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• W1508968265 abstract "We present a case of propanolol overdose with cardiovascular collapse that was treated with conventional therapy and intravenous lipid emulsion. A 27-year-old woman deliberately ingested approximately 7 g propanolol. Approximately one hour after ingestion, she presented to the emergency department having been found collapsed by her partner. On arrival, she was tolerating an oro-pharyngeal airway with a respiratory rate of 15–20 min−1; her non-invasive blood pressure was 60/30 mmHg and her pulse rate was 25 min−1. She was unresponsive to pain (Glasgow Coma Scale 3/15), her pupils were size 5, equal and sluggishly reactive to light. There was generalised tonic/clonic seizure activity. An ECG (Fig. 2a) revealed severe sinus broad complex bradycardia. ECG on admission. We administered high-concentration oxygen by facemask, an intravenous crystalloid infusion, 3 mg intravenous atropine and three glucagon boluses of 5 mg followed by an infusion of glucagon (5 mg.h−1). We also commenced an insulin infusion at 70 units.h−1 with 50% dextrose. We administered 1-mg boluses of lorazepam to a total of 8 mg for seizure activity, but this was ineffective, so we infused phenytoin 1 g followed by a further 250 mg. There was no further seizure activity following the second bolus of phenytoin. The patient’s heart rate and blood pressure did not respond to treatment, so we commenced an isoprenaline infusion at 10 μg.min−1. Despite these therapies, the patient had ongoing bradycardia and hypotension. We attempted external cardiac pacing, but were unable to gain capture. We then administered intravenous adrenaline boluses (100 μg), but the patient’s condition deteriorated, with no palpable central pulse, so we commenced cardiopulmonary resuscitation. We followed Advanced Life Support Guidelines [1] for pulseless electrical activity for two cycles, after which there was return of a palpable carotid pulse. During this time, we secured the airway with a tracheal tube. Her systolic invasive arterial pressure was now 40 mmHg and pulse rate 25–30 min−1. An infusion of high-dose adrenaline (4 mg.h−1) was commenced and both blood pressure and heart rate increased. Toxicology advice from the National Poisons Information Service was to administer activated charcoal via a nasogastric tube and to consider the use of intravenous lipid emulsion. We administered a 100-ml bolus of 20% Intralipid™ (Fresenius Kabi Ltd, Runcorn, Cheshire, UK) followed by an infusion of 400 ml over 20 min. Within 5 min following administration of the Intralipid, the requirement for adrenaline decreased and continued to do so over the next 15 min until the infusion requirement was 800 μg.h−1. We continued the intravenous glucagon infusion. Her ECG (Fig. 2b) now revealed sinus rhythm ith right bundle branch block. ECG following intra lipid treatment. Shortly after admission to the intensive care unit, her ECG (Fig. 2c), showed normal sinus rhythm with a borderline prolonged corrected QT interval. Over the next 7 h, the adrenaline infusion was reduced further and then stopped; the glucagon was stopped and the patient regained consciousness. She was extubated approximately 15 h after admission with her only comment being that she was disappointed to be alive. She was referred for ongoing psychiatric care. ECG on admission to the intensive care unit. Intravenous lipid emulsion has recently been adopted into the treatment algorithm for local anaesthetic toxicity [2]. The prevailing hypothesis is the ‘lipid sink theory’ [3] whereby the lipid emulsion partitions the drug into a lipid phase, thus creating a concentration gradient for removal of the drug from the target organ. There is some favourable animal evidence comparing saline with lipid in both verapamil and propanolol toxicity [4]. We believe this to be the first reported use of intravenous lipid emulsion to treat propanolol overdose in a patient. We would strongly recommend consideration of lipid emulsion in patients who have responded poorly to conventional therapy. Our thanks to the National Poisons Information Service for their advice on the management of this case. No external funding and no competing interests declared. Published with the patient’s written consent." @default.
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• W1508968265 date "2010-10-12" @default.
• W1508968265 modified "2023-10-17" @default.
• W1508968265 title "Intravenous lipid emulsion in propanolol overdose" @default.
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• W1508968265 doi "https://doi.org/10.1111/j.1365-2044.2010.06526.x" @default.
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