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More Than A Gesture

More Than A Gesture. Michael D. Schwartz, MD Centers for Disease Control/ ATSDR/Georgia Poison Center (Fellowship Sponsor: Oak Ridge Institute for Science & Education, Department of Energy). “There are No Interesting Cases after 3 A.M.”. 47 y/o female who ingested “a lot” of her medication

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More Than A Gesture

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  1. More Than A Gesture Michael D. Schwartz, MD Centers for Disease Control/ ATSDR/Georgia Poison Center (Fellowship Sponsor: Oak Ridge Institute for Science & Education, Department of Energy)

  2. “There are No Interesting Cases after 3 A.M.” • 47 y/o female who ingested “a lot” of her medication • 0300: Woke up and went to living room • 0310: Mother got up and found her with empty bottle • Schizophrenia • Takes Depot Haloperidol, diphenhydramine, X • Denies drugs/ETOH; does smoke • ER: Patient took 10 of DPH…but 100 of X

  3. Initial ED Course • EMS: Refused AC/C, stable, NSR • BP 120/80, P=70, T=36.1, RR/Sat=16/100% • PE: Normal pupils, cardiac, pulm., abd. • Neuro: “I want to die.” • FSBS = 100 • EKG #1 shows NSR=70, normal intervals, no acute changes

  4. Patient’s last normal ECG for a while

  5. “I Want to Die” • At the conclusion of the physical exam: the patient suddenly experienced pulseless ventricular tachycardic arrest • Shocked into sinus & restoration of pulse with the aid of a handy LifePak nearby. • Georgia Poison Center called

  6. Post-Arrest • Pulse 60, BP 70/50 (dopamine 20 mcg), • Intubated, A-line, C-line, NG, AC/C • ABG: 7.51/19/356/15/100% • K+1.0 mEq/L • Post-arrest EKG: LBBB, QRS 236 msec, QT 528 msec

  7. Post-Arrest ECG #2

  8. Labs • Urine Toxicology screen: Negative • APAP/ASA: Negative • CBC: normal • 140 105 12 178 Ca = 8.7, Mg = 2.3 • 1.3 18 1.2 • Cardiac enzymes: normal • Serum Osm: normal, Lactate: normal • LFTs: normal

  9. K+ = 1.3 Tox Attending: “I’m not sure Sodium Bicarbonate is such a good idea…” QRS = Wide NaHCO3 = Dead QT = Long

  10. What’s A Fella/ow to Do? • Switched from dopamine to norepinephrine 4 mcg/min, BP = 130/70 • “Potassium-in-Every-Orifice” Method: K=1.8 • Magnesium 4 gm IV prophylaxis for TdP • Patient’s HR holding at 82 • 300 cc 3% NaCl infused rapidly • Toxicology Fellow’s HR = 220-Age

  11. ECG #3 (2 minutes of hot salt)

  12. ECG #4 (completion of hot salt)

  13. ECG #5 (after conversion)

  14. ECG #6 (ICU Day 1) QRS 80 msec, QT 396 msec, K = 4.6, norepinephrine D/C’d

  15. A laboratory result was reported

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