It’s been a strangely calm shift when all of a sudden…
EMS wheels in a middle aged male having a generalized tonic-clonic seizure. They say he was found seizing on the street. He was given 10mg midazolam IM without cessation of seizure activity and brought to the ER.
1. What is your initial treatment and diagnostic plan?
Next…
He continues seizing after multiple rounds of benzos. His BP is 70/40, HR 150s (narrow complex), afebrile, 99% on NRB. His physical exam is significant for diaphoresis and continued tonic-clonic generalied seizures. He is persistently hypotensive after 3L NS. His labs are significant for an elevated lactate, an anion gap metabolic acidosis and moderate hypokalemia.His head CT is normal.
2. Now, what is your differential diagnosis, your top diagnosis, and your treatment plan for this patient with benzo resistant seizures?
Reminder: the best answer (with extra points for earlier submission) will win a prize of both monetary and esteem-building value.
By Dr. Andrew Grock
andygrock
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2 Comments
Nathan · December 6, 2014 at 12:52 pm
Give pyridoxine immediately. There are other things in the differential but you have to think INH toxicity in benzo resistant seizures especially with an anion gap acidosis.
sliang · December 6, 2014 at 7:51 pm
I agree with Nathan.
A, B, C, IV, O2, monitor, benzos. Get a history. Send off labs (CBC, CMP, shock, utox, tylenol, ASA, EtOH levels. May consider getting dilantin and carbamazepine levels if the patient is on AED), get EKG, CXR, head CT.
Diff dx:
1) INH toxicity- give pyridoxine. Can consider gastric lavage and activated charcoal if known time of ingestion. HD if failed standard therapy. Call MICU, poison center, psych if intentional OD
2) theophylline toxicity- give benzos. If that doesn’t work, can give phenobarbital, avoid phenytoin, poison center
3) EtOH withdrawal/DT- benzos, MICU
4) hx of seizures and med noncompliance- benzos, call neuro
5) electrolyte imbalance- correct electrolytes
6) trauma
7) infection
8) stroke