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Case Conference

Case Conference. Kapil Sharma. East Side EMS Arrives. Middle Aged white man pale, diaphoretic, gasping breaths To the Booth EMS states they picked him up from home, felt weak, fell in bathroom Bradycardic en route, Dstick normal Wife called EMS. First Look.

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Case Conference

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  1. Case Conference Kapil Sharma

  2. East Side EMS Arrives • Middle Aged white man pale, diaphoretic, gasping breaths • To the Booth • EMS states they picked him up from home, felt weak, fell in bathroom • Bradycardic en route, Dstick normal • Wife called EMS

  3. First Look • Patient c/o weak, lightheaded, mild dyspnea • Felt fine yesterday, became acutely weak and sick early this morning, awoke with symptoms • Fresh scar across the belly • Splenorenal shunt 2 weeks ago @ Methodist • History of cirrhosis, hypertension, DM, hep C UGIB(varices) • Brief PE • PERRLA, CTAB, Brady, Abd soft + NT, 1+ LE edema • Meds(brought by EMS) • Colace, Aldactone 502, Lasix 402, Nadolol 401, Protonix 401, KCL 20, 70/30 insulin • Patient goes apneic/unresponsive

  4. Next Steps • Intubation – RSI c etomidate/succ • VS – HR 40’s + junctional. BP – 60’s/40’s, SpO2 100% on vent, afebrile • Finish PE – guiac negative, No obvious source of infection/trauma, slightly elevated JVD • NG Lavage – No blood • Foley – adequate output • Femoral Line • Arterial Line(eventually)

  5. Initial ECG

  6. Labs 12.8 134 99 21 21.24 546 6.2 20 1.6 37.1 Ca 9.0, Mg 1.8, Phos 4.2 glucose - 278 Trop < 0.1, BNP 16, lactate 1.0, AST 100, ALT 337, amylase 108. Lipase 136, Alk Phos 246, t. bili 3.2, d. bili 1.3, INR 1.5, PTT 29.3 ABG 7.09/10/36/345

  7. 2 hour ED Resuscitation • Fluids • Glucose/Insulin for hyperkalemia • Corticosteroids • Atropine – no help • Empiric Antibiotics • Pressors • Dopamine 20 and Levophed at 100 • PEA arrest X 2, 5 minutes and 15 minutes • Responds well to Epinephrine • To the Unit

  8. MICU • On arrival hypertensive • Begin weaning levophed initially • Wife returns with critical information • Therapy is initiated for this patient • Patient extubated the following day, discharged 1 day later • Normal mental status and exam on discharge

  9. Diagnosis • Calcium Channel Blocker OD • Took 3 X 240 mg Verapamil SR • Wife’s medication • Confused tablets for his potassium • Glucagon boluses given in MICU • 2-4 mg boluses, no drip started • Both blood pressure and HR responded to glucagon • Calcium gluconate infusion started in MICU

  10. Discharge ECG

  11. Verapamil Overdose • Mechanism • Inhibits L type Ca channels, alpha-1c subunit • Voltage dependant binding • Phenylalkalmine Class • Significant hypotension and heart block • Metabolism – CYP3A system • N-demethylation(40%) to norverapamil • O-methylation(25%) • Clinical Effects • Hypotension, bradycardia, hyperglycemia

  12. Treatments • Decontamination – Aggressive • IV fluids • Atropine • Often ineffective • Calcium • Used to overcome block • Usually shortlived • Adrenergic Agents • Activate Gs cAMP formation and phosphorylation of calcium channels • Peripheral alpha-1 receptor activates Ca channels

  13. More Tx • Insulin/Glucose • High dose therapy – loading dose of 1Unit/kg then 0.5-2 units/kg/hour • CCB inhibit carbohydrate utilization of myocardium • Intralipid • Verapamil lipid soluble • Phosphodiesterase III Inhibitors • Inhibit cAMP breakdown • Increaed contractility • Decreases PVR

  14. More Tx • Glucagon • Increase intracellular cAMP via Gs protein • Bypasses Beta-1 receptor • More useful in BB OD rather than CCB OD • Digoxin • Limited by slow diffusion into tissues • Mechanical • Pacing • Intraaortic Balloon Pump

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