Toxin induced seizures life threatening forms of withdrawl
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Toxin-Induced Seizures: Life-Threatening Forms of Withdrawl. ACEP Scientific Assembly 2003, Boston, MA. Steven E. Aks, DO, FACMT, FACEP Fellowship Director, The Toxikon Consortium and Department of Emergency Medicine Cook County Hospital. Trauma - Tox.

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Toxin-Induced Seizures: Life-Threatening Forms of Withdrawl

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Toxin-Induced Seizures:Life-Threatening Forms of Withdrawl

ACEP Scientific Assembly 2003, Boston, MA


Steven E. Aks, DO, FACMT, FACEPFellowship Director, The Toxikon Consortium and Department of Emergency MedicineCook County Hospital


Trauma - Tox

  • A 40 year old male presents to the trauma unit at Cook County Hospital after jumping from the 4th story of a burning hotel.

  • There are obvious bilateral fracture/dislocations of his ankles, and he complains of back pain.


PE/Work up

  • T 99 P 110 RR 24 BP 110/60

  • Alert, in moderate distress secondary to pain

  • CT head, chest, abdomen/pelvis negative

  • L-S L4 compression fracture

  • + bilateral fracture dislocations


Day 2

  • Patient becomes increasingly anxious and agitated, noted to be diaphoretic.

  • HR 130 BP 160/90 RR 24 T 101

  • HEENT: PERRL at 6 mm

  • Ht: RRR S1S2 tachycardic

  • Neuro: Diffuse tremors noted bil UE’s, followed by brief tonic clonic seizure.


Punchline

  • Patient taking multiple benzodiazepines prescribed by several practitioners.

  • 100 mg diazepam required to achieve light sedation

  • 400 mg total over next 2 days

  • Taper of 10%


Life-Threatening Withdrawal Syndromes


Benzodiazepine Withdrawal

  • Similar to ethanol, barbiturate

  • Onset may be delayed

    • Long T ½

  • Resolution may take up to 10 days


Withdrawal

  • Occurs when a drug or toxin is removed or reduced and adaptive changes persist producing dysfunction


Requisite for Withdrawal

  • Adaption to a drug or toxin

  • Decreasing concentration

  • Tolerance


Human Action is Dysinhibition

  • Drugs as inhibitors

    • Benzodiazepines on GABAa

    • Opioids on opioid receptor

    • Clonidine on the alpha 2 receptor


Dysinhibition Syndrome

  • Agitation

  • Tachycardia

  • Hypertension

  • Fever, hyperthermia

  • Seizures


Flumazenil

  • Avoid in benzodiazepine dependent patients

  • 3 cases of reversal of chronic benzodiazepines leading to seizures

Spivey 1992 Clinical Therapeutics


Drinking Problem?


Ethanol

  • Increases inhibitory effects

  • Adaptive modulation

    • Inhibitory (GABAa)

    • Excitatory (NMDA)


Mild Alcohol Withdrawal

  • Tachycardia

  • Tachypnea

  • Hypertension

  • Tremor (“the shakes”)

  • Hypereflexia

  • Peak at 24 to 36 hours


Victor and Adams

  • Tremulousness

  • Seizures

  • Hallucinations

  • Delirium


Course of Neurological Disturbances

Victor and Adams 1953


Seizures

  • Usually begin 6-8 hours after last consumption of alcohol.

  • May be seen prior to autonomic symptoms

  • Self-limited

  • Can be seen at Etoh of > 100

  • CCH 1150!


Hallucinations

  • Usual visual

  • Formication

  • Auditory in ~20%

  • May last up to three days


Why Did They Die?

  • No nurses

  • Dehydration

  • Physical restraints

  • Neuroleptics


Kindling

  • Withdrawal progressively becomes worse

  • Treat aggressively to head off early!


2mg IV Q15 min

IM OK

Lack of hepatic metabolism good for cirrhotics

Shorter T ½

5 mg IV Q 15 min

IM not OK

Long T ½ with active metabolites

May accumulate in cirrhotics

Lorazepam Vs. Diazepam


The Dosing Champions


Miscellaneous

  • Phenobarbital 5 mg/kg initially

    • Bolus with 260 mg over 5 min, then 130 mg Q 30 min until light sedation

  • Pentobarbital

    • Intubate patient

    • 3-5 mg/kg bolus

    • 100 mg/hour to maintain sedation

  • Propofol


Soma

  • A 31 year old male and his 29 year old female companion presented to the ED with severe tremulousness that began 6 hours after they had discontinued daily use of Soma Solution, or 1,4 Butanediol.

  • They were taking 1 oz doses nightly as a sleep aid 5 weeks before, but they had gradually increased amounts and were taking 16 oz/day.


Soma

  • They stopped use 4 days prior and 6 hours later they developed abdominal cramping, palpitations, tremors and anxiety.

  • Attempted treating symptoms with vodka for 4 days before presentation.


Soma

  • Positive findings

    • Tachycardia 120

    • Horizontal nystagmus

    • Tongue tremors

  • Lorazepam 2 mg and Diazepam 5 mg

  • Outpatient lorazepam


GHB

  • Gamma Hydroxybutyrate

  • 1,4 Butanediol

  • Gamma Butyrolactone


Sedative Hypnotic Withdrawal

Dyer: 2001 Annals EM


GHB Withdrawal Treatment

  • Recognition!

  • Symptomatic

  • Benzodiazepines

  • Barbiturates

  • Propofol


Homer Simpson

"To alcohol! The Cause of AND solution to all of life's problems. Alcohol is a way of life. Alcohol is my way of life, and I aim to keep it."


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