UMEM Educational Pearls

Category: Toxicology

Title: Toxin Induced Status Epilepticus

Keywords: isoniazid, sulfonylureas, tetramine, bupropion (PubMed Search)

Posted: 6/26/2009 by Fermin Barrueto, MD
Click here to contact Fermin Barrueto, MD

A patient presents to the University of MD ED in generalized convulsive status epilepticus. Continuous seizure activity that is not stopped by any dose of benzodiazepine [This is actually a very rare entity]. What is your next move?

- Check your basics: Fingerstick blood glucose (hypoglycemics can cause SE)

- Phenytoin is not going to work fast enough, the clock is ticking and the patient's brain cannot handle continuous status epilepticus, after 45-60min permanent neurologic sequelae or death will occur. If the cause is toxin induced, it just won't work.

- In an area where HIV is endemic, you have to consider Isoniazid - an antituberculous drug - and administer antidotal therapy: empiric dosing of vitamin B6 (pyridoxine) 5g IV. It is the only thing that will work.

- From the ED perspective, you will also be using a barbituate though there is evidence to support the use of propofol (after intubation for both). This will hopefully stop the seizure

- General anesthesia is the last chance if all else fails.



Propofol and midazolam in the treatment of refractory status epilepticus.

Prasad A, Worrall BB, Bertram EH, Bleck TP.

Epilepsia. 2001 Mar;42(3):380-6.