Ataxic Girl

Ataxic Girl Cont'

Thank you all for excellent comments Acute carbamazepine toxicity is characterized by neurologic and cardio­vascular effects. The neurologic disturbances include nystagmus, ataxia, seizures, and coma. Cardiovascular effects include sinus tachycardia, hypotension, myocardial depression, and, rarely, cardiac conduction abnormalities such as QRS complex and QT interval prolongation. The toxicity of carbamazepine in children differs slightly from that in adults. Children experience a higher incidence of dystonic reactions, choreoathetosis, and seizures and have a lower inci­dence of ECG abnormalities. The incidence of carbamazepine-induced hyponatremia ranges from 1.8% to 40%. Increased antidiuretic hormone secretion (SIADH) or increased sensitivity of peripheral osmoreceptors to antidiuretic hormone are sug­gested mechanisms Serum Carbamazepine level can be checked.Carbamazepine cross-reacts with some toxicology screening for tricyclic antidepressants The Mainstay of management is supportive care - Multiple-dose activated charcoal is associated with improved outcomes in several studies and is rec­ommended for to patients presenting with large overdoses, if there are no contraindications. - Seizures should be treated with benzodiazepines. - Vasopressors should be used for hypotension that is refractory to fluids. - Sodium bicarbonate is recommended if the QRS complex duration exceeds 100 milliseconds (ms). Serial serum concentrations should be obtained owing to delays in peak concentrations. -Extracorporeal drug removal is reasonable in cases of severe poisonings associated with intractable sei­zures or life-threatening dysrhythmias.Intermittent hemodialysis (HD) is preferred References 1. Goldrank’s Toxicologic Emergencies 11th edition

Good evening Dr.Suad

Thanks a lot for sharing such interesting case with us, it motivate me to read about it

Q1:

Carbamazepine toxicity

-Neurologic toxicity : ataxia, nystagmus, sezuire, coma

-Anticholinergic toxicity

-CVS toxicity: ECG finding: wide QRS, QT prolongation ,

Q2:

I agree to all previous answers to start with primary survey

And I see I should not give AC , as the patient passed 1 hr from ingestion

For dialysis, it indicated if patient develop : (interactable seizuire , respiratory depression, rising carbamezapine level despite supportive care ) which already mention above by Dr.Abdulaziz and Dr.Sulaiman

as mentioned above , this is carbamazepine toxicity.

just to add , carbamazepine can act like TCA ( Sodium channel blocker) thus this pt is at risk of arrhythmia and ECG should be repeated frequently as it is a slow release tabs and because of its anticholinergic effect , the peak of the drug level may take longer to happen.

for the same reason, even if the pt was asymptomatic , she need at least 8 hrs of ED observation. now in this pt , she already show some CNS effect thus definitely she need admission and very close monitoring as if the drug level keep increasing she may deteriorate ( COMA).

regarding the management part , I will just add the rule of sodium bicarb as we said CARBMAZEPINe may act like TCA

dialysis is a great option for high levels ( >40 mg/l) , coma and in case of haemodynamic instability.

Q1:

• in this patient , the expected Carbamazepine toxicity is anticipated to fall into the severe neurotoxicity category given the fact that she ingested 10 tablets of 400 mg, so more than 50mg/kg (assuming she has an average adult weight)

Q2:

• even though she seems stable, we should not relax. As it is a controlled release tablet, carbamazepine levels can reach a peak around 12 hours after ingestion and patient condition can deteriorate to coma.

• The patient should be in a monitored bed, and go with the ABCD approach, with the usual toxicology investigations.

• Airway assessment is important as CNS depression can put her airways at risk, pre-emptive intubation should be kept on mind.

• A toxicologist should be on board, and we should decide on the benefit of decontamination with activated charcoal, after protecting her airways.

• Enhanced elimination with multi-dose activated charcoal vs hemodialysis should be decided on depending on patient condition.

• Patient should be admitted for close monitoring of vitals, ecg, and serial carbamazepine levels.

1- from the picture above and clinical presentation, she has carbamazepine toxicity which as Sulaiman mentioned Anticholinergic and antiepileptic effects. We have to be carful because it might have delayed course and follow crescendo-decrescendo course due to delayed GI motility. However, we should consider other drugs like paracetamol and aspirin.

2- managment again ABCD:

- we have to support ABC as indicated, since she is mentioning her airway and vitals normal, will keep her on monitor for any deterioration.

- for decontamination , since she is presenting 3 hours post ingestion and she is drowsy and may aspirate, will not give AC.

- if she developed seizure: Benzos

- watch for any change in ECG specialy ( widening QRS, PR prolongation) and treat accordingly.

- will consider dialysis if :

* intractable seizure

* life threatening dysrhythmias

*respiratory depression needs mechanical ventilation.

*rising level despite maximum supporting measures.

- observation for 6 hours, if she remained asymptomatic, normal vitals and lab investigations, level is normal and not rising can be discharged after psychiatry evaluation.

A1: mild-moderate CNS effects

(e.g: Ataxia.. Nystagmus ) & Anticholinergic effects.

Carbamazepin toxicity : has anticholenergic and antiepileptic effect. how to manage ?

- Resuscitate ABCDE

- It is temping to give activate charcoal yet she is drowsy unless i protect her airways

- Suppotive care , benzo if she seizes , Na bicarbs if wide qrs (ECG normal here)

- labs i will send carbamazepine level but also paracetamol level, along with VBG.

- If level if coming down when repeated and patient is improving then will continue supportive care

- I will consider dialysis if severe symtpos like refractory seizures or respiratory depression .

- Will need a psych review for her suicidal attempt

- discharge once cleared by psych when asymptomatic and level of carbamazepine is coming down .