The Diagnosis and Treatment of Seizure Disorders in the Acute Care Setting

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The Case of the Comatose PrisonerJames Roberts,
MDThe Medical College of Pennsylvania/
Hahnemann UniversityDrexel University School of
MedicineMercy Catholic Medical
CenterPhiladelphia, Pennsylvania
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Case

• A 28 y/o suspected cocaine dealer was involved
  in a police chase that ended with the suspects
  car ramming a pole. The extrication took 30
  minutes due to significant vehicle damage. The
  man was awake at the scene and was taken to a
  hospital for evaluation.

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Case

• At the hospital he had a pulse of 110/min but
  otherwise normal vital signs and no complaints.
  Other than a facial abrasion and a small scalp
  hematoma, the physical examination was normal. In
  the ED he was agitated and urinated on the floor
  of the examining room (I couldnt hold it).

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Case

• No laboratory tests or X rays were performed. He
  was observed for 2 hours, remained stable, and
  was discharged into police custody at 9pm with a
  diagnosis of minor soft tissue injuries. At the
  jail he was placed in a cell with 3 other
  prisoners. At 8am he was unarousable and was
  returned to the hospital.

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Case

• Upon arrival
• Temp 97.4 R
• BP 124/60
• Pulse 78/min
• Resp 16/min
• POx 99 on RA
• Monitor sinus rhythm
• He was incontinent of urine
• Differential diagnosis at this juncture?

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Differential Diagnosis

• Head trauma
• CVA
• Hypoglycemia/Hyperglycemia
• Drug Overdose (body packer, additional ingestion
  in jail)
• Post Ictal
• Malingering
• Wernickes encephalopathy
• Sepsis, CNS infection, hepatic coma,
  hypernatremia

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Further History

• No old records available
• No answer at home phone
• Police clueless
• Previous ED visit confirmed
• Next step further evaluation/treatment

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Further Examination

• Facial injury/scalp hematoma
• No Battles sign/ no hemotympanum
• Abdomen/chest/extremities demonstrated no
  abnormality
• No other signs of trauma
• No sign of IVDA
• Body habitus of chronic cocaine use
• What are the key components of the neurologic
  examination?

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Neurologic Examination

• No response to deep pain/no posturing
• Pupils 2-3 mm and sluggish
• Dysconjugate gaze present
• No gag reflex
• Flaccid extremities/no reflexes elicited
• Negative Babinski sign, no clonus, no
  fasciculations
• Outline the Basic Initial Treatment

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Initial Basic Treatment

• Safety net IV, Oxygen, monitor, pulse ox,
  dynamap
• Dextrostick glucose 110
• Foley catheter clear urine
• ABG pH 7.43 PO2 145 torr on 2 liters PCO2
  42 torr HCO3 23
• Intubated for airway protection
• Note no response to above procedures, including
  intubation
• What definitive tests are required at this
  juncture?

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Results of Tests

• Head CT scan negative
• CBC, Electrolytes, BUN/CR, PT/PTT Normal Urine
  drug screen () cocaine, (-) for barbs, benzo,
  opiates
• Serum ethanol 10 mg
• Lumbar puncture normal opening pressure, neg
  chemistry/no cells
• EKG Normal
• Liver function/ammonia normal
• What therapies are reasonable?

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Therapy Probably Warranted

• Small dose naloxone, charcoal, thiamine
• Toxicology/poison center consultation
• Neurology consultation
• ICU admission

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Therapy Probably Not Warranted

• Flumazenil
• Gastric lavage/WBI
• Antibiotics
• MRI

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Hospital Course

• Admitted to the ICU. Over the next 12-16 hours
  the patient slowly woke up, was extubated, and
  admitted to a 2-week crack cocaine binge, but
  denied other drugs. He related numerous such
  crashes when he ran out of money for cocaine.
• DIAGNOSIS The cocaine washout syndrome

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Pathophysiology of the Cocaine Washout Syndrome

• Most likely a lack of CNSneurotransmitters
• Norepinephrine
• Serotonin
• Dopamine

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Incidence/Clinical Caveats

• Incidence unknown, likely quite common
• No data in the medical literature, but street
  knowledge
• Occurs when drug use halted (medical illness,
  jail, insolvent)
• Precipitated in ED with minimal benzodiazepine
  administration
• Vital signs normal, usually not hypotensive,
  bradycardic
• Signs of cocaine toxicity absent
• Patients appear in a deep sleep state
• Nonresponsiveness may be quite impressive

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Clinical Approach

• Diagnosis
• Clinical diagnosis/rule out other conditions
• No known value of catecholamine level
• Urine positive for cocaine
• May require extensive, expensive R/O workup
• Treatment
• Supportive only/protect airway and vital signs
• Stimulants not warranted
• Course
• Patients wake up slowly over 12-24 hours