Successful treatment of metoprolol-induced cardiac arrest with high-dose insulin, lipid emulsion, and ECMO

The American Journal of Emergency Medicine
Jeremiah T EscajedaJon C Rittenberger

Abstract

β-Adrenergic antagonist toxicity causes cardiovascular collapse often refractory to standard therapy. Alternative therapies include high-dose insulin, lipid emulsion, and venoarterial extracorporeal membrane oxygenation (VA-ECMO). A 47-year-old man ingested 10 g of metoprolol tartrate in a suicide attempt. Upon emergency department presentation, he was comatose, bradycardic, and hypotensive. Glucagon (14 mg IV) and vasopressor/inotropic support (epinephrine 0.1 μg/[kg min], dobutamine 10 μg/[kg min]) were administered. Despite these therapies, he developed cardiac arrest for 55 minutes, requiring epinephrine (5 mg IV) and vasopressin (40 U IV) with multiple episodes of return of spontaneous circulation. Additional vasopressor administration (vasopressin 0.04 U/min, norepinephrine 0.5 μg/[kg min]) did not improve his hemodynamics. High-dose insulin (250 U IV) and 20% lipid emulsion (100 mL bolus with 200 mL/30 min infusion) were administered, and VA-ECMO was initiated with hemodynamic improvement. His postarrest neurologic examination demonstrated lack of brainstem reflexes and cortical motor response. He awoke 11.5 hours after time of ingestion. Venoarterial extracorporeal membrane oxygenation was discontinued at hospital day 3...Continue Reading

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Citations

Feb 9, 2016·Clinical Toxicology : the Official Journal of the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists·Michael LevineUNKNOWN Lipid Emulsion Workgroup
Jul 14, 2018·Clinical Toxicology : the Official Journal of the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists·Johanna Nordmark GrassErik Lindeman
Dec 14, 2016·AACN Advanced Critical Care·Jaclyn O'Connor, Suprat Saely Wilson
Apr 21, 2020·Clinical Toxicology : the Official Journal of the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists·Joe-Anthony RotellaAnselm Wong
Mar 29, 2021·Resuscitation·Carsten LottUNKNOWN ERC Special Circumstances Writing Group Collaborators
Jun 16, 2021·Notfall & Rettungsmedizin·Carsten LottJasmeet Soar
Aug 17, 2021·Clinical Toxicology : the Official Journal of the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists·Cameron UpchurchRobert G Hendrickson

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