Tomas Murphy and Sidra Ilyas delivered a great morning report today about Valproate intoxication, here are the educational highlights from today’s case:
Delirium means an acute change in mental status, do not just use altered mental status
Delirium is a case that you will see very frequently (very very very frequently ?)
So keep in mind the differential:
A) Brain:
-Epilepsy and post-ictal states
-Head injury
-HTN encephalopathy
B) Infections
-Sepsis (UTI, pneumonia, infected ulcers….)
-Encephalitis, meningitis, cerebritis
-Fever related delirium
C) Drugs and toxins
-Rx meds (opiates, BZD, antipsychotics, Li, skeletal muscle relaxants)
-Anti-histamines
-Abuse (EtOH, heroin, hallucinogens)
-Withdrawal (EtOH, BZD)
-Poisons (atypical alcohols, carbon monoxide)
D) Metabolic derangements
-Elevated/decreased Na, Elevated Ca
-Hypercarbia and hypoxemia
-Hyper/hypoglycemia
-Nutritional (Wernicke’s encephalopathy in an alcoholic…)
E) Systemic organ failure
-Uremia
-Acute/chronic liver failure
-Respiratory failure (hypercarbia and hypoxemia)
3-Valproate intoxication:
CNS: Delirium, encephalopathy (acute OD or therapeutic dose)
Vitals: Hypotension, tachycardia, respiratory depression, hyperthermia (acute overdose)
Metabolic acidosis (acute overdose)
Hyperammonemia (therapeutic levels or acute overdose). Levels are usually > 80
4-Treatment
- GI decontamination (activated charcoal) in acute overdose
- Supportive care for hypotension and respiratory depression if present (IV fluids, vasopressors, mechanical ventilation, benzodiazepines in case of seizures….)
- Carnitine for valproate toxicity associated with hyperammonemia, coma, lethargy or hepatic dysfunction. Dose: 100 mg /kg IV over 30 minutes, followed by 50 mg/kg IV every 8 hrs
A nice differential for toxidromes was discussed by Tomas at the end, check out the presentation for more info!
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