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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

Toxin-Induced Seizures:Life-Threatening Forms of Withdrawl

ACEP Scientific Assembly 2003, Boston, MA

slide2
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%
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

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
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
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
slide29
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.
slide30
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.
slide31
Soma
  • Positive findings
    • Tachycardia 120
    • Horizontal nystagmus
    • Tongue tremors
  • Lorazepam 2 mg and Diazepam 5 mg
  • Outpatient lorazepam
slide32
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."

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