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

Toxin-Induced Seizures:Life-Threatening Forms of Withdrawl

ACEP Scientific Assembly 2003, Boston, MA


Toxin induced seizures life threatening forms of withdrawl

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


Trauma tox

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

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

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

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

Life-Threatening Withdrawal Syndromes


Benzodiazepine withdrawal

Benzodiazepine Withdrawal

  • Similar to ethanol, barbiturate

  • Onset may be delayed

    • Long T ½

  • Resolution may take up to 10 days


Withdrawal

Withdrawal

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


Requisite for withdrawal

Requisite for Withdrawal

  • Adaption to a drug or toxin

  • Decreasing concentration

  • Tolerance


Human action is dysinhibition

Human Action is Dysinhibition

  • Drugs as inhibitors

    • Benzodiazepines on GABAa

    • Opioids on opioid receptor

    • Clonidine on the alpha 2 receptor


Dysinhibition syndrome

Dysinhibition Syndrome

  • Agitation

  • Tachycardia

  • Hypertension

  • Fever, hyperthermia

  • Seizures


Flumazenil

Flumazenil

  • Avoid in benzodiazepine dependent patients

  • 3 cases of reversal of chronic benzodiazepines leading to seizures

Spivey 1992 Clinical Therapeutics


Toxin induced seizures life threatening forms of withdrawl

Drinking Problem?


Ethanol

Ethanol

  • Increases inhibitory effects

  • Adaptive modulation

    • Inhibitory (GABAa)

    • Excitatory (NMDA)


Mild alcohol withdrawal

Mild Alcohol Withdrawal

  • Tachycardia

  • Tachypnea

  • Hypertension

  • Tremor (“the shakes”)

  • Hypereflexia

  • Peak at 24 to 36 hours


Victor and adams

Victor and Adams

  • Tremulousness

  • Seizures

  • Hallucinations

  • Delirium


Course of neurological disturbances

Course of Neurological Disturbances

Victor and Adams 1953


Seizures

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

Hallucinations

  • Usual visual

  • Formication

  • Auditory in ~20%

  • May last up to three days


Why did they die

Why Did They Die?

  • No nurses

  • Dehydration

  • Physical restraints

  • Neuroleptics


Kindling

Kindling

  • Withdrawal progressively becomes worse

  • Treat aggressively to head off early!


Lorazepam vs diazepam

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

The Dosing Champions


Miscellaneous

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


Toxin induced seizures life threatening forms of withdrawl

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.


Toxin induced seizures life threatening forms of withdrawl

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.


Toxin induced seizures life threatening forms of withdrawl

Soma

  • Positive findings

    • Tachycardia 120

    • Horizontal nystagmus

    • Tongue tremors

  • Lorazepam 2 mg and Diazepam 5 mg

  • Outpatient lorazepam


Toxin induced seizures life threatening forms of withdrawl

GHB

  • Gamma Hydroxybutyrate

  • 1,4 Butanediol

  • Gamma Butyrolactone


Sedative hypnotic withdrawal

Sedative Hypnotic Withdrawal

Dyer: 2001 Annals EM


Ghb withdrawal treatment

GHB Withdrawal Treatment

  • Recognition!

  • Symptomatic

  • Benzodiazepines

  • Barbiturates

  • Propofol


Homer simpson

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."


Toxin induced seizures life threatening forms of withdrawl

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