Bedside intubation with AMBU bag ventilation improves outcome for respiratory muscle paralysis in neurotoxic snake bite: a case report

Abstract

Neurotoxic snake envenomation can rapidly produce neuromuscular paralysis, bulbar dysfunction and life-threatening respiratory failure. Prompt airway protection, antivenom administration and ventilatory support are essential; however, mechanical ventilators are frequently unavailable in rural and resource-limited healthcare facilities. A 20-year-old man from rural Bangladesh presented approximately four and a half hours after a suspected Wall's krait bite to his right foot. His arrival was delayed by initial treatment from a traditional healer. On admission, he had altered consciousness, bilateral partial ptosis, excessive salivation and a positive broken-neck sign, indicating severe neurotoxicity. Although his initial oxygen saturation was 98% on room air, he rapidly developed worsening breathlessness, reduced consciousness, severe bradycardia and oxygen desaturation to 80%. Emergency bedside endotracheal intubation was performed, and ventilation was maintained manually using an AMBU bag. Neostigmine with atropine was administered, followed by three doses of polyvalent antivenom comprising a total of 30 vials. The patient was transferred approximately 55 km to a tertiary-care intensive care unit while continuous AMBU-bag ventilation was maintained. He subsequently received mechanical ventilation for approximately 72 hours. His neurological and respiratory functions gradually recovered, and he was successfully extubated on the fourth day. He remained clinically stable and was discharged without apparent neurological or respiratory complications. Immediate bedside intubation and continuous AMBU-bag ventilation can provide a lifesaving bridge to definitive mechanical ventilation in patients with neurotoxic snakebite-induced respiratory paralysis. Training healthcare professionals in manual ventilation and ensuring the availability of basic airway equipment may substantially reduce preventable snakebite mortality in resource-limited settings.