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Hypotension and Seizure in a Healthy Young Woman an Otherwise Healthy Young Woman Is Convulsing, Diaphoretic, and Unresponsive When She Is Brought to the ED

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Hypotension and Seizure in a Healthy Young Woman an Otherwise Healthy Young Woman Is Convulsing, Diaphoretic, and Unresponsive When She Is Brought to the ED CASE STUDIES IN TOXICOLOGY Series Editor: Lewis S. Nelson, MD Hypotension and Seizure in a Healthy Young Woman An otherwise healthy young woman is convulsing, diaphoretic, and unresponsive when she is brought to the ED. Her ECG demonstrates cardiotoxicity, and it is known that she took her own medication. The authors discuss the clues used to identify the precipitating agent, as well as considerations in case management. Zhanna Livshits, MD, Jason Chu, MD, and Lewis Nelson, MD Case The patient receives a 2-mEq/kg bolus of sodium A 23-year-old African woman with no significant bicarbonate (3 x 50 mEq ampoules), and shortly medical or psychiatric history presents to the ED 1 thereafter a repeat ECG demonstrates a heart rate of hour after she ingested her own medication follow- 145 beats/min with dramatically improving intervals. ing an argument with her boyfriend. Her roommate The QRS complex is 110 ms, and the QT interval is found her convulsing and called EMS. EMS person- 414 ms (Figure 2, page 16). nel note that the patient was minimally responsive and they administered naloxone and dextrose without What class of agent most likely produced this noticeable clinical improvement. They also note that patient’s hemodynamic and ECG findings? the patient exhibited signs of convulsive activity. The findings on the ECG raise concern for exposure Upon arrival to the ED, the patient has the follow- to an agent that either (1) antagonizes the myocar- ing vital signs: blood pressure, 50/20 mm Hg; heart dial sodium channel, slowing depolarization and pro- rate, 103 beats/min; respiratory rate, 30 breaths/min; longing the QRS complex (which increases the QT temperature, 37.4°C; oxygen saturation, 100% on a interval duration), or (2) antagonizes both the myo- nonrebreather mask. In the ED, she has frequent epi- cardial sodium and potassium channels, with direct sodes of generalized convulsions lasting less than 30 simultaneous effect on depolarization (QRS complex) seconds. Though the patient is unconscious and unre- and repolarization (QT interval). The vital signs also sponsive, her pupils are at midposition and sluggishly suggest the possibility of exposure to an agent from reactive. Her skin is diaphoretic, her lungs are clear to one of these classes. Blockade of the myocardial so- auscultation, and her bowel sounds are normoactive. dium channel slows impulse conduction through the An ECG obtained shortly after arrival demon- His-Purkinje system, slowing the rate of depolariza- strates a heart rate of 150 beats/min, a QRS com- tion of the myocardial tissue and thus the force of plex duration of 200 ms, and a QT interval of contraction. This effect alone may lead to hypoten- 525 ms (Figure 1). sion, change in mental status, and seizures due to diminished cerebral perfusion. The Table (page 17) Dr. Livshits is a fellow in medical toxicology in the lists available medications that are sodium channel department of emergency medicine at the New York University School of Medicine in New York City and antagonists in overdose. the New York City Poison Control Center. Dr. Chu is The medications that prolong the QT interval du- an assistant professor of clinical medicine at Columbia ration through potassium channel blockade are nu- University College of Physicians and Surgeons in New merous and are comprehensively outlined on various York City and an attending physician at St. Luke’s- Roosevelt Hospital Center in New York City. Dr. Nelson is Web sites, such as qtdrugs.org. Antimalarials, bupro- an associate professor in the department of emergency pion, cyclic antidepressants, diphenhydramine, and medicine and director of the medical toxicology fellowship propoxyphene are associated with seizures as well, program at the New York University School of Medicine and the New York City Poison Control Center. He is also a independently of the myocardial sodium channel member of the EMERGENCY MEDICINE editorial board. blockade. 14 EMERGENCY MEDICINE | AUGUST 2010 www.emedmag.com CASE STUDIES IN TOXICOLOGY FIGURE 1. Initial ECG. What did the patient ingest? are much less prominent with chloroquine overdose. The patient’s ethnicity and unremarkable psychiat- Neurologic manifestations of chloroquine overdose ric history (ie, no antidepressants available) point include sedation, dizziness, headache, and seizures. to the likelihood of exposure to an antimalarial. It is commonly accepted that acute ingestion of The patient later admitted to ingesting 6 g of chlo- more than 5 g of chloroquine (>30 to 50 mg/kg) is roquine. She had the medication available from a associated with life-threatening cardiotoxicity. Clini- previous prescription for malaria prophylaxis. cal effects following overdose occur rapidly, gener- Chloroquine was discovered in 1934 in Ger- ally within 1 to 3 hours. Oral chloroquine is rapidly many and rapidly gained recognition as an effec- absorbed and has a very high volume of distribution tive antimalarial agent.1 Due to the development (>100 L/kg), suggesting that hemodialysis to enhance of resistance, chloroquine is not as widely used its clearance has limited utility. Chloroquine toxicity for malaria prophylaxis as it had been, and chlo- may be associated with hemolysis due to oxidative roquine toxicity in the US is no longer a frequent stress in people with glucose-6-phosphate dehydro- phenomenon. genase deficiency. Chloroquine shares many similarities with quinine. Both are cardiotoxic, as well as ototoxic and oculo- How should this toxicity be managed? toxic. Both potentiate the release of insulin from pan- Severe chloroquine toxicity marked by ECG and/or creatic islet cells, resulting in hypoglycemia. Although hemodynamic changes with CNS depression should perhaps more cardiotoxic than quinine, chloroquine be aggressively treated to maximize survival. The ma- is much less toxic to the ear, eye, and islet cell. The jority of the data for management of chloroquine tox- clinical effects of quinine overdose are commonly re- icity comes from France and dates to the 1980s. The ferred to as cinchonism, a term derived from the name data suggest that early intubation and ventilation, of quinine’s source: the Cinchona tree. