Case Conference

1
Case Conference

• Toxicology
• Presenter ??? / ???
• Aug. 26, 2002

2
Patient Profile

• ??? 63-year-old
• Date of admission Aug. 9.2002, 1135am
• Consciousness verbal
• T 35.4?C PR61/min RR 18/min BP 49/16 ?
  70/28 mmHg
• Triage by Nurse II

3
Chief complaint

• Conscious change after committed suicide by
  overdosed oral medications

4
History of Present Illness

• 63-year-old man with history of hypertension
  received regular medication control from CGMH.
• He ate over 70 tablets/ capsules of the OPD drugs
  as for suicide at 8am.
• Conscious changed at 9-10am and was found and
  sent to our ED by family.
• No drug formula was available on the arrival .

5
Past Medical History

• Hypertension regular controlled
• No DM, other systemic illness
• Smoking 1-2 PPD
• Alcohol 200 500 ml of beer / day

6
Physical Examination

• Consciousness stupor, E1V1M4
• Pupil 3mm / 3mm
• Neck supple
• Breath sound clear
• Heart sound irregular heart beat
• Abdomen soft
• Extremities movable

7
ECG monitor
8
12-lead ECG
9
Impression

• Drug overdose , unknown medication
• AV dissociation with hypotension

10
Orders

• TRIAGE Class I
• CBC/DC
• BCS
• PT/APTT
• Digoxin level
• EKG, BP monitor
• EKGintubation
• On CVP
• NS challenge 500ml
• On critical
• F/S 120

• Dopamine 2amp in D5W 250 run 20ml/hr
• On TCP
• On NG
• Active Charcoal 1bot Mg citrate 1bot via NG
• CXR (portable)
• Hold on endo
• DC active charcoal , mg citrate,
• ABG,
• O2 mask 10L/min

11
Laboratory findings

• CBC WBC11800 S76.5 L15 M8 E0.5 Hgb 18.5
  Hct 50.3 Platelet 185
• PT INR 1.13 PTT 26.35/ 31.3
• BCS Glu 135 GOT28, BUN21 CRTN 3.0 Na 137
  K3.2 Ca 9.4CPK226 TnI lt0.1 CK-MB 22
• ABG pH 7.43 pCO2 23.8 PO2245.6 BE -5.8
  HCO315.9 Sat 99.9
• CXR borderline cardiomegaly

12
Medications from CGMH

• Diltialem, Losartan, Thiazide, Bisolvon.

13
Hospital course

• On TVP
• ICU admission
• Calcium gluconate, Dopamine, IV fluid
• Amiodarone for chemoconversion
• ARF recovered gradually
• Discharged with excellent performance

14
Approach to antihypertensives overdose

• ABC
• IV O2 Monitor
• Mental status change Glucose naloxone as
  initial intervention
• Hypotension
• N/S, L/R 500ml challenge or 10 20mL/kg
• Dopamine 2 5 mcg/kg/min
• Activated charcoal, gastric decontamination
• Determine the medication

15
CCB overdose overview
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CCB overdose features

• Bradycardia with hypotension
• Altered mental status
• Generalized weakness
• Metabolic acidosis with hyperglycemia
• Sinus arrest on ECG
• Refractory shock

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CCB overdose complication 1

• Cardiovascular Hypotension, sinus bradycardia,
  sinus arrest, AV block, AV dissociation,
  junctional rhythm, asystole ventricular
  dysrhythmias uncommon except with bepridil
• Pulmonary Respiratory depression, apnea
  pulmonary edema ARDS
• Gastrointestinal Nausea, vomiting bowel
  infarction (rare)

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CCB overdose complication 2

• NeurologicLethargy, confusion, slurred speech,
  coma seizures (uncommon) cerebral infarction
  (rare)
• Metabolic Metabolic (lactic) acidosis
  hyperglycemia (mild) hyperkalemia (mild)
• Dermatologic Flushing, diaphoresis, pallor,
  peripheral cyanosis

