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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):
- Montelukast 10 mg (Singulair) – leukotriene receptor antagonist. mild tox profile (3698 pediatric ingestions from Texas Poison Control: 95% asymptomatic)
- Promethazine 25 mg (Phenergan) – Anticholinergic (56% tachycardia, 42% delirium, 2% mechanical ventilation, 1% hypotension)
- Cyproheptadine 4 mg – Anticholinergic; mild tox profile (892% of OD in one case series had no or mild symptoms)
- Clonazepam 1 mg (Klonipin) – Common: respiratory depression and hypotension; Rare: heart block/dysrythmia
- Amitriptyline 25 mg – TCA – Hypotension. QRS widening with R wave in AVR
- Treatment:
- antidote = sodium bicarbonate
- crystalloid for hypotension
- Pressors for refractory hypotension
- Treatment:
- Amlodipine 5 mg – Calcium Channel Blocker – Common: Bradycardia, hypotension, heart block; Rare: apnea, pulmonary edema, ARDS, coma, Lactica acidosis, hypoerglycemia, bowel infarction
- Treatment:
- IVF
- High Dose Calcium (inotrope)
- Pressors – Isoproterenol
- Glucagon
- Atropine
- High Dose Insulin – 1-10 unit/kg/hr infusion (consider simultaneous glucose infusion)
- Treatment:
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!):
- AF with RVR
- DVT
- ipsilateral limb ischemia > Necrotizing fasciitis > AKA
- Pleural Effusion > chest tube
- Bowel perforation (due to ischemia) > laparotomy
- Trach/PEG
- Abdominal Wall Abscess > I&D
Learning Points:
- RUSH exam early for undifferentiated shock
- Restrictive lung strategy to avoid ARDS
- Multi-agent OD: contact Poison Control – they can actually help! 1-800-411-8080
- 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.