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 20-year-old girl was brought to the emergency department with a history of sudden onset convulsions. There was no history of fever, drug usage, trauma, or any past history of convulsions before the onset of convulsions. The patient was given a single dose of intravenous (IV) diazepam 10 mg for control of generalized tonic-clonic convulsion but since control over the convulsions was achieved, a loading dose of phenytoin 1 g was given. As the convulsions persisted, propofol 50 mg IV was given, which controlled the convulsions. Computed tomography (CT) scan head revealed no abnormality. Electroencephalograpy could not be done due to lack of facilities. Blood sugar, electrolytes, and arterial blood gas analysis showed no deviation from normal values. Noninvasive blood pressure, electrocardiography, and oxygen saturation monitoring was done. The patient was then shifted to the intensive care unit (ICU) and IV infusion of midazolam 0.1 mg/kg/h was initiated and phenytoin 100 mg given 8 hourly. There was no episode of convulsions thereafter. The patient developed hypotension for which inotropic support was started. A central venous cannulation was done to guide the fluid therapy and titrate the dose of inotrope. Breathing was normal and there was no need to mechanically ventilate the patient.\nOn arrival in the ICU, the relatives accompanying gave some history of domestic dispute and doubt of ingestion of some substance. A Ryle's tube was inserted and gastric lavage given. The patient had complaint of nausea, vomiting, and abdominal discomfort for which symptomatic treatment was given. The patient's sensorium improved the next day and she gave the history of ingestion of contents of two bottles of mosquito repellent available in the house commercially marketed as All-Out (prallethrin 1.6% w/w liquid, 35 mL in each bottle, that is, total dose of 1120 mg). The patient had excessive secretions so atropine 0.6 mg IV was started at 4 hourly intervals, in addition to antiemetics and proton-pump inhibitors. The condition of the patient improved gradually and by 5th day the patient was shifted to the ward from where she was discharged on the 7th day.