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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

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)



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.