaust gas of the motorcycle was brought up, but due to the lack of symptoms in the father, who was riding the motorcycle with the child, and the lack of problems in the previous motorcycle rides, it was ruled out. In a detailed physical examination of the child, the effect of two bites or a distance of one centimetre on medial side of the right ankle was seen, due to the lack of local pain and the simultaneous presence of neurological symptoms and relative loss of consciousness and sudden severe weakness and it was strongly suggested that the child was bitten by a snake from the family of Cobra.Treatment and Management:The child received supportive treatment, fluid therapy, pain relief, and 18 vial polyvalent antivenom. After 3 days, he was discharged from the hospital with normal tests and good general condition and normal examinations.Discussion:Snake bites are a common medical emergency in many parts of the world, especially in tropical and subtropical regions. The severity of the symptoms depends on the type of snake and the amount of venom injected. Children are particularly vulnerable to snake bites due to their smaller body size and less blood volume 1.The diagnosis of snake bite is usually made based on the characteristic bite marks and the presence of symptoms such as severe pain, swelling, and systemic effects.The treatment of snake bites includes supportive care, pain relief, and administration of antivenom. Early administration of antivenom is critical to prevent severe systemic effects and complications. It is important to identify the type of snake and administer the appropriate antivenom. In this case, the child received polyvalent antivenom, which is effective against multiple types of snakes. 2Snake bites can cause local, hematological and neurological systemic symptoms in children. Especially in cobra bites, neurological symptoms and impairment of acetylcholine release in synapses are more common. Therefore, sudden weakness and cranial nerve disorder and speaking disorder may occur. Other neurological and systemic disorders may be Ptosis, dyspnea, abdominal Pain , Diplopia ,Decreasing level of consciousness and vomiting.3-7In the case of the child in question, apparently, after riding the motorcycle, a snake, probably of the cobra type, wrapped around the base of the motorcycle and bit the child’s ankle, and the child suffered sudden weakness and impaired consciousness due to the neurological symptoms caused by the snake venom. In the initial examination of every child with impaired consciousness and sudden weakness, after initial stabilization and control of the airway, breathing and circulation, an examination and taking a quick history, the physician usually looks for differential diagnosis, including infectious, metabolic disorders, cardiovascular problems, trauma, phase Post-ictal convulsions and poisonings . Considering that the key to diagnosing this child’s problem was only the traces of two tick bites in the ankle area of the right leg, which was far from being diagnosed, it faced a challenge at first.Conclusion:1-Snake bites, especially cobra bites, can be one of the causes of weakness and reduced consciousness in children.2- Snake bite sometimes has unusual manifestations and diagnosis especially in children is difficult and requires careful attention and thorough examination.3- Snakebite in children is one of the most important medical emergencies and the medical staff must be familiar with it.
