Snakebite, scorpion and envenomation

Neuroparalysis: airway, ventilation and neostigmine

Reviewed Nov 2026·2 references
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Neurotoxic envenoming kills by respiratory failure, which is completely survivable with timely intubation and ventilation. Monitor bulbar function and breath count, intubate early, give ASV, and try atropine-neostigmine, which helps cobra bites far more than krait.

At the bedside

Timed steps
  1. 1

    Bedside

    Monitor

    Ptosis, neck flexion weakness, bulbar signs (nasal voice, pooling), single breath count < 20 or inability to complete sentences, paradoxical breathing; hourly.

  2. 2

    Early

    Airway

    Intubate for bulbar palsy with pooling or respiratory distress; bag-valve-mask ventilation during transfer if needed.

  3. 3

    Cobra especially

    Neostigmine trial

    Atropine 0.6 mg IV, then neostigmine 1.5 mg IV; improvement in ptosis/strength within 1 h indicates response – continue 0.5 mg every 30 min, then taper.

  4. 4

    Supportive

    Ventilate

    Lung-protective volume-control ventilation; sedation; DVT prophylaxis once coagulation normal. Krait paralysis may need days to weeks of ventilation.

  5. 5

    Clinical

    Wean

    Return of ptosis/neck strength, breath count, adequate cough; tracheostomy if prolonged.

Neostigmine trial (adult)

Neostigmine

IV
Dose
1.5 mg after atropine 0.6 mg; if response, 0.5 mg every 30 min

Child: atropine 0.05 mg/kg + neostigmine 0.04 mg/kg.

Red flag · call your senior now
Pooling of secretions or inability to lift the head: secure the airway.
Red flag
Fixed dilated pupils in krait bite do not indicate brain death – full recovery is possible.
Pitfall
Declaring brain death in a totally paralysed krait patient.
Pitfall
Neostigmine without atropine pre-treatment.
Pearl
Patients may be fully aware while paralysed: sedate and talk to them.

References

  1. 1

    Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. Standard Treatment Guidelines: Snakebite. New Delhi: MoHFW/NHSRC; June 2016

  2. 2

    World Health Organization Regional Office for South-East Asia. Guidelines for the management of snakebites. 2nd ed. New Delhi: WHO SEARO; 2016

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