seizures and hyperthermia associated with poisoning or drug overdose l.
Skip this Video
Loading SlideShow in 5 Seconds..
Seizures and Hyperthermia Associated with Poisoning or Drug Overdose PowerPoint Presentation
Download Presentation
Seizures and Hyperthermia Associated with Poisoning or Drug Overdose

Loading in 2 Seconds...

play fullscreen
1 / 44

Seizures and Hyperthermia Associated with Poisoning or Drug Overdose - PowerPoint PPT Presentation

  • Uploaded on

Seizures and Hyperthermia Associated with Poisoning or Drug Overdose. Kent R. Olson, MD, FACEP, FACMT Medical Director, San Francisco Division California Poison Control System University of California, San Francisco. Causes of Status Epilepticus in the ED.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

Seizures and Hyperthermia Associated with Poisoning or Drug Overdose

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.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
seizures and hyperthermia associated with poisoning or drug overdose

Seizures and Hyperthermia Associated with Poisoning or Drug Overdose

Kent R. Olson, MD, FACEP, FACMT

Medical Director, San Francisco Division

California Poison Control System

University of California, San Francisco

causes of status epilepticus in the ed
Causes of Status Epilepticus in the ED
  • 1980-1989 Urban SF Hospital – 154 pts
  • Anticonvulsant drug withdrawal: 39
  • Alcohol-related: 39
  • Drug Toxicity: 14 (9%)
  • CNS infection: 12
  • Lowenstein DH & Alldredge BK et al: Neurol 1993; 43
  • Causes of drug-induced seizures (“drug” = drug or poison)
  • Consequences and complications of drug-induced seizures
  • Anticonvulsants for drug-induced seizures
  • Management of drug-induced hyperthermia
  • A 27 yo man was admitted with an unknown drug overdose, unresponsive but breathing. Pupils 5 mm. Absent bowel sounds.
  • Frequent jerking movements.
  • BP 120/80, HR 100/min
  • ECG:
case continued
Case (continued)
  • Shortly after admission he developed recurrent generalized seizures.
  • With the onset of seizures, the QRS interval increased to 0.20 sec.
  • The BP fell to 70 mm systolic, and dopamine and norepinephrine were given.
case continued8
Case (continued)
  • Three hours after admission, the rectal temperature was noted to be 107 F.
  • Despite intensive supportive care, he developed multi-organ failure and died.
complications of drug induced seizures
Complications of Drug-Induced Seizures
  • Hypoxemia
  • Shock Brain Damage
  • Hyperthermia
  • Rhabdomyolysis
  • Metabolic acidosis
  • Other drug-specific complications
common causes of drug induced seizures
Common Causes of Drug-Induced Seizures
  • Cocaine, amphetamines, other stimulants
  • Tricyclic antidepressants
  • Other antidepressants & antipsychotics
  • Diphenhydramine
  • Isoniazid
  • Many others
  • Olson KR et al: Am J Emerg Med 1993; 11:565-568
treatment of drug induced seizures
Treatment of Drug-Induced Seizures
  • ABCD’s:
    • Airway
    • Breathing
    • Circulation
    • Dextrose
  • Anticonvulsants
    • Specific antidote, if available
  • Cooling measures

Antiepileptic-Drug Therapy for Status Epilepticus.

From: Lowenstein DH & Alldredge BK: NEJM 1998; 338:970

anticonvulsants for drug induced seizures
Anticonvulsants for Drug-Induced Seizures

Specific antidote,

if available




Pentobarbital, Propofol, or Midazolam

tricyclic and related antidepressants
Tricyclic and Related Antidepressants
  • Cardiotoxicity often worsened by seizures
    • Use bicarb to restore/maintain pH > 7.4
  • Muscle twitching, absent sweating increase risk of hyperthermia
    • Consider neuromuscular paralysis
  • No specific antidote for seizures
    • Do not use physostigmine, phenytoin
cocaine amphetamines
Cocaine & Amphetamines
  • Seizures are usually brief, self-limited
    • Prolonged or multiple seizures suggests complications such as intracranial hemorrhage, head injury, hyperthermia, etc
  • Treatment:
    • Sedation
    • Anticonvulsants if needed
    • Cooling measures
  • 16 year old took 200 Benadryl™ tablets
  • Agitation, somnolence, seizure
  • Wide complex QRS
  • Diphenhydramine is most common
    • Seizures usually brief, self-limited
    • Accompanied by mild-moderate anticholinergic findings
    • Massive diphenhydramine OD may cause TCA-like cardiotoxicity
  • Treatment:
    • Anticonvulsants if needed
    • Bicarbonate for TCA-like QRS prolongation
isoniazid inh
Isoniazid (INH)
  • Common TB drug
  • Marked lactic acidosis
    • pH 6.8-6.9 common after even 1-2 brief seizures
  • Treatment of seizures:
    • Diazepam often effective
    • Pyridoxine is specific antidote - give 1 gm for each gm OD; 5 gm if dose unknown
pyridoxine for inh overdose
Pyridoxine for INH overdose






