›Tick antitoxin serum
›Canine-derived hyperimmune serum has been used in severe human Ixodes holocyclus paralysis on a named-patient basis; it is not a licensed human product and benefit is unproven
›High risk of anaphylaxis and serum sickness — give only in a resuscitation area with adrenaline drawn up, under specialist and poisons-centre guidance, with informed consent
›Administer as a graded infusion per the product protocol, with observation every 15 minutes and a slowed or stopped infusion for any reaction
›Adrenaline 0.5 mg intramuscularly (0.5 ml of 1 mg/ml) for anaphylaxis, repeated every 5 minutes as needed; paediatric dose 0.01 mg/kg to a maximum of 0.5 mg
›Consult the regional poisons information centre for current advice on antitoxin availability and dosing
Airway and ventilatory support
›Escalating support
›Supplemental oxygen titrated to SpO2 94 to 98 percent, or 88 to 92 percent in chronic hypercapnic lung disease
›Avoid unnecessary high inspired oxygen — hypercapnia, not hypoxia, is the early problem and high flow can mask a falling vital capacity
›Airway positioning, suctioning, and chest physiotherapy for secretions
›Non-invasive ventilation only as a short bridge in a cooperative patient who can protect the airway
›Indications to intubate
›Forced vital capacity below 20 ml/kg, negative inspiratory force weaker than -30 cmH2O, or a fall over 30 percent from baseline
›Rising PaCO2 above 45 mmHg, refractory hypoxaemia, aspiration, or inability to clear secretions
›Do not wait for apnoea or a crash — intubate semi-electively on the trend
›Ventilator and weaning
›Lung-protective settings with adequate expiratory time; expect a short ventilation course in Dermacentor disease
›Wean when vital capacity is above 20 ml/kg, negative inspiratory force is stronger than -30 cmH2O, cough is effective, and secretions are controlled
›Diaphragm ultrasound and a spontaneous breathing trial before extubation
Rapid sequence intubation
›Prepare semi-electively on the respiratory trend, not at the point of apnoea
›Pre-oxygenate fully — a weak diaphragm gives little apnoea reserve
›Anticipate prolonged and potentiated blockade from a non-depolarising agent at a toxin-impaired junction
›Ketamine
›Ketamine 1.5 to 2 mg/kg IV push
›Haemodynamically neutral induction agent; reduce to 1 mg/kg IV in shock or catecholamine depletion
›Verify against current pediatric guideline before use
›Etomidate
›Etomidate 0.3 mg/kg IV push as an alternative induction agent
›Single-dose adrenal suppression is rarely clinically important; avoid repeat dosing
›Verify against current pediatric guideline before use
›Rocuronium
›Rocuronium 1.2 mg/kg IV for paralysis
›Preferred neuromuscular blocker; effect may be prolonged and potentiated by the toxin-impaired junction
›Keep sugammadex 16 mg/kg IV available for immediate reversal of a rocuronium dose
›Verify against current pediatric guideline before use
›Suxamethonium
›Suxamethonium 1.5 mg/kg IV only if rocuronium is unavailable
›Relatively contraindicated once the patient has been immobile or denervated beyond about 72 hours, because of exaggerated potassium release and risk of hyperkalaemic arrest
›Check a recent potassium in mmol/l and be ready to treat hyperkalaemia with calcium if it must be used
›Verify against current pediatric guideline before use
Supportive intensive care
›Venous thromboembolism prophylaxis for the immobile patient
›Enoxaparin 40 mg subcutaneously once daily, or 30 mg every 12 hours; reduce to 30 mg once daily if creatinine clearance is under 30 ml/min
›Unfractionated heparin 5000 units subcutaneously every 8 to 12 hours if renal failure or an imminent procedure
›Intermittent pneumatic compression in children and whenever anticoagulation is contraindicated
›Eye and skin care
›Lubricating eye drops every 2 hours and ointment with lid taping overnight for incomplete eye closure from facial weakness
