Post Your Cases > Lipid emulsion given after suicide attempt w 3g lamotrigine and 3g hydroxyzine

A 27 year old male called 911 after intentional ingestion of 3g of lamotrigine and 3g of hydroxyzine. Upon arrival to the ER, approximately one hour after ingestion, the patient had slurred speech and was lethargic, but was able to respond to questions and provided his own history. The patient subsequently began to speak incoherently and became increasingly somnolent. An emergency room nurse reported possible seizure activity (described as involuntary shaking). Three hours after ingestion he did not respond to sternal rub and was intubated for airway protection. Initial ABG revealed acidosis of 7.28.

Infusion of 20% lipid emulsion was initiated six hours after ingestion- a 150mL bolus was given over 30 minutes followed by a rate of 50mL/hr for eight hours. Sodium bicarb was given to keep ph at goal of 7.45-7.5. The patient was kept on a continuous telemetry and no cardiac abnormalities were recorded. EEG was performed and did not reveal seizure activity. He was successfully extubated twenty-four hours after intubation. Lamotrigine levels were drawn and results (available two days later) showed an initial level of 19.8mg/L. Graph of lamotrigine levels show a slope twice the value between the two data points before and after fat emulsion administration was initiated compared to the slope between other data points. (1.5 hours after ingestion levels were 19.8. 5h after ingestion level was 18.5. Emulsion was administered 6h after ingestion. 8h after ingestion level was 15.4. Levels could not be checked for the next 10 hours bc blood was too chylous for laboratory analysis. Levels 25 h after ingestion were 13.1. Levels 32 h after ingestion were 13.0. 35h after ingestion were 11.9).

The patient’s triglyceride level peaked at 768 just before discontinuation of the lipid emulsion. Laboratoty analysis was not possible after hour 2 of fat emulsion administration until 3 hours after fat emulsion was discontinued. The patient had no permanent neurologic deficits and was discharged to an inpatient psychiatric facility.

It is unclear whether further neurotoxicity or cardiotoxicity was avoided with the administration of fat emulsion, but that can not be ruled out as a possibility.
October 4, 2014 | Unregistered CommenterMelissa Reimer-McAtee, MD
(pt was 88kg)
October 4, 2014 | Unregistered CommenterMelissa Reimer-McAtee, MD