(747) Polysubstance Ingestion Mimicking Brain Death

Introduction: Toxicologic mimickers of brain death have been previously identified and primarily include snake envenomation, baclofen, and tricyclic antidepressants. These patients are unresponsive, intubated, and have absence of most or all brain stem reflexes. Despite this, patients typically recover. We present a patient with physical exam and EEG findings suggestive of brain death after intentional lacosamide and gabapentin ingestion.

Description: An 11-year-old female with von Willebrand disease and Chiari malformation presented to the emergency department with altered mental status and seizure-like activity. There was concern for ingestion but rapid urine drug screen was negative. Other significant labs included a lactic acidosis without electrolyte derangement. She subsequently had two cardiac arrests from ventricular arrhythmias, lasting 5 and 7 minutes. CT head showed no acute findings. Initial GCS was 3T, with absent brainstem reflexes and myoclonus upon stimulation. Continuous EEG showed myoclonic status epilepticus progressing to spontaneous burst suppression pattern, followed by diffuse slowing and attenuation over the first 24hr, which is a poor prognostic factor after cardiac arrest. MRI was normal, without any signs of anoxic injury. Supportive medical care was continued, and the patient’s exam gradually improved. She was extubated on hospital day 6 and discharged on day 10 at her neurologic baseline. Expanded urine drug screening resulted after discharge and was positive for lacosamide and gabapentin, which were present in the patient’s home and had not been given during hospitalization.

Discussion: This is a novel case of lacosamide and gabapentin ingestion mimicking brain death. Lacosamide’s action on sodium channels can lead to cardiac arrhythmias, and both medications can cause significant neurologic depression. This highlights the need for ongoing discussion on early neurological prognostication after cardiac arrest, particularly in cases of unknown etiology.