Phase 1: initial manifestations, duration and treatment | Phase 2: neurological symptoms and signs before treatment, duration and treatment | Phase 3: neurological symptoms and signs after treatment, duration and treatment |
Onset: between 5 and 60 min after the accident: local small bleeding, mild local pain and paraesthesia, and radiation of pain and local myalgia. Transferred to the nearest hospital. | Onset: 1 hour after the bite, the patient showed bilateral palpebral ptosis, diplopia and dysarthria. Snake identification, toxicological centre contacted, antivenom requested and toxicologist informed. 2 hours after the bite, she experienced dysphonia, difficulty walking and decreased strength in the upper limbs, generalised myalgia and muscle tremors, and headache and dizziness. Rest with immobilisation of the patient, local cleansing and antibiotic therapy (ceftriaxone 1 g intravenously daily) were instituted. A local incision with suction was out of therapeutic range (90 min post bite). Tetanus toxoid 0.5 mL was also given intramuscularly. Acetaminophen 1 g intravenously three times daily was given. 3–6 hours after the bite, the sensorium was clear and the cranial and peripheral nerve functions were intact. However, there was severe difficulty speaking, dysphagia and profuse sialorrhoea. She developed mild shortness of breath. Oxygen therapy was given at 8 L/min via a face mask. The patient was put on NPO and a nasogastric tube was inserted. Nebulisations every 6 hours with epinephrine 5 mg were given. Pantoprazole 40 mg intravenously daily was given. 2 L of dextro-saline intravenous fluid was given daily for 2 days. Transferred to the ICU for close neurological and respiratory monitoring, possible intubation and ventilatory support. Constant mouth suctioning of secretions was instituted. ABG done was normal. A skin test for sensitivity to coral snake antivenin (Laboratorios Probiol, Colombia) was negative. This antivenom was manufactured using Micrurus mipartitus venom. One vial of this antivenom should neutralise at least 1 µg of the coral snake venom. | 6–18 hours after the bite, antivenom was given (1 vial every 4 hours) intravenously. No improvement in the myasthenic syndrome was noticed. Constant mouth suctioning of secretions continued. The sensorium was clear and the cranial and peripheral nerve functions were intact. The shortness of breath continued but no deterioration was seen. Nebulisations every 6 hours with epinephrine 5 mg continued. 18–34 hours after the bite, antivenom was given (1 vial every 4 hours) intravenously. No improvement in the myasthenic syndrome was noticed. Constant mouth suctioning of secretions continued. The sensorium was clear and the cranial and peripheral nerve functions were intact. The shortness of breath continued but no deterioration was seen. Nebulisations every 6 hours with epinephrine 5 mg continued. ABG was normal. Rapid and progressive recovery of the myasthenia: atropine-neostigmine therapy was administered. A progressive recovery of the patient was observed. Full recovery: atropine-neostigmine therapy was repeated half an hour later. Improvement continued. Full recovery was achieved. Discharged from the ICU: discharged from ICU 2 days from admission. Intravenous fluid was discontinued. The patient was placed on normal diet after removing NSG tube. Parenteral antibiotic, pantoprazole and paracetamol were discontinued. Discharged from the hospital: discharged on the fifth day postadmission, with improvement of the myasthenia, but still showing mild palpebral ptosis. Cefuroxime was given at 500 mg orally two times per day for 5 days. Clinical follow-up: moderate motor weakness lasted 7 days, and ptosis (figure 1D), ageusia and fatigability lasted 10 days. Transitory loss of taste lasted approximately 18 days. |
ABG, arterial blood gas; ICU, intensive care unit; NPO, nothing by mouth; NSG, nasogastric.