•Anticholinesterase drugs such as edrophonium and neostigmine have also been recommended for the treatment of neuroparalytic snake envenomation. They should be given with atropine to take care of their harmful effect.

•Ten milligram of edrophonium or 0.5 mg of neostigmine should be given over 2–3 min with atropine (0.6 mg). In case the patient improves, he/she should be managed with neostigmine/atropine over the next 24–48 h.

•General ICU management—propped up nursing, ulcer prophylaxis, DVT prophylaxis, glucose control and appropriate sedation, and analgesia.

•Majority of patients usually recover within 48 h.

Step 11: Manage complications

•Patients who develop complications should be managed in the ICU till they are resolved (Table 71.3).

•Consider fasciotomy and wound debridement if local swelling and necrosis is severe enough to threaten viability of the limb and life.

Table 71.3 Admission to the ICU

Circulatory shock, cardiac dysfunction, pulmonary edema

Hemorrhage, hypovolemia

Coagulopathy, disseminated intravascular coagulation

Coma, seizures, intracranial hemorrhage

Cranial nerve dysfunction

Rhabdomyolysis, renal failure, hyperkalemia

Gastrointestinal bleeding

Respiratory failure

Anaphylaxis (component of venom or antivenom)

Step 12: Discharge from the ICU

The patient can be discharged from the ICU if the following conditions are present:

•Resolution of paralysis more than 24 h

•Fifty percent improvement in creatine phosphokinase and potassium

•Peak expiratory flow rate (PEFR) more than 100 L/min

•Normal oximetry and blood gas analysis on room air

•Normalization of BT, CT, CRT, and platelets more than 50,000

•Stable or improved urine output

Suggested Reading

1.Aggarwal R, Aggarwal AN, Gupta D, et al. Low dose of snake antivenom is as effective as high dose in patients with severe neurotoxic snake envenoming. Emerg Med J. 2005;22:397–9.

The article clearly demonstrates no advantage of high-dose antivenom therapy.

2.Punde DP. Management of snake-bite in rural Maharashtra: a 10-year experience. Natl Med J India. 2005;18:71–5.

3.Agrawal PN, Aggarwal AN, Gupta D, Behera D, Prabhakar S, Jindal SK. Management of failure in severe neuroparalytic snake envenomation. Neurol India. 2001;49(1):25–8.

It gives an overview of mechanical ventilation in snake envenomation.

4.Naphade RW, Shetti RN. Use of neostigmine after snake bite. Br J Anaesth. 1997;49:1065–8.

This article gives an overview of neostigmine in the management of neuroparalytic snake envenomation.