EDECMO 27 – A Real-World Case of a Crashing Multi-Drug OD Patient Saved with ED ECMO

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Dan McCollum MD
Assistant Program Residency Director at Georgia Regents University
Augusta, Georgia
Academic Medical center, Level 1 Trauma Center: census >90,000/yr

“If someone is doing an effective therapy out of the back of a truck successfully, and you can’t make it work in your hospital, then you suck and should feel bad.”

Case: 38 y/o female multi-drug OD on (possibly):

1. Montelukast 10 mg (Singulair) – leukotriene receptor antagonist. mild tox profile (3698 pediatric ingestions from Texas Poison Control: 95% asymptomatic)
2. Promethazine 25 mg (Phenergan) – Anticholinergic (56% tachycardia, 42% delirium, 2% mechanical ventilation, 1% hypotension)
3. Cyproheptadine 4 mg  – Anticholinergic; mild tox profile (892% of OD in one case series had no or mild symptoms)
4. Clonazepam 1 mg (Klonipin) – Common: respiratory depression and hypotension; Rare: heart block/dysrythmia
5. Amitriptyline 25 mg – TCA – Hypotension.  QRS widening with R wave in AVR
   • Treatment:
     • antidote = sodium bicarbonate
     • crystalloid for hypotension
     • Pressors for refractory hypotension
6. Amlodipine 5 mg – Calcium Channel Blocker – Common: Bradycardia, hypotension, heart block; Rare: apnea, pulmonary edema, ARDS, coma, Lactica acidosis, hypoerglycemia, bowel infarction
   • Treatment:
     1. IVF
     2. High Dose Calcium (inotrope)
     3. Pressors – Isoproterenol
     4. Glucagon
     5. Atropine
     6. High Dose Insulin – 1-10 unit/kg/hr infusion (consider simultaneous glucose infusion)

Timeline before ECMO:

• 02:00-17:00     Estimated time of ingestion:  (2-15 hours PTA).
• 19:00                 Presentation to ED
• 19:30                 BP 55/33; sats 93% on 60% FiO2
• 19:41                  PEA ARREST #1
  • Epinephrine, Atropine, Sodium Bicarbonate, Calcium Gluconate, D50
  • Narcan > No response
• 19:54                  Bradycardia with pulse
• 20:10                  Bicarbonate gtt
• 20:15                  Epinephrine gtt
• 20:18                  High Dose Insulin bolus, then gtt
• 20:31                  TC pacing
• 20:40                 Norepi gtt, Charcoal
• 20:46                 CXR = pulmonary edema
• 21:07                  Bivent initiation
• 21:14                  Intralipid bolus
• 21:16                  Glucagon
• 21:21                  43/29 with sats 69% and pulse 70
• 21:31                 pRBC transfusion initiated

Total Meds used in resuscitation:

• Calcium Gluconate:                21 Amps
• Sodium Bicarbonate:             19 Ams
• Epinephrine:                           9.5 mg + drips
• Insulin:                                     ~150 units

Complications during hospitalization (but the patient is alive!):

1. AF with RVR
2. DVT
3. ipsilateral limb ischemia > Necrotizing fasciitis > AKA
4. Pleural Effusion > chest tube
5. Bowel perforation (due to ischemia) > laparotomy
6. Trach/PEG
7. Abdominal Wall Abscess > I&D

Learning Points:

1. RUSH exam early for undifferentiated shock
2. Restrictive lung strategy to avoid ARDS
3. Multi-agent OD: contact Poison Control – they can actually help! 1-800-411-8080
4. ECMO is a bridge to metabolism/recovery.

“If someone is doing an effective therapy out of the back of a truck successfully, and you can’t make it work in your hospital, then you suck and should feel bad.” – Dan

*and special thanks to Dan McCollum for creating and sharing the Napoleon Dynomite memes.