Methods (Differential diagnosis, investigations and treatment)
We prepared the antivenom, injectable anti-neurotoxic drugs (Neostigmine), atropine, adrenalin, chlorpheniramine, and hydrocortisone. In the meantime, within 10-15 minutes of clinical examination, patients’ breathlessness increased and became unconscious. Oxygen saturation suddenly fell to 40%, and severe bradycardia (heart rate <40b/min) developed. Then the patient was intubated at the bedside with the help of an anesthesiologist and ventilation was maintained with an Ambu bag, then the 1st dose of the polyvalent snake antivenin containing ten vials was given by intravenous infusion with ready of the bed-side anti-anaphylactic measures. Injectable subcutaneous Neostigmine 2.5 mg along with intravenous Atropine 1.2 mg was given for neurotoxic features. As there was no satisfactory improvement after 1st dose, we gave the 2nd dose of antivenom containing another 10 vials after 1 hour of 1st dose. We made a call to the Intensive Care Unit (ICU) of Rangpur Medical College Hospital (RpMCH) for a bed and then referred to RpMCH for ICU support with maintaining ventilation by Ambu bag which was 55 km away from Nilphamari.
The patient was received at the ICU of RpMCH on 9thOctober 2023 and they continued the treatment for venomous snake bite with neurotoxicity and respiratory failure. Investigation reveals complete blood count- Hemoglobin 13.6 gm/dl, Erythrocyte sedimentation rate 12 mm in 1st hour, total white blood cell count 8.6×109/L, neutrophil 66%, platelet count 261×109/L. Liver function tests showed serum alanine aminotransferase 24 IU, serum aspartate aminotransferase 45 IU, Prothrombin time 15 sec, Activated Partial Thromboplastin Time 26 sec, serum Creatinine 1.00 mg/dl, serum Cardiac troponin- I <0.01 ng/mL, random blood glucose was 122 mg/dL. Urine analysis showed normal physical, biochemical, and microscopic examination and its amount was 2300 mL/day. They managed the patient with synchronized mechanical ventilation and subcutaneous injection of Neostigmine 3mg and intravenous atropine 1.2mg 4 hourly along with other supportive management. The 3rd dose of polyvalent snake antivenin containing another 10 vials were administered intravenously with ready of the bedside anti-anaphylactic measures on the same day. The patient was maintaining mechanical ventilation for the next 72 hours.