Gullien Barre Syndrome Following Snake Bite

8/3/2019 Gullien Barre Syndrome Following Snake Bite

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Guillain Barre Syndrome Following Snake BiteGuillain B

arre Syndrome Following Snake Bite

Dr. M. Chandrasheker

Head Of The Department

Dept. Of Anesthesiology &

Critical Care

Dr. Y. Samyukta (P.G.)

OSMANIA MEDICAL

COLLEGEDr. S. Mathews

Asst. Professor

OSMANIA MEDICALCOLLEGE.


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CASE HISTORY

A sixteen year old female alleged to

have been bitten by snake on 25/08/11

at 2:00am presented with chief

complaints of mild pain on right hand.


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CASE HISTORY

After preliminary examination and

management in private hospital at

SHAMSHABAD, she was referred toOsmania General Hospital and reached

OGH at 4:00 am, along with dead

snake(Krait)


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CASE HISTORY

On examination in RICU patient was

conscious, mild ptosis present and afebrile.

Pulse rate - 74/min

Blood pressure- 90/60 mmHg

Heart S1+, S2+

Lungs - Clinically clear.


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CASE HISTORY

After confirmation of snake bite, Immediately

she was administered 100ml of antisnake

venom in 100 ml of 0.9% saline(loading dose)along with myopyrrolate infusion 2ml/hr

(neostigmine2.5mg + glycopyrrolate 0.5 mg per

amp.) with antibiotic coverage.


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CASE HISTORY

After 1 hr..

Patient was unconscious and not

responding to deep painful

stimuli, Glasgow Coma Scale 3

{E1 M1 V1. }

Patient was intubated and

started mechanical ventilation


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CBPHb - 10.8 gm/dl

TLC - 15,200 cell/mm3

Platelets - Adequate

Blood group - O +ve

Random blood sugar - 60 mg/dl

Renal function tests

Blood urea - 36 mg/dlSerum creatinine - 0.9 mg/dl

CASE MANAGEMENT-INVESTIGATIONS


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CASE MANAGEMENT-INVESTIGATIONS

Serum electrolytes

Sodium - 132 meq/dl

Potassium - 4 meq/dl

Coagulation profile

20 min(WBCT) Whole blood clotting time-clotted

Bleeding time - 2 min 25 sec

Clotting time - 4 min 35 sec

Prothrombin - 16.1 sec

INR - 1.27

Chest X Ray - NAD

ECG Normal Sinus Rhythm

ABG - Normal


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CASE MANAGEMENT

During First Six days.

Ventilatory mode: Volume Assist Control mode

Patient received

4 vials ASV 6th hrly (total 24 vials)

Inj. Myopyrrolate Infusion ( 2 ml/hour)

Broad spectrum antibiotic coverage.


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CASE MANAGEMENT

During First Six days.

VITALS:Patient unconscious, E1 M1 V1

Pupils fixed and dilatedBlood pressure :

Systolic - 130-74 mmHg

Diastolic - 90-55 mmHg

Pulse Rate - 92-123/minUrine Output -1200-1300ml /day


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CASE MANAGEMENT

On 7

th

DAY Patient regained consciousness

QUADRIPARESIS noted

Patient on Ventilator

AfebrilePulse rate - 140/min

Blood pressure - 106/55 mmHg

Heart and lungs - NAD

Urine output - 4200 ml/day


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CASE MANAGEMENT

On examination of CNS;Higher functions - Normal

Cranial nerves - Normal

Sensory system - Normal

Motor systemTone: Hypotonia in all 4 limbs

Power: Upper and lower limbs showed 0/5 proximallybut 0/5 distally.

Reflexes

Plantar response - Absent

Deep Tendon Reflexes - Absent


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CASE MANAGEMENT

CRITICAL ILLNESSNEUROPATHY

GULLIAN BARRE

SYNDROME

NEUROPHYSICIAN OPINION


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CASE MANAGEMENT

From 8th to 11th DAYPatient conscious

Febrile (100F -102F)

Tracheostomy on 8th day

Ventilatory mode SIMV from 11th day

Pulse Rate 86/min 140/min

Blood pressure systolic 100-110 mmHg

A complete blood count, comprehensive serumbiochemical analysis within normal limits

(Along with tip and urine cultures)


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CASE MANAGEMENT

From 8th to 11th DAYCNSTone: Hypotonia in all 4 limbsPower: LT,RT UL

Proximal 1/5Distal 3/5

LT, RT LLProximal 0/5Distal 1/5

Plantar response -ABSENTDeep Tendon Reflexes - ABSENT.

Polyuria > 4L/day Continued for 3 days.On 9th day Inj. Vasopressin 20U s.c. was givenempirically after sending investigations , to rule out DI


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CASE MANAGEMENT

ResolvingATN

CENTRAL

DIABETESINSPIDUS

POLYURIA


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On 8th day

Urine osmolality 536 osm/kg

Serum osmolality 318 osm/kg

On 11th day

Urine osmolality 483 osm/kg

Serum osmolality 292 osm/kg

Urine osm>300osm/kg

CASE MANAGEMENT

Uosm / Sosm > 1.3


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Serum Cortisol 22.24 g/dL (Fasting 8 A.M)

(Normal Values : 5-20 g/dL)

Thyroid Profile

T4 - 7.9 g/dl (5-11 g/dl)

T3 - 126 ng/dl (95-190 ng/dl)TSH - 1.16 U/ml (0.4-6 U/ml)

24 hrs Urine Potassium 97 mEq/day (25-120 mEq/L/day)

24 hrs urine creatinine 995 mg/day (1-2 gm/day)

MRI and CT BRAIN normal.

CASE MANAGEMENT


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CASE MANAGEMENT

Resolving

ATN

Central

Diabetes

Insipidus

Treatment :

Input aimed to maintain CVP 8 mmHg

with Crystalloids, colloids, total parental

nutrition.


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CASE MANAGEMENT

From 8th to 11th DAY

TREATMENT

Nutritional support (TPN)

Tracheostomy tube careBowel and bladder care

Physiotherapy

Antibiotics

SedationPsychological counseling.


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CASE MANAGEMENT

From 12th

to 20th

dayInvestigations

A complete blood count, comprehensive serumbiochemical analysis within normal limits

CSF analysis On 12th day

Protiens: 54mg/dl

Sugars: 85mg/dl

Cells 4 cells/mm3 (100% Lymphocytes)

Nerve conduction studies on 12th day

Demyelination with secondary axonaldegeneration


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CASE MANAGEMENT

From 12th to 20th day

TREATMENT

Plasmapheresis is the treatment of choice.

Initially 3 sessions in 10 days period.

Later 4 sessions over 2 weeks.

Injection methylprednisolone 1 gm in 100 ml NSIV for 3 days

Nutritional support (enteral feeding, initially

nasogastric feeding and PEG was done on 15th day.


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CASE MANAGEMENT

From 12th to 20th day

TREATMENT(contd..)

Tracheostomy tube care

Bowel and bladder carePhysiotherapy

Antibiotics

Psychological counseling.


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CASE MANAGEMENT

From 12th to 20th DAYPatient conscious

Afebrile

Initially on CPAP later T-piece

PULSE RATE 98/MIN 125/min

Blood pressure systolic 96 114 mmHg

After the third Plasmapheresis, the patientnoticed increased strength


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CAS

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CASE MANAGEMENT

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BLOOD PRESSURE

SYSTOLIC PRESSURE DIASTOLIC PRESSURE


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CASE MANAGEMENT

At 5 weeks after admission

Power improved

LT, RT UL

Proximal 3/5

Distal 3/5

LT, RT LL

Proximal 2/5

Distal 3/5


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GB SYN

SNAKE

BITE

TT

ASV

CONCLUSION


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CONCLUSION

GBS can occur following a snake bite, after theadministration of tetanus toxoid orantisnakevenom but, due to poor documentationand reporting, the actual incidence might be much

more than the reports in the literature suggest.

There have been cases where clinical, biochemical,and electrophysiological studies were allsuggestive of GBS, without the history of any

antecedent factor other than snake bite ,ASV oradministration of tetanus toxoid.


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CONCLUSION

In our patient also, considering thetemporal association of the symptoms withthe history of snake bite and the

administration of antisnake venom / tetanustoxoid, as well as the absence of any otherantecedent event, we considered the GBS asbeing secondary to one of these factors


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CASE REPORTS

Till date only 2 cases reported.Arch Phys Med Rehabil. 1996;77:72931 Chuang TY,Lin SW, Chan RC. Bungarus multicinctus. The patientregained consciousness after 8 days. At 3 weeks

after admission, patient was weaned. Total of 5sessions of plasmapheresis

Ann Indian Acad Neurol. 2010 Jan-Mar; 13(1): 6768. Abhishek Srivastava, A. B. Taly,1 AnupamGupta,2 Aumir Moin,3 and T. Murali2 Kokilaben

Dhirubhai Ambani Hospital and Medical ResearchInstitute, Mumbai in 2010 .bitten by snake 6 weeksback. no Ventilatory support.Plasmapheresis no?


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4. Bakshi R, Graves MC. Guillain-Barr syndromeafter combined tetanus-diphtheria toxoid

vaccination.J Neurol Sci. 1997;147:2012.

6. de Letter MA, Visser LH, van der Mech FG, AngW, Savelkoul HF. Distinctions between critical illness

polyneuropathy and axonal Guillain-Barr syndrome.J Neurol Neurosurg Psychiatry. 1999;67:1289

7. Tuttle J, Chen RT, Rantala H, Cherry JD, RhodesPH, Hadler S. The risk of Guillain Barr Syndrome

after tetanus-toxoid-containing vaccines in adultsand children in the United States.Am J Public Health.1997;87:20458.

REFERENCES


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Newton N, Jr, Janati A. Guillain-Barr syndrome aftervaccination with purified tetanus toxoid. South Med

J. 1987;80:10534.

REFERENCES


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AT PRESENT..Patient is on metal tracheostomy tube.

POWER

3/5 in all 4 limbs

HOPE THE BEST

FOR THIS PATIENT.


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Thank You

Gullien Barre Syndrome Following Snake Bite

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