A 55 year old gentleman presented with mixed overdose of 10 g nortriptyline and moderate doses of ACE –I, quetiapine, b blocker.
On arrival in ED he became rapidly obtunded and cardiovascularly unstable. He was intubated, given an initial bolus of 100ml sodium bicarbonate 8.4% and started on high dose norepinephrine and epinephrine drips.
Resuscitation efforts continued. QRS duration prolonged to 135 ms. Over the next few hours he was given Sodium bicarbonate 8.4% total 800 ml. Glucagon was given in doses of 1mg, total 6mg. Calcium chloride was given in slow doses of 10 ml 10%. Total 60ml. Fluid resuscitation was with normal saline guided by echocardiography and clinical assessment. High dose insulin with glucose was given to target of 4units/kg/h. Potassium was replaced as needed.
No arrhythmias occurred and magnesium was not given. Intralipid 20% was given roughly 3 hours post presentation as per suggested guidelines and up to a total of 1.5 litres (the total dose available in the hospital). In retrospect there may have been a modest stabilisation of haemodynamic parameters during and immediately following the intralipid. However this was relatively short lived. ECMO and IABP were not available. The patient continued to decline and despite maximal resuscitation efforts he died around 10 hours post presentation.
On arrival in ED he became rapidly obtunded and cardiovascularly unstable. He was intubated, given an initial bolus of 100ml sodium bicarbonate 8.4% and started on high dose norepinephrine and epinephrine drips.
Resuscitation efforts continued. QRS duration prolonged to 135 ms. Over the next few hours he was given Sodium bicarbonate 8.4% total 800 ml. Glucagon was given in doses of 1mg, total 6mg. Calcium chloride was given in slow doses of 10 ml 10%. Total 60ml. Fluid resuscitation was with normal saline guided by echocardiography and clinical assessment. High dose insulin with glucose was given to target of 4units/kg/h. Potassium was replaced as needed.
No arrhythmias occurred and magnesium was not given. Intralipid 20% was given roughly 3 hours post presentation as per suggested guidelines and up to a total of 1.5 litres (the total dose available in the hospital). In retrospect there may have been a modest stabilisation of haemodynamic parameters during and immediately following the intralipid. However this was relatively short lived. ECMO and IABP were not available. The patient continued to decline and despite maximal resuscitation efforts he died around 10 hours post presentation.