1 / 38

Toxin-Induced Seizures: Life-Threatening Forms of Withdrawl

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.

amelie
Download Presentation

Toxin-Induced Seizures: Life-Threatening Forms of Withdrawl

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Toxin-Induced Seizures:Life-Threatening Forms of Withdrawl ACEP Scientific Assembly 2003, Boston, MA

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

  3. 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.

  4. 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

  5. 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.

  6. 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%

  7. Life-Threatening Withdrawal Syndromes

  8. Benzodiazepine Withdrawal • Similar to ethanol, barbiturate • Onset may be delayed • Long T ½ • Resolution may take up to 10 days

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

  10. Requisite for Withdrawal • Adaption to a drug or toxin • Decreasing concentration • Tolerance

  11. Human Action is Dysinhibition • Drugs as inhibitors • Benzodiazepines on GABAa • Opioids on opioid receptor • Clonidine on the alpha 2 receptor

  12. Dysinhibition Syndrome • Agitation • Tachycardia • Hypertension • Fever, hyperthermia • Seizures

  13. Flumazenil • Avoid in benzodiazepine dependent patients • 3 cases of reversal of chronic benzodiazepines leading to seizures Spivey 1992 Clinical Therapeutics

  14. Drinking Problem?

  15. Ethanol • Increases inhibitory effects • Adaptive modulation • Inhibitory (GABAa) • Excitatory (NMDA)

  16. Mild Alcohol Withdrawal • Tachycardia • Tachypnea • Hypertension • Tremor (“the shakes”) • Hypereflexia • Peak at 24 to 36 hours

  17. Victor and Adams • Tremulousness • Seizures • Hallucinations • Delirium

  18. Course of Neurological Disturbances Victor and Adams 1953

  19. 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!

  20. Hallucinations • Usual visual • Formication • Auditory in ~20% • May last up to three days

  21. Why Did They Die? • No nurses • Dehydration • Physical restraints • Neuroleptics

  22. Kindling • Withdrawal progressively becomes worse • Treat aggressively to head off early!

  23. 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

  24. The Dosing Champions

  25. 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

  26. 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.

  27. 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.

  28. Soma • Positive findings • Tachycardia 120 • Horizontal nystagmus • Tongue tremors • Lorazepam 2 mg and Diazepam 5 mg • Outpatient lorazepam

  29. GHB • Gamma Hydroxybutyrate • 1,4 Butanediol • Gamma Butyrolactone

  30. Sedative Hypnotic Withdrawal Dyer: 2001 Annals EM

  31. GHB Withdrawal Treatment • Recognition! • Symptomatic • Benzodiazepines • Barbiturates • Propofol

  32. 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."

  33. Questions?

More Related