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.