---

24yr male presented 3hrs after consumption of unknown quantity of pesticide endosulfan poison (Container was available to us after a while)

He was first seen at another small hospital where he was treated as per the norms of organophospate poisoning with atropine 100ml and pralidoxime 1gm. He was given 200mg of phenobarbitone and 5mg midazolam, intubated there and shifted to us as they could not control his seizures. They had also catherized him.

On arrival to our ED he was having continous generalized tonic clonic seizures. The paramedic could ventilate him despite his seizures.

P-70
BP-Could not be measured. Radial pulses were palpable.
RR-Ventilated at 24/min
Sp02-Sporadically showed 85-90% due to seizures
T-108.6F (Axillary)
Approx wt 50kg
Catheter had dark colored urine

He had a cardiac arrest immediately. CPR was started continued for 5 mins with no response. Persistent asystole. He recieved 10ml of 10%% calcium gluconate and 100ml of sodium bicarbonate iv bolus during CPR as well as 1mg of adrenaline. The atropine which was still flowing was allowed to continue. With another 5mins of CPR he responded with a good pulse of 140/min.

We assumed he was highly likely to have consumed Endosulfan.

Immediate problems were:
Refractory seizures
Hyperthermia
Rhabdomyolysis

We started ice water cooling measures and a 1L fluid bolus with normal saline.
He recieved the following drugs in approx 20-35mins
Inj Midazolam 5mg IV
Inj Midazolam 5mg IV
Inj Thiopentone 100mg IV
Inj Thiopentone 100mg IV
Inj Lorazepam 5mg IV
Inj Phenytoin 1000mg IV
Inj Thiopentone 100mg IV (Seizures persisting in face & neck)
Inj Phenobarbitone 1000mg IV
Inj Thiopentone 100mg IV (Seizures persisting in face only)
Inj Lorazepam 5mg (All seizure activity subsided)

His post resus ABG showed a pH of 7.0 and K+ of 5.9

He was admitted to an intensive care unit but was discharged against medical advice 24 hrs later due to financial contraints in his family.
Therefore could not be follwed up.

We had controlled his seizures with multiple drugs.
Every hospital has its own method or protocol of managing such patients.


What is the ideal treatment of seizures in endosulfan poisoning?
Are there any proper evidence or studies?


(No specific antidote. Control seizures with phenobarbital supported with diazepam. Atropine, pralidoxime, morphine derivatives and adrenergic compounds are contraindicated - BAYER MATERIAL SAFETY DATASHEET FOR ENDOSULFAN May 2007)
.