Post Your Cases > TCA overdose hemodynamic instability successfully reversed with Intralipid

A Male in his mid-20s was found unconscious by EMS at a train station at night and was transported to the emergency department. The patient was then found to be in a wide-complex tachycardia and had subsequent seizures and a cardiac arrest. He was resuscitated with multiple boluses of NaHCO3. His electronic health record indicated multiple previous presentations secondary to TCA overdose.

The patient was admitted to the ICU, intubated, and although his QRS complex was normalized on a NAHCO3 infusion, he required progressively higher doses of norepinephrine and epinephrine infusions to maintain his blood pressure.

When the daytime ICU team arrived, the patient was on 70micrograms/minute of IV norepinephrine and 20micrograms/minutes of IV epinephrine to maintain a mean arterial pressure of 65mm Hg. The suggestion to give intralipid was made and a bolus of 100mL was given push with the remaining 400mL in the bag infused over the next 30minutes, for a total dose of 500mL over 30minutes.

Over the next 6 hours the patient's blood pressure responded and he was successfully weaned off all of his norepinephrine and epinephrine infusions. We was subsequently extubated the next day and was a GCS 15 the day following that and was transfered to the psychiatry service. The patient's TCA screen was positive and he admitted to taking 85 tablets of 50mg amitriptyline (total dose 4.25g amitriptyline).
February 21, 2010 | Unregistered CommenterPaul Engels
Great case, Paul...thanks for posting. a few things come to mind. First, i'd request you posting it with my sister (or at least sibling) organisation: www.lipidregistry.org. just go to the site and register. next, i think it makes sense for you to write this up, at least as a letter-to-the-editor, but better yet, a full case report. as you probably know there are ample data in support of using lipid in TCA toxicity, and I've heard of at least one impressive case...but nothing published yet. quetiapine, haldol, verapimil, yes. TCA, no. so you could be first.
finally, as you also probably know i have a solid body of published data showing that epi is inimical to effective lipid rescue and additional data now indicating that it may just be bad in general. persistent low output seems a natural response to prolonged epi infusion, and may explain why so few patients survive that even when the underlying sepsis or other problemm is fixed. i would submit that this patient's prolonged recovery was in fact related to the high dose epi and norepi infusion. i'm curious: did he at any time have either pulmonary edema or evidence of poor gas exchange (either high A-a DO2 or high pCO2)?
keep in touch and let me know your thoughts and how the patient is doing.
regards,
guy
February 22, 2010 | Registered Commenter[Guy Weinberg]
Thanks Paul for this post. Please post on the lipid registry as this is very relevant to the data collection on that site.

Pure conjecture, I know, but given the way this gentleman responded, I wonder if there may have been scope to have given the lipid earlier. Just a thought, Very well done in any case!
February 24, 2010 | Unregistered CommenterDavid Uncles