19
CCB overdose - treatment 1

• Phase 1
• Boluses of atropine, calcium, fluids
• Phase 2
• Catecholamine infusions
• Calcium infusion
• Glucagon infusion
• Insulin glucose infusion
• Phosphodiesterase infusion
• External or transvenous cardiac pacing
• Invasive monitoring

• Phase 3
• Consider IABP, cardiac bypass

20
CCB overdose treatment 2

• A. Airway, ventilation, O2
• B. Large bore catheter, N/S 10 20ml/kg
• C. Keep pH gt 7.20, Klt5.0 meq/L
• D. Prepare for TCP
• E. 0.1 CaCl2 10 20mg/kg, maintenance
  20mg/kg/h
• F. 0.1mg/kg glucagon Bolus. maintenance 0.1
  mg/kg/h

21
CCB overdose treatment 3

• G. Dopamin 10 mcg/kg/min, sys. BP gt100
• H. HRlt 40 ? pacing, HR 60 80/min
• I. Hypotension persists ? amrinone 750mcg/kg,
  10mcg/kg/min
• J. Insulin-dextrose RI 1u/kg bolus, keep 1u/kg/h
  with G50W 1ml/kg/h via CVP
• K. CVVHD, charcoal hemoperfusion, IABP ECMO

22
Drug induced AV dissociation

• Digoxin
• Beta blockers
• Calcium channel blockers
• Amiodarone
• Procainamide
• Class IC

23
Beta blocker overdose

• Manifestations and Complications of ß-Blocker
  Overdose in Order of Decreasing Frequency
• Bradycardia (65/90 cases)
• Hypotension (64/90)
• Unconsciousness (50/90)
• Respiratory arrest or insufficiency (34/90)
• Hypoglycemia (uncommon in adults)
• Seizures (common only with propranolol, 16/90)
• Symptomatic bronchospasm (uncommon)
• VT or VF (6/90)
• Mild hyperkalemia (uncommon)
• Hepatotoxicity, mesenteric ischemia, renal
  failure (rare or single case reports)
• Data in parentheses from Langemeijer JJM et al
  Neth J Med 40308, 1992.

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Noncardiac Symptoms of Digitalis Intoxication

• General
• Weakness
• Fatigue
• Malaise
• Gastrointestinal
• Nausea and vomiting
• Anorexia
• Abdominal pain
• Diarrhea
• Ophthalmologic
• Blurred or snowy vision
• Photophobia
• Yellow-green chromatopsia (also red, brown, blue)
• Transient amblyopia, diplopia, scotomata,
  blindness

• Neurologic
• Dizziness
• Headache
• Confusion, disorientation, delirium
• Visual and auditory hallucinations
• Paranoid ideation, acute psychosis
• Somnolence
• Abnormal dreams
• Paresthesias and neuralgia
• Aphasia
• Seizures

25
Dysrhythmias Associated with Digitalis Toxicity

• Nonspecific
• PVCs, especially bigeminal and multiform
• First-, second- (Wenckebach), and third-degree AV
  block
• Sinus bradycardia
• Sinus tachycardia
• Sinoatrial block or arrest
• Atrial fibrillation with slow ventricular
  response
• Atrial tachycardia
• Junctional (escape) rhythm
• AV dissociation
• Ventricular bigeminy and trigeminy
• Ventricular tachycardia
• Torsades de pointes
• Ventricular fibrillation
• More Specific, but not Pathognomonic
• Atrial fibrillation with slow, regular
  ventricular rate (AV dissociation)
• Nonparoxysmal junctional tachycardia (rate 70 to
  130)
• Atrial tachycardia with block (atrial rate
  usually 150 to 200)
• Bidirectional ventricular tachycardia

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Thiazide overdose

• Toxicity
• Volume contraction
• BP ? HR? AMS
• Electrolyte derengaments
• Na ? K ? Ca ? Mg ? Cl ?
• Rash pruritis, hearing loss, leukopenia
• Treatment
• Normal saline, potassium replacement

27
Losartan overdose

• Symptom
• Hypotension
• Bradycardia
• Management
• IV ormal saline
• Observation
• Monitoring

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AV dissociation