›Pressure-area care, repositioning every 2 hours, and a pressure-redistributing mattress
›Bladder and bowel
›Intermittent or indwelling catheterisation for retention, with monitoring of post-void residuals
›Bowel regimen with a stimulant laxative such as senna plus a stool softener to prevent ileus and constipation
›Nutrition and aspiration prevention
›Nil by mouth while bulbar weakness or an unsafe swallow is present; nasogastric feeding once the airway is secured or the swallow is cleared
›Head of the bed elevated to 30 degrees
›Rehabilitation
›Early physiotherapy, passive range of motion, and splinting to prevent contractures
›Occupational and speech therapy as bulbar and limb function return
Symptom control and co-transmitted infection
›Analgesia and antipyresis for bite-site discomfort or incidental fever
›Paracetamol
›Paracetamol 1000 mg orally or IV every 6 hours in adults; maximum 4000 mg in 24 hours
›Children 15 mg/kg every 6 hours; maximum 75 mg/kg per day not exceeding 4000 mg per day
›Cap at 3000 mg per day in adults under 50 kg or with frailty, hepatic impairment, or malnutrition
›Ibuprofen
›Ibuprofen 400 mg orally every 8 hours with food in adults; maximum 1200 mg per day without specialist advice
›Children 10 mg/kg every 6 to 8 hours; maximum 40 mg/kg per day
›Avoid in dehydration, renal impairment, active peptic ulcer disease, or pregnancy from 20 weeks
›Empirical therapy for suspected co-transmitted rickettsial or ehrlichial infection (fever, rash, headache, cytopenias)
›Doxycycline
›Doxycycline 100 mg orally or IV every 12 hours in adults
›Children 2.2 mg/kg every 12 hours; maximum 100 mg per dose
›First-line at any age for suspected Rocky Mountain spotted fever — short courses do not stain paediatric teeth, and treatment should not wait for confirmatory testing
›Continue for at least 3 days after defervescence, usually 5 to 7 days in total
›Tetanus prophylaxis
›Update a tetanus-containing vaccine if the bite wound is dirty and the last dose was over 5 years ago, or over 10 years for a clean wound
›Antihistamine for a local bite reaction
›Cetirizine 10 mg orally once daily in adults and children 12 years and older; 5 mg once daily for children 6 to 12 years
Therapies with no role or potential for harm
›Intravenous immunoglobulin and plasma exchange
›Both are ineffective — tick paralysis is toxin-mediated, not antibody-mediated
›Reserve the standard regimens (intravenous immunoglobulin 0.4 g/kg per day for 5 days, or plasma exchange over 5 sessions) for cases where Guillain-Barre syndrome is confirmed or strongly favoured after a negative tick search
›Corticosteroids
›No benefit in tick paralysis; do not give prednisolone or methylprednisolone for this indication
›Acetylcholinesterase inhibitors
›Neostigmine and pyridostigmine do not reverse the presynaptic toxin effect and can add cholinergic toxicity; not indicated
›Empirical broad-spectrum antibiotics
›Not indicated for tick paralysis itself; treat only a specific tick-borne infection or a documented secondary infection such as aspiration pneumonia
›Aminoglycosides and magnesium
›Both further impair neuromuscular transmission and can deepen weakness — avoid where possible; if an aminoglycoside is essential, monitor respiratory mechanics closely
›Aggressive fluid loading
›Not therapeutic — tick paralysis does not cause hypovolaemia; give fluids only for a specific deficit and avoid volume overload in a patient who may need ventilation
›Vasopressors and inotropes
›Rarely needed; reserve for documented shock
›Autonomic hypertension in Ixodes holocyclus disease is usually transient — use a short-acting titratable agent rather than aggressive treatment
›Fibrinolysis and mechanical circulatory support
›No role — there is no thrombotic or cardiogenic component to tick paralysis
›If either is being considered, the working diagnosis is a mimic such as basilar artery thrombosis and should be re-examined