alexa Sea Snake Bites Resulted in a Mimic of Brain Death | OMICS International
ISSN: 2161-0495
Journal of Clinical Toxicology

Like us on:

Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Sea Snake Bites Resulted in a Mimic of Brain Death

Feng Li1, Kepeng Li2, Binbin Sun3, Shengjian Tang4 and Fangjun Liu4*

1Department of Health Care, Unit 3; Affiliated Weifang People's Hospital, Weifang Medical University, Weifang, Shandong, China

2Department of Intensive Care, Affiliated Weifang People's Hospital, Weifang Medical University, Weifang, Shandong, China

3Department of Diagnostic Ultrasound, Affiliated Zhucheng People’s Hospital, Weifang Medical University, Zhucheng, China

4Hospital for Plastic Surgery, Weifang Medical University, Weifang, Shandong, China

*Corresponding Author:
Fangjun Liu
WEIFANG Medical University, 288 Sheng Li East Street
Weifang, Shandong, P.R. China
Phone: +86 13054772295
Fax: 001-208-4602411
Email: [email protected]

Received date: 16 April, 2015 Accepted date: 06 May, 2015 Published date: 14 May, 2015

Citation: Feng Li, Kepeng Li, Sun B, Tang S, Fangjun Liu (2015) Sea Snake Bites Resulted in a Mimic of Brain Death. J Clin Toxicol 5:250. doi: 10.4172/2161-0495.1000250

Copyright: © 2015 Feng Li, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Clinical Toxicology

Abstract

A 69 year old man with deep coma presented after an alleged history of sea snake bite. Patient presented with irresponsiveness to painful stimuli, complete ptosis, internal and external ophthalmoplegia. He was given continuous ventilator support despite signs of brain stem dysfunction. On admission day 20, the patient was weaned off ventilator and discharged from the hospital. Whenever treating patients who were suspected with a history of snake bite, an emergency physician should always consider severe envenomation in the differential diagnosis of acute neuroparalytic syndrome, which may avert the unfortunate misdiagnoses of brain death.

Keywords

Brain death; Snake bites; Snake envenomation; Ophthalmoplegia

Introduction

Brain death is defined as the function loss of cerebrum and brain stem, resulting in coma, no spontaneous respiration and irresponsiveness of all brain stem reflexes [1]. However, a coma with symptoms and signs largely consistent with brain death may also occur following a fatal sea snake envenomation. This mimic of brain death presented in emergency room could pose a dilemma to emergency physicians regarding continuation of therapy [2].

Case Presentation

A 69 year old man with comatose presented to our emergency department from a local community hospital. He was allegedly bitten by a sea snake (later confirmed by the patient after his recovery) on his left inner ankle while walking along the shore of China yellow sea in the morning. He passed out during his walking back home, and was urgently taken to a community hospital. He was intubated, put on ventilator support, and was given one dose of anti snake venom therapy (unknown dose) before referring to our hospital along with a provisional diagnosis of sea snake bite with suspected brain death.

On examination, the pulse was 100 beats per minutes, the blood pressure was 100/70 mm Hg, oxygen saturation (SaO2) was 70% and body temperature was 98.1°F. Patient presented with deep coma, irresponsiveness to painful stimuli, complete ptosis, internal and external ophthalmoplegia. There was no deep tendon and plantar reflexes after given the eliciting stimulus. The Glasgow Coma Scale Score was E1VTM1. He had bilateral fixed dilated pupils measuring about 6 mm in diameter, which were not reacting to the light stimulus. His breathing was quick and shallow with apnea. He had grade 0 power in all four limbs. Three clean and typical fang marks were found on his left inner ankle with no signs of bleeding or swelling. He became anuric upon catheterization.

Under endotracheal intubation and some spontaneous respiratory effort, the patient was being ventilated via a mechanical ventilator on a synchronized intermittent mandatory ventilation (SIMV) mode. He was treated with polyvalent anti snake venom therapy at a dose of 100 ml stat, followed by intravenous (IV) injection of Furosemide 20 mg and Dexamethasone 10 mg, and infection prophylaxis together with supportive cares. Over a period of 48 hours, both pupils have constricted back to normal with voluntary eye movements, and the oxygen saturation improved. However, he still had grade 0 power in his four limbs, and showed no spontaneous respiratory movements and no responses on tracheal suctioning. The patient went onto full ventilator support along with continuous supportive cares. During the next 4 days, the patient presented gradual neurologic recovery with a response to verbal commands by moving his limbs and raising the eyebrows. At 10 days after sea snake bites, the patient presented with acute complication of gastrointestinal stress ulcer bleeding, and was treated with medicine to protect the gastric mucosa, inhibit gastric acid secretion along with supportive therapy. He was weaned off the ventilator and extubated after 15 days of ventilation. The patient was breathing well and had complete neurological recovery, and discharged on the 20th day of admission in a stable condition.

Discussion

Snake toxins vary greatly in their functions, among which two broad classes of toxins are neurotoxins (mostly found in elapids) and hemotoxins (mostly found in viperids) [3,4]. Polypeptide neurotoxins in snake venoms can cause muscle paralysis by binding to the postsynaptic portion at the neuromuscular junction to produce a competitive or noncompetitive nicotinic acetylcholine receptor blockade, or affecting the mode of neurotransmitter release at the presynaptic motor nerve endings to cause irreversible loss of functions; hence, clinical recovery occurs slowly and only with the formation of a new neuromuscular junctions [5-7].

Usually, little or no pain is involved in sea snake bites, and it is rare for any local signs to be presented after envenoming [8]. However, a delayed onset of severe envenomation resulting in respiratory muscle weakness might occur due to the absorption of neurotoxin into wound bed, which apparently is a major component of elapids and some sea snake venoms [5,9,10]. Neuromuscular paralysis is the predominant toxic effect of sea snake venom, which can cause a rapid development of respiratory failure (as in the present case). Together with the sequelae of cardiac arrest and renal failure, respiratory paralysis will more likely result in the hypoxic effect on the brain that eventually lead to a mimic of brain death [5]. Brain death implies the irreversible function loss of cerebrum and brain stem, which clinically presented as the absence of pupillary light, corneal, oculocephalic, oculopharyngeal, oculovestibular, and respiratory reflexes [5]. Absent cerebral functions are manifested by occurrence of deep coma and both internal and external ophthalmoplegia as seen in this case, which would misdiagnose the brain death in many ways [2]. This mimic of brain death can falsely guide an emergency physician to consider withdrawing the ventilator support, which has become mostly trustful to efficiently wear off the effects of venom even without assistance of anti-snake venom (ASV) [5,10]. Although this option of solely giving mechanical ventilation support is only acceptable to cases where there is no ASV or dilemma in diagnosis.

In conclusion, it is vitally important that severe snake envenomation shall always be considered in the differential diagnosis of acute neuroparalytic syndrome when an emergency physician is accepting comatose patients, especially if associated with a known suspect of sea snake bites in a coastal area. This care will avert the unfortunate misdiagnoses of brain death, which often pose a dilemma to the emergency physicians regarding continuation of therapy.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Article Usage

  • Total views: 12030
  • [From(publication date):
    June-2015 - May 24, 2018]
  • Breakdown by view type
  • HTML page views : 8260
  • PDF downloads : 3770
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2018-19
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2018 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
Leave Your Message 24x7