Post Your Cases > Cardiac arrest after suicide attempt - saving drug - Intralipid?
Hi Bo,
Thanks for posting this important case - the first example of probable reversal of calcium channel blocker with lipid infusion. There have been some very good animal studies looking at verapamil showing a positive effect of lipid emulsion....but you've really done it in a human! Congratulations for saving a life, too.
Your case description is nearly identical to that of the bupropion overdose: Another young girl attempting suicide, an in-house, witnessed arrest; prolonged ineffective resuscitation with LOTS of pressor agents. Then, rapid recovery after lipid.
It's particularly impressive that she recovered given her very low pH. I agree, the CPR was excellent given the good neurological outcome (just like the bupropion case) and you have really made a difference in someone's life. And maybe made converts of the cardiologists and intensivists, too.
Note that in all of my animal studies, pulmonary edema occurs with high dose vasopressors...including epi, but especially with vasopressin. Did this girl get any ADH? Note also that the bupropion girl (and other reports of resuscitations from LA toxcitiy using lots of epi) had extremely bad pulmonary edema. Your report exactly mimics what we see in the lab.
Finally, as you know, I must recommend you submit this case for peer review
good luck and thanks again,
guy
Thanks for posting this important case - the first example of probable reversal of calcium channel blocker with lipid infusion. There have been some very good animal studies looking at verapamil showing a positive effect of lipid emulsion....but you've really done it in a human! Congratulations for saving a life, too.
Your case description is nearly identical to that of the bupropion overdose: Another young girl attempting suicide, an in-house, witnessed arrest; prolonged ineffective resuscitation with LOTS of pressor agents. Then, rapid recovery after lipid.
It's particularly impressive that she recovered given her very low pH. I agree, the CPR was excellent given the good neurological outcome (just like the bupropion case) and you have really made a difference in someone's life. And maybe made converts of the cardiologists and intensivists, too.
Note that in all of my animal studies, pulmonary edema occurs with high dose vasopressors...including epi, but especially with vasopressin. Did this girl get any ADH? Note also that the bupropion girl (and other reports of resuscitations from LA toxcitiy using lots of epi) had extremely bad pulmonary edema. Your report exactly mimics what we see in the lab.
Finally, as you know, I must recommend you submit this case for peer review
good luck and thanks again,
guy
January 18, 2009 |
[Guy Weinberg]
[Guy Weinberg]
On the 16.th of December 2008, an 18 year old female, 50 kg, 160cm, attempted suicide by ingesting calcium antagonists, levothyroxin, losartan and alcohol. She was admitted to the cardiac ward at 03.00 AM, hyoptensive but awake and relevant. She was given active carbon after her stomach had been emptied. At 06.00 AM she was transferred to the ICU. CVK and A-line was unsuccessfully attempted. At 06.50 she went into cardiac arrest, at which point CPR according to ALS was performed. Within the next 70 min she had 2 periods with asystoli, extreme bradycardia and various arythmias. During this period she was treated with epinephrine (9mg), atropine (2mg), isoprenalin, HCO3, CaCl, and liquid.
Arriving at work 08.00 AM, I was told that my colleagues were still working on the patient. The team of anaesthesiologists, cardiologists and thorax anaesthesiologists were discussing whether it was time to terminate the treatment. Being an eager US - PNB performer, I suggest intralipid – with some question marks from the bystanders - and by 08.10 AM administered 50ml intralipid 20% followed by 400 ml Intralipid 20% over 15 – 20 min. Thanks to Guy Weinberg’s work and this homepage.
After 5 min of continuous CPR the patient converted to SR and regained circulation. At that time the Ph: 6.78 in a venous sample. CVK, Swan Ganz kath., A-line, and dialysis catheter were now possible to install. She developed pulmonary oedema within the next hour. It was impossible to oxygenate the patient and she was transferred to an adjacent university hospital for ECMO. She developed compartment syndrome in the left UE. She was treated for 6 days with ECMO, on the 8. day she was weaned from the respirator, and had a conversation with her parents – with no sign of neurological deficit.
My considerations:
1. Very efficient CPR performed!
2. Intralipid might be the saving drug.
3. Thanks to Guy
4. If possible blood samples should be taken prior to intralipid administration.
5. Consider having Intralipid in the ICU, emergency room and cardiac ward.
6. Intralipid is not well known in cardiologist circles or even anaesthesiologist circles yet.
Bo Gottschau MD. DENMARK.