EDECMO 27 – A Real-World Case of a Crashing Multi-Drug OD Patient Saved with ED ECMO

Dan McCollum MD 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.

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