A 23 Year Old Woman who Presents with New Onset SE Brandon Wills, DO, MS Fellow, Clinical Toxicology Toxikon Consortium of Cook County Clinical Instructor

A 23 Year Old Woman who A 23 Year Old Woman who Presents with New Onset SEPresents with New Onset SE

Brandon Wills, DO, MSFellow, Clinical Toxicology

Toxikon Consortium of Cook County

Clinical Instructor in Emergency Medicine

University of Illinois at Chicago

Brandon Wills, DO, MS

Case PresentationCase Presentation

• 23 year-old female presents to the ED with generalized seizures x 3

• Pt. found by family member initially somnolent


Past Medical History & Social HistoryPast Medical History & Social History

• No details available (initially)


Physical ExamPhysical Exam

• VS: AF; 90/50; 116; 24; 97% on NRM

• Pt. having repeated brief generalized seizures with intermittent recovery

• HEENT- pupils 5mm, reactive

• CV- Tachy, no M/G/R

• Lungs- CTAB

• Skin- Warm, pink, dry

Your Differential Diagnosis?Your Differential Diagnosis?


Differential DiagnosisDifferential Diagnosis

• Neurologic• Infectious etiologies• Metabolic• Endocrine• Toxicologic


ED CourseED Course

• What would be your initial management?


ED CourseED Course

• What would be your initial management?• IV, O2, Monitor• IV ativan• Bedside glucose• Send laboratory studies• CT head?


ED CourseED Course

• Pt. given several doses of IV ativan without improvement

• Pt. was then intubated, sedated with propofol


Lab ResultsLab Results

• EKG: Sinus tach, narrow complex• HCO3- 10• Anion gap- 25• ABG- 6.99/28/172/7• WBC- 25.4• Chemistry = wnl• Utox- nl• ASA/APAP- negative• LFT’s- nl


ED CourseED CourseWe Want More HistoryWe Want More History

• No history of seizure disorder

• No history of trauma

• Family members arrive with an empty bottle of INH


• What would be your next step in this patient’s management?

ED CourseED Course


Isonicontinic Acid Hydrazide INHIsonicontinic Acid Hydrazide INH

Structurally similar to

• Pyridoxine (B6)

• NAD

• Nicotinic acid (Niacin)



Pyridoxine(Vitamin B6)

INH

Nicotinic Acid(Niacin)



Gyromitra species Rocket fuel

Structurally Similar Toxins

Monomethylhydrazine


Hydrazine EpidemiologyHydrazine Epidemiology11

INH

426- Exposures

58- Minor

70- Moderate

80- Major

1- Deaths

Gyromitra Species

44- Exposures

13- Minor

10- Moderate

0- Major

0- Deaths

1. AAPCC 2001 TESS Data


PathophysiologyPathophysiology

Glutamic Acid GABAGlutamic acid decarboxylase

pyridoxal-5'-phosphate

Pyridoxine pyridoxal-5'-phosphate (Active B6)X

pyridoxine phosphokinase

INH Metabolites


INH ToxicokineticsINH Toxicokinetics

Therapeutic dose: 5-15 mg/kg

Toxic dose: >20 mg/kgsignificant toxicity >40 mg/kg

Peak [ ]: 2 hours

Elimination T1/2: 70-180 minutes


Clinical ManifestationsClinical Manifestations

Triad:

1. Refractory seizures

2. Severe metabolic acidosis

3. Coma


Clinical ManifestationsClinical Manifestations

Early: May mimic anticholinergic toxidrome

(N/V, tachycardia, ataxia, mydriasis, CNS dep.)

Late: Seizures, acidosis

Chronic: Hepatotoxicity


Lab StudiesLab Studies

• Chemistries

• Lactate

• EKG

• Hepatic enzymes

• +/- INH levels


Treatment of ToxicityTreatment of Toxicity

1. A,B,C’s2. Initial resuscitation and supportive care3. Decontamination

- Lavage?- Whole bowel irrigation?

- Activated charcoal?

4. Enhanced elimination5. Antidotes



1. A,B,C’s



2. Initial resuscitation and supportive care

IV Fluids

Benzodiazepines

+/- Sodium bicarb



3. Decontamination- Lavage?

- Whole bowel irrigation?

- Activated charcoal?



4. Enhanced elimination

Hemodialysis?



5. Antidotes

Pyridoxine (B6)


Case CourseCase Course

Toxikon is a Medical Toxicology Consortium Including Cook County Hospital, The University of Illinois Hospital, and Rush Presbyterian St.

Luke's Medical Center

The Toxikon Consortium



• Recommended IV pyridoxine

• Pharmacy unable to mobilize B6

• Contacted Rush antidote depot for courier

• Pt. given 5g IV



• Seizure activity terminated• Repeat ABG: 7.31/34/503/17• Pt. extubated the following day• Transferred to psych facility on hospital

day 3


Teaching PointsTeaching Points

• Consider INH toxicity with patients presenting with refractory seizures



• Remember to treat the patient, not the poison (A,B,C’s)



• Gyromitra species are another source of hydrazine



• What is the antidote for INH-induced seizures?

•Pyridoxine (B6)•Dosing- gram (INH ingested):gram (B6)•Unknown ingestions, start with 5 grams IV•IV pyridoxine supplies are often limited•PO B6 may be crushed and given NG

Questions???Questions???

Documents

A 23 Year Old Woman who Presents with New Onset SE Brandon Wills, DO, MS Fellow, Clinical Toxicology Toxikon Consortium of Cook County Clinical Instructor