Pyridoxine (Vit B-6)


Glutamic Acid




  • 28 year old man had a seizure and was brought to the ER by a friend
  • Tox screen (+) for amphetamines
  • But, he denied amphetamine use
  • He had borrowed one of his friend’s pills, which had been obtained from…
  • Bupropion
    • Antidepressant = Wellbutrin™
    • Well-known cause of seizures
    • Can occur even at therapeutic antidepressant doses
    • Can give false-positive result for amphetamines on tox screening
other antidepressants etc
Other antidepressants & etc
  • All the SSRI’s have been associated with seizures in OD
  • - Venlafaxine
  • - Fluoxetine
  • - Citalopram
  • Newer and older antipsychotics also
new anticonvulsants causing seizures
New Anticonvulsants Causing Seizures
  • Lamotrigine
  • Topiramate
  • Tiagabine
    • One case report of status epilepticus resistant to benzos, controlled with propofol
  • Haney ST et al: Internet J Toxicol 2004, 1(2)
case of the hot taquitos
Case of the hot taquitos
  • 5 people with new onset seizures
  • None had prior sz
  • Utox negative
  • All had eaten taquitos purchased from a convenience store
case cont
Case (cont.)
  • Leftover taquitos were found to contain the pesticide endrin
  • Organochlorine pesticides
    • DDT
    • Endrin
    • Aldrin
    • Lindane
another case
Another case
  • 36 year old man ingested some Elston Gopher Getter™ Bait
  • Developed “seizures” (diffuse tonic spasms) but remained awake during and between events
  • Popular poison for thousands of years
    • Strychnos nux vomica
  • Not true “seizures” as CNS is minimally affected (until victim is hypoxic)
  • Spinal cord glycine receptor action
    • Inhibits inhibitory action of glycine on spinal cord reflex motor response
    • Similar to tetanus
final hot case
Final “hot” case
  • 21 yo released from a drug rehab facility for a home visit
  • Became agitated, combative, shoving his brother, talking nonsense  GM seizure
  • HR 160/min, T 105.7 F
  • Skin red, dry
  • Incontinent
hot dude cont
Hot dude, cont.
  • Utox negative
  • LP: meningitis!!
rule outs
“Rule outs”
  • “A T O M I C”
  • A: alcohol withdrawal
  • T: trauma/tomography
  • O: overdose
  • M: metabolic
  • I: infection
  • C: carbon monoxide
hyperthermia temp 40 c
Hyperthermia (Temp > 40 C)

