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More Than A Gesture
Michael D. Schwartz, MD
Centers for Disease Control/
ATSDR/Georgia Poison Center
(Fellowship Sponsor: Oak Ridge Institute for Science & Education, Department of Energy)
“There are No Interesting Cases after 3 A.M.”
• 47 y/o female who ingested “a lot” of her medication– 0300: Woke up and went to living room
– 0310: Mother got up and found her with empty bottle
• Schizophrenia• Takes Depot Haloperidol, diphenhydramine, X• Denies drugs/ETOH; does smoke
• ER: Patient took 10 of DPH…but 100 of X
Initial ED Course
• EMS: Refused AC/C, stable, NSR
• BP 120/80, P=70, T=36.1, RR/Sat=16/100%
• PE: Normal pupils, cardiac, pulm., abd.
• Neuro: “I want to die.”
• FSBS = 100
• EKG #1 shows NSR=70, normal intervals, no acute changes
Patient’s last normal ECG for a while
“I Want to Die”
• At the conclusion of the physical exam: the patient suddenly experienced pulseless ventricular tachycardic arrest
• Shocked into sinus & restoration of pulse with the aid of a handy LifePak nearby.
• Georgia Poison Center called
Post-Arrest
• Pulse 60, BP 70/50 (dopamine 20 mcg),
• Intubated, A-line, C-line, NG, AC/C
• ABG: 7.51/19/356/15/100%– K+ 1.0 mEq/L
• Post-arrest EKG: LBBB, QRS 236 msec, QT 528 msec
Post-Arrest ECG #2
Labs
• Urine Toxicology screen: Negative• APAP/ASA: Negative• CBC: normal• 140 105 12 178 Ca = 8.7, Mg = 2.3• 1.3 18 1.2• Cardiac enzymes: normal• Serum Osm: normal, Lactate: normal• LFTs: normal
Tox Attending: “I’m not sure Sodium Bicarbonate is such a good idea…”
K+ = 1.3
NaHCO3 = Dead
QT = Long
QRS = Wide
What’s A Fella/ow to Do?
• Switched from dopamine to norepinephrine 4 mcg/min, BP = 130/70
• “Potassium-in-Every-Orifice” Method: K=1.8
• Magnesium 4 gm IV prophylaxis for TdP
• Patient’s HR holding at 82
• 300 cc 3% NaCl infused rapidly
• Toxicology Fellow’s HR = 220-Age
ECG #3 (2 minutes of hot salt)
ECG #4 (completion of hot salt)
ECG #5 (after conversion)
ECG #6 (ICU Day 1) QRS 80 msec, QT 396 msec, K = 4.6, norepinephrine D/C’d
A laboratory result was reported
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