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 anti- snake
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
EMAN
AGEM
ENT
020
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HEART RATE
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CASE MANAGEMENT
0
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BP
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