No abstract

Learning Objective: Recognize nonspecific and delayed presentations of malignant hyperthermia (MH). Case: A 22-year-old male was admitted with drug overdose. He was found to be afebrile and drowsy with shallow respirations in the ER and was intubated for airway protection. CXR showed a right lower lobe infiltrate. Five hours later in the MICU, he was noted to be flushed and tachycardic with a temperature of 104.8ЊC. Cultures were obtained; Tylenol and antibiotics administered with a cooling blanket applied later. A review of medications given in the ER revealed succinylcholine. A CPK level of 37,789 U/L, elevated urine myoglobin, and high fever suggested malignant hyperthermia with rhabdomyolysis. The patient became normothermic after two doses of dantrolene. He was counseled about MH on discharge. Discussion: MH is a rare genetic disorder due to the mutations of ryanodine receptor in skeletal muscles. It usually occurs after administration of inhaled anesthetics or depolarizing muscle relaxants. Clinical features include marked fever, muscle rigidity, metabolic acidosis, rhabdomyolysis and hemodynamic instability. Hyperthermia develops within minutes to hours following exposure to disease-inducing medications. Many of the early signs are nonspecific and can mimic those of other etiologies. In our case, delayed diagnosis of MH was due to not only late-onset hyperthermia, but also initial attribution of his fever to aspiration pneumonia. Treatment includes discontinuation of triggering agents, oxygenation and use of dantrolene along with cooling measures. This case demonstrates the variability of presentation and underscores the need for continuous monitoring whether in a surgical or medical setting.

Snakebite, though considered to be occurring primarily in rural settings, may develop complications requiring intensive care. Reported here are 164 serial cases of snake poisoning managed at the ICU of our hospital over a five-year period. Snake was identified in 72 patients (krait-24, cobra-3, Russell viper-16, saw-scaled viper-29), but could not be identified in 96 cases. The time lapse between bite and first treatment received ranged from 1-6 hours. Patients were transferred to tertiary care centers with development of complications like severe bleeding, oliguria, anuria or neuromuscular weakness with the time range being 2 hours to 5 days. Out of 164 patients, 105 presented with vasculotoxic complications and 59 with neurotoxic complications. Patients with vasculotoxic snakebite had local swelling (100%), ecchymosis(58%), cellulitis (44%), local bleeding (54%) and gangrene of digits (5%). Systemic envenomation manifested as defective coagulation (100%), spontaneous systemic bleeding (78%), hypotension (24%), oliguria (42%), thrombocytopenia (52%), presence of fibrin degradation products (36%), low fibrinogen (26%) and intravascular hemolysis (42%). Average time required for reversal of bleeding diatheses was 2.44 days. Requirement of anti-snake venom (ASV) being 4-100 vials. 51 patients were given fresh frozen plasma and 26 patients required blood transfusion. Acute renal failure developed in 24 patients of which 16 patients required dialysis. Patients with neurotoxic snake bite had ptosis (100%), dysphagia (89%), weakness in limbs (64%), respiratory distress (75%), loss of consciousness (20%), drowsiness (38%), and convulsion (9%).Time interval for manifestation of symptoms was 10 minutes to 8 hours. 32 patients had hypoxia and/or hypercapnea. 34 patients required ventilatory support (50%) and range of ventilatory support was 16 hours to 15 days. ASV required was between 4-34 vials and neostigmine was between 2-192 mg. Unusual features noticed were in the nature of hematomyelia, massive left upper limb necrosis requiring amputation, resistant ventricular arrhythmia, myocarditis with pulmonary edema. 4 patients developed anaphylactic reaction to ASV and 2 patients developed severe cholinergic crisis following neostigmine injection. Despite the critical care management 12 (7.3%) patients expired, 8 vasculotoxic (7.6%) and 4 neurotoxic (6.8%) due to various etiologies.