List Archives

Sat Aug 26 07:48:26 BST 2006

Unlikely I think - he still has electrical status 15 days after injury,
despite high doses of multiple agents which generally would be used to
cover drug withdrawal. But thank you for the thought.

Ian

>>> drmandy at rediffmail.com 26/08/2006 3:12pm >>>
Dear Dr Seppelt..

This patient has had a past history of IV drug abuse, and was on
chronic methadone treatment. Is there a likelihood of opioid withdrawal
in this patient as the sedation/anti-convulsant combination does not
have an opioid as a component. Can you throw some light on this
please...

Although this is an assumption on my part as I have seen a few patients
develop this syndrome inside the ICU. But not the extent of this
uncontrolled status epilepticus. It manifests as a irritable patient
with sympathetic over-activity, tremorsetc.. But seizures have been
described in opioid withdrawal... Your views please on this..

Regards...

Mandeep

Dr Mandeep Singh
MBBS, MD Anaes
AIIMS, New Delhi,India

On Sat, 26 Aug 2006 Ian Seppelt wrote :
>Any good suggestions welcome, for a difficult management problem.
>
>A 33 y/o was transferred to my ICU 15 days ago following a road
trauma.
>Circumstances unclear - high speed crash into tree in rural area
about
>400km from here, with entrapment and difficult extrication.
Apparently
>conscious throughout and not hypoxic. Ambulance rendezvous with
>helicopter team who described an agitated, injured man GCS 12, who
was
>electively intubated without difficulty. He was then transported to a
>regional hospital for trauma assessment. Past history IV drug use,
now
>stable on a methadone programme, hepatitis C and essential
hypertension.
>No prior history of epilepsy.
>
>Injuries included sternal fracture, right lung contusion, undisplaced
>fracture of right maxillary antrum, transverse midshaft fracture R
>femur, comminuted right patellar fracture and multiple lacerations.
FAST
>negative. CT brain, chest and abdomen otherwise normal. Spine normal.
To
>theatre for ORIF of femur and wiring of patella. Intraoperatively the
>only adverse event was a transient sudden loss of ETCO2.
>
>Postoperatively he developed a generalised clonic status epilepticus.
>He was loaded with phenytoin then clonazepam, a midazolam infusion,
>magnesium and propofol. Repeat brain CT normal.
>
>He was then transferred to my ICU for ongoing neurointensive care
>management. The ongoing generalised clonic staus epilepticus was only
>controlled with initially boluses of thiopentone and then a
thiopentone
>infusion to burst suppression on continuous EEG. MRI/MRA/MRV normal.
>Lumbar puncture normal. Fat embolism suspected but had none of the
usual
>signs of fat embolism syndrome and there was no sign of right to left
>shunt or pulmonary hypertension on TOE.
>
>After a number of days of burst suppression he has been allowed to
>surface - again to a generalised clonic status. Triple
anticonvulsants
>with therapeutic doses of phenytoin and valproate and piracetam.
>Bilaterally normal SSEPS. EEG again shows polyspike activity every
>minute or so, maximally centrally and seen bilaterally. Repeat MRI
>yesterday (14 days) still normal. Propofol to suppress seizures and
>today I have loaded him with phenobarbitone (trying to avoid going
back
>down the thiopentone coma route).
>
>He has had a tracheostomy and is getting over a nosocomial pneumonia
>(probably caused by the thiopentone!). His wife is dejected and is
>talking withdrawal of treatment. I am very uncomfortable with that on
>the grounds that:
>
>1. We don't know what the problem is [everybody is blaming hypoxia or
>maybe cerebral fat embolism but there is no good evidence for either
of
>these],
>2. We don't have control of his seizures unless we anaesthetise him,
>and
>3. Some people have suggested he might be responsive even when having
>the seizures (a variant of Lance-Adams syndrome??)
>
>While I agree the likely outcome is poor I have emphasized to his
wife
>that it is too early to write him off! She is adamant that he would
not
>wish to survive unless it was in a very good functional state.
>
>I welcome any advice or comments! What is the cause? What is the best
>treatment? How do you prognosticate in this situation?
>
>[Nb I have his wife's permission for this post, as he could well be
>identifiable from the information I have given]
>
>Best wishes, Ian
>
>Ian Seppelt FANZCA FJFICM
>Senior Staff Specialist
>Dept of Intensive Care Medicine
>The Nepean Hospital, PO Box 63 Penrith NSW 2751
>Clinical Lecturer, University of Sydney
>
>######################################################################
>Attention:
>This message is intended for the addresses named and may contain
>confidential information. If you are not the intended recipient,
please
>delete it and notify the sender. Views expressed in this message are
>those of the individual sender, and are not necessarily the views of
>Sydney West Area Health Service.
>
>
>This e-mail has been scanned for viruses
>######################################################################
>--
>trauma-list : TRAUMA.ORG
>To change your settings or unsubscribe visit:
>http://www.trauma.org/traumalist.html 

--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html

######################################################################
Attention: 
This message is intended for the addresses named and may contain 
confidential information. If you are not the intended recipient, please
delete it and notify the sender. Views expressed in this message are 
those of the individual sender, and are not necessarily the views of 
Sydney West Area Health Service.

This e-mail has been scanned for viruses
######################################################################

List Archives

For your convenience, find the Trauma List Archive Below

Help needed - post traumatic status epilepticus