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.
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.