and hyperthermia associated with poisoning or d癫痫发作和热疗与中毒或d相关课件

SeizuresandHyperthermiaAssociatedwithPoisoningorDrugOverdose KentR Olson MD FACEP FACMTMedicalDirector SanFranciscoDivisionCaliforniaPoisonControlSystemUniversityofCalifornia SanFrancisco CausesofStatusEpilepticusintheED 1980 1989UrbanSFHospital 154ptsAnticonvulsantdrugwithdrawal 39Alcohol related 39DrugToxicity 14 9 CNSinfection 12LowensteinDH43 Outline Causesofdrug inducedseizures drug drugorpoison Consequencesandcomplicationsofdrug inducedseizuresAnticonvulsantsfordrug inducedseizuresManagementofdrug inducedhyperthermia Case A27yomanwasadmittedwithanunknowndrugoverdose unresponsivebutbreathing Pupils5mm Absentbowelsounds Frequentjerkingmovements BP120 80 HR100 minECG Case continued Shortlyafteradmissionhedevelopedrecurrentgeneralizedseizures Withtheonsetofseizures theQRSintervalincreasedto0 20sec TheBPfellto70mmsystolic anddopamineandnorepinephrineweregiven Case continued Threehoursafteradmission therectaltemperaturewasnotedtobe107F Despiteintensivesupportivecare hedevelopedmulti organfailureanddied ComplicationsofDrug InducedSeizures HypoxemiaShockBrainDamageHyperthermiaRhabdomyolysisMetabolicacidosisOtherdrug specificcomplications CommonCausesofDrug InducedSeizures Cocaine amphetamines otherstimulantsTricyclicantidepressantsOtherantidepressants11 565 568 CallstotheSFPoisonCenteraboutdrug relatedseizures TreatmentofDrug InducedSeizures ABCD s AirwayBreathingCirculationDextroseAnticonvulsantsSpecificantidote ifavailableCoolingmeasures Antiepileptic DrugTherapyforStatusEpilepticus From LowensteinDH338 970 AnticonvulsantsforDrug InducedSeizures Benzodiazepine Phenobarbital Phenytoin Pentobarbital Propofol orMidazolam Specificantidote ifavailable TricyclicandRelatedAntidepressants CardiotoxicityoftenworsenedbyseizuresUsebicarbtorestore maintainpH 7 4Muscletwitching absentsweatingincreaseriskofhyperthermiaConsiderneuromuscularparalysisNospecificantidoteforseizuresDonotusephysostigmine phenytoin Cocaine Amphetamines Seizuresareusuallybrief self limitedProlongedormultipleseizuressuggestscomplicationssuchasintracranialhemorrhage headinjury hyperthermia etcTreatment SedationAnticonvulsantsifneededCoolingmeasures Case 16yearoldtook200Benadryl tabletsAgitation somnolence seizureWidecomplexQRS Antihistamines DiphenhydramineismostcommonSeizuresusuallybrief self limitedAccompaniedbymild moderateanticholinergicfindingsMassivediphenhydramineODmaycauseTCA likecardiotoxicityTreatment AnticonvulsantsifneededBicarbonateforTCA likeQRSprolongation Isoniazid INH CommonTBdrugMarkedlacticacidosispH6 8 6 9commonaftereven1 2briefseizuresTreatmentofseizures DiazepamofteneffectivePyridoxineisspecificantidote give1gmforeachgmOD 5gmifdoseunknown PyridoxineforINHoverdose Glutamate GABA Pyridoxal 5 phosphate GlutamicAcidDecarboxylase INH Pyridoxine VitB 6 Case 28yearoldmanhadaseizureandwasbroughttotheERbyafriendToxscreen foramphetaminesBut hedeniedamphetamineuseHehadborrowedoneofhisfriend spills whichhadbeenobtainedfrom Zyban BupropionAntidepressant Wellbutrin Well knowncauseofseizuresCanoccurevenattherapeuticantidepressantdosesCangivefalse positiveresultforamphetaminesontoxscreening Otherantidepressants etc AlltheSSRI shavebeenassociatedwithseizuresinOD Venlafaxine Fluoxetine CitalopramNewerandolderantipsychoticsalso NewAnticonvulsantsCausingSeizures