LAUSR

Learning Objectives: Bifenthrin, from the Type 1 pyrethroid family, theoretically has a low toxicity in humans. In insects, this insecticide class prolongs the activation of neuronal voltage-dependent Na+ channels. But the mammalian channel has many isoforms, which is believed to account for its lower toxicity in humans, making it a safer insecticide for household use. Its slow absorption, dose dependency, and adverse effects have yet to be clearly defined in pediatrics. To date, there is one other report of pediatric pyrethroid co-ingestion, but this would be the first case of only Bifenthrin. Methods: A 4-year-old male with history of prematurity and IVH causing hydrocephalus s/p VP shunt presented with neuropathy, tremors, and tachycardia that progressed to status epilepticus and respiratory failure after ingesting 2–3 ounces of bifenthrin. Initial lab work was normal. His seizures were refractory to 2 administrations of lorazepam 1 mg/kg, levetiracetam 30 mg/kg, and midazolam drip. Within 12 hours of ingestion, he required a load of pentobarbital 10 mg/kg, repeat load of 9 mg/kg over 20 minutes, and was finally stabilized on a drip of 5 mg/kg/hr. By EEG, he was in refractory status for 110 minutes. His total time in burst suppression was 88 hours. Some other manifestations of ingestion included QT prolongation on hospital day 2 and DI requiring a vasopressin drip. His course was further complicated by H. flu pneumonia. Ultimately, he was discharged to a rehabilitation facility, where he regained all previous skills and suffered no neurologic deficit. Results: Though thought of as a preferred insecticide for household use, this case highlights potential dangers of pyrethroid ingestion in pediatric patients. Without literature on sole ingestions of Bifentrin, this case could inform practitioners on a potentially deadly presentation in a pediatric patient. The theoretical dose dependent effect of bifenthrin combined with the slower onset of action are demonstrated. This patient exhibited many atypical features of Bifenthrin ingestion, including respiratory failure, status epilepticus, and EKG abnormalities such as tachycardia and prolonged QT. His seizures were refractory to many anti-epilepticus, ultimately requiring burst suppression. In the future, ingestions that have initial signs consistent with this case may be managed more aggressively to prevent refractory status epilepticus, which is known to have poor morbidity and mortality.