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:
  1. IVF
  2. High Dose Calcium (inotrope)
  3. Pressors – Isoproterenol
  4. Glucagon
  5. Atropine
  6. 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.

“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.” – Dan

*and special thanks to Dan McCollum for creating and sharing the Napoleon Dynomite memes.

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

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