A 25-year-old female was brought to the emergency department with a history of nausea, vomiting, dizziness, abdominal pain, and altered sensorium. She was weighing around 55 kgs. She had given history of ingestion of two bottles (refills) of mosquito repellent available in the house, 2 h before she was brought to the hospital. (Each refill containing 45 ml (396 mg) transfluthrin). On examination, patient was conscious, pupils bilaterally semi constricted and sluggishly reactive to light. On auscultation of lungs crepitations were present bilaterally. Respiratory rate was 28/min. Blood pressure was 110/70 mmHg. In emergency ward, gastric lavage was performed and then continuous gastric aspiration was started through Ryles tube. Oral syrup charcoal 10 ml was given, and Ryles tube was closed at proximal end for some time. Then again aspiration through Ryles tube was continued. Atropine 0.6 mg, pantoprazole 40 mg and ondansetron 4 mg were given intravenously. Tonic-clonic convulsions were observed after 1 h of admission in the emergency ward. Injection phenytoin 700 mg bolus, injection diazepam 10 mg, injection hydrocortisone 100 mg, injection frusemide 20 mg, were administered intravenously. Oxygen enrichment was continued. However, patient had continuous uncontrolled convulsions. Then patient was shifted to intensive care unit and midazolam 5 mg and propofol 100 mg (80 mg + 20 mg) were administered intravenously. Endotracheal intubation was successfully performed with 7.5 mm ID endotracheal tube, and cuff was inflated and oxygen enrichment at 4–6 L/min via T-piece was initiated. Midazolam 4 mg/h and propofol 200 mg/h IV infusions were started. SpO2 was maintained at 100%. Blood pressure was 94/62 mmHg. Pulse rate was 74/min. Arterial blood gas (ABG) reports were normal. Neurophysician advised IV mannitol (20%)100 ml twice a day and IV phenobarbitone (SOS) for seizures.\nPatient was seizure free for few hours but again seizures started, and not controlled even with repeat doses of phenytoin, midazolam, propofol, and phenobarbitone. At that time blood pressure was 80/40 mm of Hg, respiratory rate was 35/min, pulse rate was 190/min, and SpO2 was 95%. Serum potassium, calcium, and sodium were 2.98 mmol/L, 2.5 mmol/L and 129 mmol/L, respectively. Injection dopamine was started at 10 μgm/kg/min. Potassium chloride 1.5 g and hypertonic saline were administered. Despite repeated doses of phenytoin, midazolam, propofol and phenobarbitone, seizures were not controlled. Elective ventilation was planned after muscle paralysis to control seizures. Patient was paralyzed by injection vecuronium 4 mg bolus and 4 mg/h IV infusion , and put on controlled mechanical ventilation (CMV) mode for elective ventilation. Vecuronium was continued at 4 mg/h. Blood pressure further decreased gradually and dopamine dose was increased and propofol infusion was stopped. ABG reports did not show any changes. Computed tomography scan of brain and chest X-ray were normal. Input/output charting for fluids was maintained. Central venous pressure remained at 5-8 cm H2O. Patient was kept on a ventilator for 48 h electively and then gradually weaning started. Vecuronium and midazolam infusion were stopped, and mode of ventilation was changed to synchronized intermittent mandatory ventilation (SIMV). Airway pressure support was set to 15 cm H2O with positive end expiratory pressure of 4 cm H2O. Patient's pulse rate was 102 beats/min, blood pressure 132/82 mmHg and SpO2 remained above 96%.\nPatient had total leucocyte count on day 1 of 7200/mm3 and it increased to 22,000/mm3 on the day 2, 32,000/mm3 on the day 3 and 13,000/mm3 on the day 4, all with neutrophilia without other signs of septicaemia, although antibiotics were continued. The counts decreased to 4000/mm3 on day 6. After 48 h on ventilator, dopamine infusion was tapered down in next 6 h and then stopped. About 6 h on SIMV mode, spontaneous respiration was noticed at 16 breaths/min. Muscle relaxation was reversed with inj. neostigmine 2.5 mg and inj.glycopyrrolate 0.4 mg. Patient started breathing spontaneously with adequate tidal excursion and followed verbal commands and then extubated. Oxygen through mask was given at flow of 4–5 L/min. Respiratory rate was 25 breaths/min, blood pressure was 108/72 mmHg and pulse rate, 119/min. Pupils were normally reacting to light. Patient was nebulised with mistabron 3 mg, repeated 8 hourly. Patient was referred to psychiatrist for counselling. On the day 4, patient was shifted to ward and discharged uneventful from hospital on 7th day.
A 16-year-old girl was admitted to the ICU with a history of consuming poison (20 ml of deltamethrin containing 12.5mg/ml, total dose = 250mg) following a domestic dispute. She presented with status epilepticus. As per the details gathered from the relatives, the patient was having continuous generalized tonic clonic seizures (GTCs) (status) since one hour prior to admission and was even convulsing during her transfer to the hospital. On arrival the patient was immediately intubated and ventilated and resuscitation started.\nThe convulsions were treated with injection Lorazepam, but there was no response. Further, doses of IV Midazolam/ Valproate/Phenobarbitone were given, but the convulsions continued. A bolus does of Thiopentone was then given, after which she stopped convulsing. She was started on a thiopentone infusion. Despite the thiopentone infusion, she had four episodes of GTCs in the next six hours, which were managed with further boluses of thiopentone (200mg) and increase in rate of the infusion. Inotropes were started and IV fluids were continued which were guided by CVP and arterial BP monitoring. Her rhythm on ECG was normal and lungs were clinically dry. CNS examination was not possible because she was sedated with thiopentone. Her pupils were dilated (6mm) and fixed.\nAn EEG showed 80% suppression of the brain. CT scan showed diffuse cerebral edema with effacement of sulci and chinking of lateral ventricles.\nLab reports showed normal S. cholinesterase levels (4340 IU/L), normal serum electrolytes and urine negative for myoglobin.\nAfter 48 hours of being on thiopentone infusion (24 hours without convulsions), she was weaned off thiopentone infusion. The patient was triggering the ventilator well by the next day (day 4). Supports were hence taken off gradually. The patient's pupils became reactive by day 5.\nIn the following days, the patient was tracheostomized (in view of anticipated prolonged mechanical ventilation) and T-piece trials were initiated soon. By day 11, she was opening eyes to call and was moving all four limbs, but with reduced power. Tracheostomy was decannulated on day 14 [].\nNerve conduction studies were done in view of her poor muscle strength which showed “severe, generalized, predominantly motor axonal polyneuropathy”.\nThe patient was shifted to the ward after 18 days of ICU stay, on supportive care. Wheelchair ambulation was started on day 21 and the patient was discharged on day 26.