Introduction: Status epilepticus (SE) is a neurologic emergency with diverse causes, including rare medication-induced neurotoxicity. Both local anesthetic systemic toxicity (LAST) and tranexamic acid (TXA)-induced seizures are uncommon, but their combined use may increase the risk of severe central nervous system complications. We report a rare case of refractory status epilepticus (RSE) after a hair transplant, likely triggered by synergistic neurotoxicity from local anesthetics and TXA. Description: A 48-year-old healthy man developed SE during a hair transplant after receiving 1300 mg oral TXA, 13.6 mL 4% Septocaine, 8 mL 0.5% lidocaine, 18 mL Marcaine, and 500 mg IV TXA. He had a tonic-clonic seizure unresponsive to 10 mg IV midazolam and was intubated by EMS. He was treated with levetiracetam and lipid emulsion therapy for suspected LAST. EEG showed ongoing seizures, prompting escalation of midazolam and propofol infusions and initiation of ketamine drip to achieve burst suppression. Maintenance therapy included levetiracetam and fosphenytoin. Brain MRI showed no acute abnormalities. After sustained burst suppression, midazolam was tapered and ketamine discontinued following a seizure-free period. His ICU course was complicated by ARDS from ventilator-associated pneumonia and renal failure requiring dialysis. The etiology of RSE was suspected to involve local anesthetics administered to the vascular scalp, TXA, or both. Discussion: RSE is a life-threatening emergency requiring prompt diagnosis and broad diagnostic consideration. While seizures are a known feature of LAST, SE is rare. High doses of local anesthetics lower seizure threshold by inhibiting GABA-A receptors, blocking potassium channels, and activating L-type calcium channels. TXA can induce seizures by inhibition of glycine and GABA-A receptors. In this case, either or both agents likely contributed to RSE. Treatment included lipid emulsion therapy for LAST and infusions of midazolam, propofol, and ketamine. General anesthetics like propofol are first-line for TXA-induced seizures. This case underscores the need for early recognition and management of rare neurotoxic effects from combined local anesthetics and TXA, especially in highly vascular areas where systemic absorption can cause life-threatening neurologic complications.
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