IV/O2/Monitor/FINGERSTICK

Ativan 2mg/min for 5 minutes. Full set of labs.

If still seizing, Load with AE. Textbook says fosphenytoin, but word on the street is that keppra is being used here as well.

      1.  phenobarb vs propofol vs benzo drip vs ketamine. Intubate for airway protection.

      2. start thinking about causes for benzo-resistant seizures. My list includes (with antidote in parenthesis): INH (pyridoxime), Na channel blocker such as TCA (bicarb), meningoencephalitis (acyclovir, ceftriaxone, vanco, +/- ampicillin), ETOH w/d (way more benzos), and lastly – Theophylline toxicity.

     3.  Obviously we need more history. To evaluate the above patient, I would: give pyridoxime, do an ECG to check for terminal R in AVR (if absent, very unlikely Na channel on board), possibly LP or give empiric abx. I would definitely continue giving benzos and put the patient into a propofol coma, which would necessitate intubation. Consult MICU/Neuro.

Given the above clues, the answer to the caseis…Theophylline Toxicity – though this is clearly a tough diagnosis to make from the above case.

Theophylline, a methylxanthine – like caffeine – is an older asthma medication with a limited therapeutic window. In overdose, pt’s almost always present with vomiting, and toxicity is associated with: refractory status epilepticus, hypokalemia, hyperglycemia, persistent hypotension, SVT, rhabdo (from the seizures/  fasiculations/ myoclonus).  

Supportive:

Vomiting- anti-emetics

seizures – see above. Benzo’s then pentobarb vs propofol

Hypotension –  IVF but, if  persistent – phenylephrine as theophylline causes hyptension through B2 agonism. Epi/norepi are less useful. Case reports of B-Blocker use (esmolol) to improve CV status. Which sounds crazy!

SVT – adenosine unlikely to work. Benzo’s recommended with very careful/slow use of dilt/verapamil.

Remove Poison:

GI decontamination, hemodialysis (or charcoal hemoperfusion if available) indicated if: seizures, ventricular dysrhythmias, or fluid resistant hypotension.