LETTER TO THE EDITOR

https://doi.org/10.5005/jp-journals-10071-23851
Indian Journal of Critical Care Medicine
Volume 25 | Issue 12 | Year 2021

Snakebite Mimicking Brain Death: Bedside Clues

Subramanian Senthilkumaran1https://orcid.org/0000-0001-5262-8367, Namasivayam Balamurugan2, Nanjundan Karthikeyan3, Ponniah Thirumalaikolundusubramanian4https://orcid.org/0000-0003-1814-8743

1Department of Emergency and Critical Care, Manian Medical Center, Erode, Tamil Nadu, India

2Department of Neurosciences, SIMS Chellam Hospital, Salem, Tamil Nadu, India

3Department of Emergency Medicine, Hamad General Hospital, Doha, Qatar

4Department of Internal Medicine, Trichy SRM Medical College Hospital and Research Center, Trichy, Tamil Nadu, India

Corresponding Author: Subramanian Senthilkumaran, Department of Emergency and Critical Care, Manian Medical Centre, Erode, Tamil Nadu, India, Phone: +91 9994634444, e-mail: maniansenthil@yahoo.co.in

How to cite this article: Senthilkumaran S, Balamurugan N, Karthikeyan N, Thirumalaikolundusubramanian P. Snakebite Mimicking Brain Death: Bedside Clues. Indian J Crit Care Med 2021; 25(12):1464.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Agarwal et al.1 have successfully managed three cases of snakebites who manifested features similar to brain death but were not true brain dead. Most likely these cases might have gone on to a status of locked-in syndrome (LIS). LIS is a status in which there is complete paralysis of voluntary muscles in all parts of the body except for those that control eye movements. Moreover, this condition makes an individual completely mute and paralyzed in a conscious patient.2 In these individuals, communication may be possible through eye movements.

Keywords: Anti-snake venom, ICU management of snake bite, Neurotoxic snake bite.

Dear Editor,

Agarwal et al.1 have successfully managed three cases of snake bites who manifested features similar to brain dead but were not true brain dead. Most likely these cases might have gone on to a status of locked-in syndrome (LIS). Locked-in syndrome is a status in which there is complete paralysis of voluntary muscles in all parts of the body except for those that control eye movements. Moreover, this condition makes an individual completely mute and paralyzed in a conscious patient.2 In these individuals, communication may be possible through eye movements.

We share some of the useful bedside clues below to distinguish true brain dead from LIS based on our previous experiences.3

  1. Movement of eyes and eyelids: Kindly observe the response for nonverbal communication in the form of upward eye movement “yes” and downward eye movement to say “no”, when these pseudo brain dead/locked-in syndrome cases are questioned in an understandable manner.4

  2. Preservation of frontalis muscle activity: In many of the pseudo brain dead/locked-in syndrome cases frontalis muscle tends to escape. In such cases, victims may respond to commands by way of constriction of frontalis muscles.

  3. Electrophysiological changes: Eliciting somatosensory-evoked potential responses in these victims with median nerve stimulation not only help the treating clinician to identify these cases but also give confidence to convince the patient’s relatives to continue the treatment.5

  4. Pupillary response:Mid dilated to constricted pupils may be seen when the eye is opened passively in such suspected cases, in contrast, to fully dilated pupils in brain dead cases.

Doctors have to exercise caution before declaring brain dead, as it has social, legal, emotional, ethical, and professional components. Hence, it is important to examine the cases thoroughly and observe for subtle manifestations/response to commands at the bedside before embarking any statements to the caregivers. Moreover, students of health sciences shall be taught and trained on these bedside clues to differentiate true brain dead from pseudo ones or LIS.

ORCID

Subramanian Senthilkumaran https://orcid.org/0000-0001-5262-8367

Ponniah Thirumalaikolundusubramanian https://orcid.org/0000-0003-1814-8743

REFERENCES

1. Agarwal S, Kaeley N, Khanduri S, Kishore N. Brain dead presentation of snake bite. Indian J Crit Care Med 2018;22(7):541–543. DOI: 10.4103/ijccm.IJCCM_318_17.

2. Senthilkumaran S, Balamurugan N, Nath Jena N, Thirumalai kolundusubramanian P. Locked-in syndrome in post snake bite: can it be unlocked? Trop Doct 2018;48(3):257. DOI: 10.1177/0049475518755274.

3. Senthilkumaran S, Balamurugan N, Menezes RG, Thirumalai kolundusubramanian P. Snake bite and brain death-cause for caution? Am J Emerg Med 2013;31(3):625–626. DOI: 10.1016/j.ajem.2012.11.033.

4. Senthilkumaran S, Ananth C, Menezes RG, Thirumalai kolundusubramanian P. Snake bite and brain death–handle with care. Indian J Anaesth 2015;59(5):333. DOI: 10.4103/0019-5049.156906.

5. Sethi PK, Rastogi JK. Neurological aspects of ophitoxemia (Indian krait)–a clinico-electromyographic study. Indian J Med Res 1981;73:269–276. PMID: 7239611

________________________
© The Author(s). 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.