LamotrigineTopiramateTiagabineOnecasereportofstatusepilepticusresistanttobenzos controlledwithpropofolHaneySTetal InternetJToxicol2004 1 2 Caseofthehottaquitos 5peoplewithnewonsetseizuresNonehadpriorszUtoxnegativeAllhadeatentaquitospurchasedfromaconveniencestore Case cont LeftovertaquitoswerefoundtocontainthepesticideendrinOrganochlorinepesticidesDDTEndrinAldrinLindane Anothercase 36yearoldmaningestedsomeElstonGopherGetter BaitDeveloped seizures diffusetonicspasms butremainedawakeduringandbetweenevents Strychnine PopularpoisonforthousandsofyearsStrychnosnuxvomicaNottrue seizures asCNSisminimallyaffected untilvictimishypoxic SpinalcordglycinereceptoractionInhibitsinhibitoryactionofglycineonspinalcordreflexmotorresponseSimilartotetanus Final hot case 21yoreleasedfromadrugrehabfacilityforahomevisitBecameagitated combative shovinghisbrother talkingnonsense GMseizureHR160 min T105 7FSkinred dryIncontinent Hotdude cont UtoxnegativeLP meningitis Ruleouts ATOMIC A alcoholwithdrawalT trauma tomographyO overdoseM metabolicI infectionC carbonmonoxide Hyperthermia Temp 40C HeatProduction HeatDissipation Basalmetabolism Muscleactivity Ambienttemperature CORETEMP Vasodilation Conduction Radiation Evaporation Drug InducedHyperthermia Mechanisms Musclehyperactivity Cocaine AmphetaminesSeizuresReducedsweating AnticholinergicsIncreasedcellularmetabolism SalicylatesDintrophenol ComplicationsofHyperthermia Hypotensionduetovasodilation sweating MIBraininjuryfromhypotension hyperthermia prolongedseizures hypoxemiaCoagulopathyduetoreducedproductionofclottingfactors andendothelialwalldamageRhabdomyolysiscausedbymusclehyperactivity hyperthermia andreducedmusclebloodflowRenalfailurefrommyoglobinuria hyperthermia MalignantHyperthermia SpecificdisorderofmusclecellMostcommonlyassociatedwithgeneralanesthetics succinylcholine halothane Rigidity acidosis hyperthermiaSpecifictreatment DantroleneNMparalysisisnoteffective NeurolepticMalignantSyndrome Associatedwithchronicantipsychoticuse haloperidol etc MechanismiscentraldopamineblockadeLead piperigidity diaphoresis alteredmentalstatus hyperthermiaSpecifictreatment Bromocriptine NMparalysis SerotoninSyndrome SSRIODoraddedtoMAOinhibitors also MAOI Meperidine Trazodone Tryptophan Dextromethorphan othersConfusion agitation increasedmuscletone especiallylowerextr clonus SpecificTreatment Cyproheptadine NMparalysis AnticholinergicSyndrome Dilatedpupils tachycardia decreasedbowelsounds urinaryretentionAgitation delirium orcomaMusculartwitchingcommonAbsentsweatingTreatment Physostigmine withcaution Usualcoolingmeasures ManagementofHyperthermia Actquicklytopreventbraindamage death ABC s Dextrose Protectairway assistventilationGivesupplementaloxygenIVfluidbolusifhypotensive ifneededbasedonbedsideBS Anticonvulsants ifseizuresarepresent ManagementofHyperthermia cont Rapidexternalcooling StripclothingTepidsponging fanningDonotuseicepacks Neuromuscularparalysis T 106Forpersistentszormusclerigidity MostrapidlyeffectiveRxUsenon depolarizingagent ManagementofHyperthermia cont Suspectmuscledefect malignanthyperthermia persistentmusclerigiditydespiteNMparalysis GiveDantroleneContinueexternalcooling EvaporativeCooling WeinerJS KhogaliM Aphysiologicalbody coolingunitfortreatmentofheatstroke Lancet 1980 1 8167 507 9 SomeReferences AlvarezFG GuntupalliKK Isoniazidoverdose fourcasereportsandreviewoftheliterature Intensi