the case.
87 year old female presents to your ED following an intentional overdose. She tells you that approximately 4 hours ago she ingested ‘most of [her] digoxin tablets’ that she bought earlier in the afternoon. [Read more…]
a little low…
the case.
A 48 year old female arrives to ED via ambulance following an intentional overdose. Her husband discovered her taking tablet after tablet in the bathroom at home. She has a history of depression & diabetes and reports feeling ‘a little low’…
As the paramedics finish handover, they hand you these…. [Read more…]
a test of metal…
The case.
64 year old female who is day 1 post elective left total-knee replacement. She has a past medical history of osteoarthritis, bipolar disorder and depression for which she takes quetiapine, lithium and paracetamol. You are asked to see her on the ward for optimization of her pain management with a concern that she “just isn’t quite right” with confusion & new onset of word finding difficulties.
a poison puzzler…
the case.
23 year old female is bought to ED by her family after an intentional overdose of ~ 100 ‘diet tablets’ which she ingested 1.5-2 hours earlier.
big black spider…
The Case.
A sunny Saturday morning in Sydney and your 56 year old patient was just outside doing some gardening when they feel a rather sharp bite on their right hand (on webspace between thumb and index finger).
He arrives to the ED distressed and very anxious. His vitals signs are normal and he has localised pain only.
He then hands you this saying “this is the bugger that bit me !!” …..
Where do you go from here ??
another ECG case…
The Case.
I was superficially involved in this case of a 32 year old suicidal patient who ingested two full packets of Solian (amisulpride) (~ 24 grams) approximately 90 minutes prior to arrival to ED.
On initial assessment he was GCS 12/15 & had a systolic BP of 115 mmHg.
This is his ECG….
AMISULPRIDE TOXICITY.
Amisulpride – What is it ?
a benzamide neuroleptic (atypical antipsychotic) with high affinity for the dopamine (specifically D2-2) receptor.
- used for acute & chronic schizophrenia (both negative & positive symptoms)
- unlike other neuroleptics, it has minimal affinity for 5HT, alpha, H1 or cholinergic receptors.
Dose-based Risk Assessment.
- < 8g = mild-moderate sedation, mild anticholinergic features.
- QT prolongation & torsades are reported (in as little as 4.6g ingestion)
- 8-15g = Increasing sedation & depressed level of consciousness.
- Cardiotoxicity includes hypotension, QRS & QT prolongation, bundle-branch blocks & torsades.
- > 15g = Significant risk of delayed coma & cardiotoxicity…
Signs & Symptoms.
- Mild-Moderate: Mydriasis, lethargy, drowsiness and sedation, bradycardia, agitation, hyperthermia and extrapyramidal symptoms.
- Severe toxicity: Seizures, coma, hypotension, and QTc prolongation. Torsades & VT are reported in intentional overdose.
Management.
- Resuscitation area / full cardiorespiratory monitoring.
- Patients may require intubation / mechanical ventilation
- Minimum of 16 hours telemetry mandated for ingestion >4g
- Decontamination (oral activated charcoal) is recommended for > 4 grams in previous 4 hours.
- No antidote.
- Enhanced elimination not useful
- Control of QT / risk of Torsades
- Magnesium (2g IV over 1-2 minutes, repeat x1 –> infusion of 0.5-1.0g / hour)
- Chemical or electrical atrial overdrive pacing.
- Correct electrolyte abnormalities (specifically hypomagnesaemia, hypokalaemia & hypocalcaemia)
Disposition.
As a rule; all ingestions > 4 grams should be monitored for at least 16 hours and until all ECG intervals are normal….
- Asymptomatic adults with inadvertent/minor exposure may be monitored at home.
- Significant/deliberate amisulpride overdose are observed for at least 16 hours after ingestion.
- Continuous cardiac monitoring and serial ECGs.
- If no dysrhythmias or QT prolongation at 16hrs –> discharged after psychiatric evaluation.
- Dysrhythmias or QT prolongation on ECG –> intensive care setting for continuous cardiac monitoring and treatment.
ECG: Sinus rhythm @ 83bpm. Normal axis. PR ~200ms. QRS ~120ms. QTc ~560ms !!!
His management (after discussion with our Toxicology gurus) included;
- Intubation
- NG tube w/ activated charcoal administration
- Two further doses of charcoal
- MgS04 (20mmol x2)
- Isoprenaline infusion with target HR >100 bpm
- Dropped QT down to ~500msec
He survived his first night in the ICU….
- Murray L, Daly F, Little M & Cadogan M. Toxicology Handbook. 2nd Edition. Elsevier 2011.
- Isbister GK et al. Amisulpride deliberate self-poisoning causing severe cardiac toxicity including QT prolongation and torsades de pointes. Med J Aust 2006; 184 (7): 354-356.
- Isbister GK, Balit CR, Macleod D, Duffull SB. Amisulpride overdose is frequently associated with QT prolongation and torsades de pointes. J Clin Psychopharmacol. 2010 Aug;30(4):391-5.
- http://lifeinthefastlane.com/book/toxicology/amisulpride/
- Micromedex 2.0 (Toxicology Summary) “SULPIRIDE AND RELATED AGENTS”
- http://lifeinthefastlane.com/ecg-library/basics/qt_interval/