Heat Production

Heat Dissipation

Basal metabolism




Muscle activity


Ambient temperature


drug induced hyperthermia mechanisms
Drug-Induced Hyperthermia - Mechanisms
  • Muscle hyperactivity:
    • Cocaine, Amphetamines
    • Seizures
  • Reduced sweating:
    • Anticholinergics
  • Increased cellular metabolism:
    • Salicylates
    • Dintrophenol
complications of hyperthermia
Complications of Hyperthermia
  • Hypotension due to vasodilation, sweating, MI
  • Brain injury from hypotension, hyperthermia, prolonged seizures, hypoxemia
  • Coagulopathy due to reduced production of clotting factors, and endothelial wall damage
  • Rhabdomyolysis caused by muscle hyperactivity, hyperthermia, and reduced muscle blood flow
  • Renal failure from myoglobinuria, hyperthermia
malignant hyperthermia
Malignant Hyperthermia
  • Specific disorder of muscle cell
  • Most commonly associated with general anesthetics (succinylcholine, halothane)
  • Rigidity, acidosis, hyperthermia
  • Specific treatment:
    • Dantrolene
    • NM paralysis is not effective
neuroleptic malignant syndrome
Neuroleptic Malignant Syndrome
  • Associated with chronic antipsychotic use (haloperidol, etc.)
  • Mechanism is central dopamine blockade
  • Lead-pipe rigidity, diaphoresis, altered mental status, hyperthermia
  • Specific treatment:
    • Bromocriptine?
    • NM paralysis
serotonin syndrome
Serotonin Syndrome
  • SSRI OD or added to MAO inhibitors:
    • also: MAOI + Meperidine, Trazodone, Tryptophan, Dextromethorphan, others
  • Confusion, agitation, increased muscle tone (especially lower extr. clonus)
  • Specific Treatment:
    • Cyproheptadine?
    • NM paralysis
anticholinergic syndrome
Anticholinergic Syndrome
  • Dilated pupils, tachycardia, decreased bowel sounds, urinary retention
  • Agitation, delirium, or coma
  • Muscular twitching common
  • Absent sweating
  • Treatment:
    • Physostigmine? (with caution)
    • Usual cooling measures
management of hyperthermia
Management of Hyperthermia
  • Act quickly to prevent brain damage/death
  • Protect airway, assist ventilation
  • Give supplemental oxygen
  • IV fluid bolus if hypotensive



if needed based on bedside BS


if seizures are present

management of hyperthermia cont
Management of Hyperthermia (cont.)

Rapid external cooling

  • Strip clothing
  • Tepid sponging + fanning
  • Do not use ice packs

T > 106 F or

persistent sz or

muscle rigidity

  • Most rapidly effective Rx
  • Use non-depolarizing agent

Neuromuscular paralysis

management of hyperthermia cont42
Management of Hyperthermia (cont.)

persistent muscle rigidity

despite NM paralysis

Suspect muscle defect

(malignant hyperthermia)

  • Give Dantrolene
  • Continue external cooling
evaporative cooling
Evaporative Cooling

Weiner JS, Khogali M: A physiological body-cooling unit for treatment of heat stroke. Lancet. 1980;1(8167):507-9.

some references
Some References
  • Alvarez FG, Guntupalli KK. Isoniazid overdose: four case reports and review of the literature. Intensive Care Med. 1995 Aug;21(8):641-4.
  • Beaubien A et al. Antagonism of imipramine poisoning by anticonvulsants in the rat. Toxicol Appl Pharmacol 1976;38:1–6
  • Blake KV et al: Relative efficacy of phenytoin and phenobarbital for the prevention of theophylline-induced seizures in mice. Ann Emerg Med. 1988 Oct;17(10):1024-8
  • Centers for Disease Control (CDC). Endrin poisoning associated with taquito ingestion--California. MMWR Morb Mortal Wkly Rep. 1989 May 19;38(19):345-7.
  • Clark RF, Vance MV. Massive diphenhydramine poisoning resulting in a wide-complex tachycardia: successful treatment with sodium bicarbonate.
  • Haney ST et al: Tiagabine-induced status epilepticus responds to propofol. Internet J Toxicol 2004, 1(2)
  • Lowenstein DH, Alldredge BK. Status epilepticus at an urban public hospital in the 1980s. Neurology 1993;43:483-488
  • Lowenstein DH & Alldredge BK: Status epilepticus. NEJM 1998; 338:970
  • Mayron R, Ruiz E. Phenytoin:does it reverse tricyclic antidepressant induced cardiac conduction abnormalities? Ann Emerg Med 1986;15:876–80
  • Olson KR, Benowitz NL. Environmental and drug-induced hyperthermia. Pathophysiology, recognition, and management. Emerg Med Clin North Am. 1984 Aug;2(3):459-74.
  • Olson KR et al. Seizures associated with poisoning and drug overdose. Am J Emerg Med. 1994 May;12(3):392-5.
  • Stecker MM et al. Treatment of refractory status epilepticus with propofol: clinical and pharmacokinetic findings. Epilepsia 1998;39:18-26
  • Yarbrough BE, Wood JP. Isoniazid overdose treated with high-dose pyridoxine. Ann Emerg Med. 1983 May;12(5):303-5.
  • Wood DM et al: Case report: Survival after deliberate strychnine self-poisoning, with toxicokinetic data. it Care. 2002; 6(5): 456–459 Ann Emerg Med. 1992 Mar;21(3):318-21.