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• W2006109280 abstract "Dr. Michael Filbin: Today’s case is that of a 46-yearold woman found unconscious on the floor of her apartment by her boyfriend who immediately called 911. Upon paramedic arrival the patient was noted to be unresponsive, lying on the bedroom floor. The boyfriend told paramedics that she had a history of bipolar disorder for which she took Valproic Acid. She had not been depressed recently and had never made a suicide attempt in the past. She had no known drug allergies. She did not smoke, drink alcohol, or use illicit drugs. The vital signs on EMS arrival included a heart rate of 148 beats per minute (bpm), blood pressure of 90/60 mm Hg, and shallow respirations of 14 breaths per minute. The Glascow Coma Scale was noted to be 4, with eyes opening to painful stimulus but without verbal or motor response. Dr. Eric Nadel: Are there any questions or comments at this point? Dr. Theodore Benzer: In a 46-year-old female found unresponsive with a psychiatric history, a medication overdose is a likely etiology. Did you ask the medics whether empty pill bottles were evident at the scene? Valproic Acid in overdose leads to depressed consciousness and eventual coma, although I wouldn’t expect it to account for such a rapid heart rate. In any comatose patient, definitive airway control is of primary importance, and I would strongly consider immediate endotracheal intubation in this woman. I would also advocate cardiac monitoring to elucidate the nature of the tachycardia in addition to rapid determination of the blood glucose level. Empiric naloxone also should be given at this point. Dr. Filbin: There were no pills missing from her Valproic Acid bottle, and there was no evidence in the home that would suggest a toxic ingestion. The patient was next placed on a cardiac monitor by the paramedics and was found to have ventricular tachycardia (VT) at a rate of approximately 150 bpm (Figure 1). An 18-gauge intravenous (IV) line was placed and 500 cc of normal saline was administered as a bolus. Glucometry showed a blood glucose level exceeding 500 mg/dL. Lidocaine 100 mg IV was administered, and after 2 min she converted to a sinus rhythm at approximately 70 bpm (Figure 2). Her mental status remained depressed, and she was intubated for airway protection without complication. During transport to the hospital, she had another episode of VT that again resolved with an additional 100 mg bolus of lidocaine IV. A lidocaine drip was started at 2 mg per minute IV. Dr. David Brown: The paramedics might have initially opted for immediate synchronized cardioversion in this patient with VT, hypotension, and altered mental status. If medications are chosen as primary therapy, another option would have been to administer amiodarone, which recently has been added to the Advanced Cardiovascular Life Support (ACLS) guidelines for the management of VT and wide complex tachycardia of" @default.
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• W2006109280 title "Hyperglycemic hyperosmolar nonketotic coma" @default.
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• W2006109280 doi "https://doi.org/10.1016/s0736-4679(01)00283-9" @default.
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