EDECMO 27 – A Real-World Case of a Crashing Multi-Drug OD Patient Saved with ED ECMO

What this episode covers

Dan McCollum MD Dan McCollum MD Assistant Program Residency Director at Georgia Regents University Augusta, Georgia Academic Medical center, Level 1 Trauma Center: census >90,000/yr "If someone is doing an effective therapy out of the back of a truck successfully, and you can’t make it work in your hospital, then you suck and should feel bad."   Case: 38 y/o female multi-drug OD on (possibly): * Montelukast 10 mg (Singulair) - leukotriene receptor antagonist. mild tox profile (3698 pediatric ingestions from Texas Poison Control: 95% asymptomatic) * Promethazine 25 mg (Phenergan) - Anticholinergic (56% tachycardia, 42% delirium, 2% mechanical ventilation, 1% hypotension) * Cyproheptadine 4 mg - Anticholinergic; mild tox profile (892% of OD in one case series had no or mild symptoms) * Clonazepam 1 mg (Klonipin) - Common: respiratory depression and hypotension; Rare: heart block/dysrythmia * Amitriptyline 25 mg - TCA - Hypotension. QRS widening with R wave in AVR * Treatment: * antidote = sodium bicarbonate * crystalloid for hypotension * Pressors for refractory hypotension * Amlodipine 5 mg - Calcium Channel Blocker - Common: Bradycardia, hypotension, heart block; Rare: apnea, pulmonary edema, ARDS, coma, Lactica acidosis, hypoerglycemia, bowel infarction * Treatment: * IVF * High Dose Calcium (inotrope) * Pressors - Isoproterenol * Glucagon * Atropine * High Dose Insulin - 1-10 unit/kg/hr infusion (consider simultaneous glucose infusion)   Timeline before ECMO: * 02:00-17:00 Estimated time of ingestion: (2-15 hours PTA). * 19:00 Presentation to ED * 19:30 BP 55/33; sats 93% on 60% FiO2 * 19:41 PEA ARREST #1 * Epinephrine, Atropine, Sodium Bicarbonate, Calcium Gluconate, D50 * Narcan > No response * 19:54 Bradycardia with pulse * 20:10 Bicarbonate gtt * 20:15 Epinephrine gtt * 20:18 High Dose Insulin bolus, then gtt * 20:31 TC pacing * 20:40 Norepi gtt, Charcoal * 20:46 CXR = pulmonary edema * 21:07 Bivent initiation * 21:14 Intralipid bolus * 21:16 Glucagon * 21:21 43/29 with sats 69% and pulse 70 * 21:31 pRBC transfusion initiated   Total Meds used in resuscitation: * Calcium Gluconate: 21 Amps * Sodium Bicarbonate: 19 Ams * Epinephrine: 9.5 mg + drips * Insulin: ~150 units Complications during hospitalization (but the patient is alive!): * AF with RVR * DVT * ipsilateral limb ischemia > Necrotizing fasciitis > AKA * Pleural Effusion > chest tube * Bowel perforation (due to ischemia) > laparotomy * Trach/PEG * Abdominal Wall Abscess > I&D   Learning Points: * RUSH exam early for undifferentiated shock * Restrictive lung strategy to avoid ARDS * Multi-agent OD: contact Poison Control - they can actually help! 1-800-411-8080 * ECMO is a bridge to metabolism/recovery.

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