Case of the Month #6: Answer

Excellent responses from our residents. Winner of this month goes to SLiang for a more complete answer (and including the correct answer on the differential)! Congratulations.

To review the case before proceeding, see here

In short, young man with refractory seizures associated with hypotension, and hypokalemia.

1. What is your initial treatment and diagnostic plan?

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.

 

2. The patient continues to seize. Clues include: hypotensive, hypokalemic, AG metabolic acidosis, nml head CT. Now, what is your differential diagnosis, your top diagnosis, and your treatment plan for this patient with benzo resistant seizures? 

      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.

 

3. Explanation of this presentation

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).  

 

 

4.Definitive treatment?

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.

 

 

 

By Dr. Andrew Grock with special thanks to Dr. Sage Wiener

 
References

Tintinalli’s

Goldfrank’s

Prabhakar H1, Bindra A, Singh GP, Kalaivani M.Propofol versus thiopental sodium for the treatment of refractory status epilepticus (Review).Cochrane Database Syst Rev. 2012 Aug 15;8:CD009202. 

Jagoda, Andy MD, FACEP, Colucciello, Stephen A. MD, FACEP. Seizures: Accurate Diagnosis And Effective Treatment. EBmedicine.net. Oct, 2000.

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The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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andygrock

  • Resident Editor In Chief of blog.clinicalmonster.com.
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