Post Your Cases > Intralipid in combined TCA and paracetamol OD - rapid resolution QTc

19 yr old presented via A&E with a significant amitriptyline OD (2.1g) plus at least 12g paracetamol. GCS was 14 on arrival of paramedics, 8 on arrival to A&E, falling rapidly to 3 within 10mins of arrival.
QTc was 422ms, rapidly prolonging to a maximum of 621ms (QRS slightly prolonged but remained within normal limits).
She was intubated for airway protection and received in total 3 x 50ml 8.4% sodium bicarbonate as boluses. Her BP had been 90 systolic on arrival, falling to low 80s and high 70s systolic despite 2L colloid and 1L crystalloid.
30mins after arrival to A&E her QTc had prolonged to 621 and BP 73/43, she was given 1.5ml/kg (150ml) intralipid as a bolus, followed by 350ml over the next 45mins. She was also given glucagon by A&E staff (?dose).
Within 20minutes, QTc had shortened to 500ms and BP was >120 systolic. She also required sedation to keep her ETT-tolerant. After another hour QTc was 450ms and systolic BP>100 despite 250mg propofol/hr sedation.
ECG the following morning was completely normal, she was extubated and made a full recovery, being discharged from ICU that evening.
Temporally very much related to intralipid (but also following bicarb and glucagon) - first time I have used it. Very impressed!
February 23, 2011 | Unregistered CommenterCaroline Sampson
Thank you Caroline
We too have experience of a rapid reduction in QTc following Intralipid in several patients. Did you have any problems with serial measurements of Paracetamol levels after the patient received Intralipid?
March 4, 2011 | Unregistered CommenterDavid Uncles
this is a very interesting case, unfortunately leaving some more questions; not only, what about the blood levels of paracetamol, but, what about the clinical course of the paracetamol intoxication? in case there have been toxic levels, what therapeutic strategy would have been chosen? antidote (fluimucil) is very successive in altering the toxic metabolism of paracetamol; has there been knowledge about the levels BEFORE initiating lipids? is fluimucil still effective in this case or also drowning in the lipid sink?
October 23, 2011 | Unregistered Commenterstefan poechacker
Let me referree here: I agree with all of you. Caroline, your case really is impressive, especially since the BP went from 70's to >120. As Dr. Uncles points out, the narrowing of QT here would act as an indicator or bioassay of tissue TCA levels, suggesting htat the lipid sink is in play. Of course, the logP for amitriptyline is favorable (~6). Contrariwise the log P for acetomenophin is quite low (0.3) so, as Stefan points out, this is probably not a great candidate for the lipid rescue, but fortunately, there are other effective options. I'm looking forward to Dr. Uncles publishing a compendium of cases with lipid reversing prolonged QT's.
October 26, 2011 | Registered Commenter[Guy Weinberg]