Locked-in Syndrome Following a King Cobra (Ophiophagus hannah) Envenomation

The incidence of envenoming from king cobra,  Ophiophagus hannah  in human is relatively rare. Its venom  acts on the postsynaptic region of the neuromuscular junction  causing  descending flaccid  paralysis.  Locked-in  syndrome  is a clinical state of inability to provide motor response  in a conscious patient.  Many reported cases   of  locked-in   syndrome   following  neurotoxic  snake-bite   mimics   brain death.  We report  a case  of a middle  aged  man  who  presented with progressive neurological deficit following a king cobra bite over his right arm. He had local and systemic neurotoxic envenoming.  His condition deteriorated, and was intubated and  ventilated  in the emergency department. He received  a total of  33 vials of the Ophiophagus hannah  monospecific antivenom and  subsequently recovered well with no neurological deficit. Retrospectively,  he was able to recall the events and  while  he was lying paralysed  and  intubated under  minimal  sedation  in the intensive  care  unit.  He  described it as a terrifying  and  painful  experience. This case highlights the rare presentation of locked-in  syndrome  following a systemic envenoming from a king cobra bite. It is important to differentiate neurotoxic snake envenoming lock-in  syndrome  from  brain  dead.  Patients  are unable  to respond to physical  pain  and  require  adequate analgesia. A patient  suffering this highly distressing experience may require psychological support.