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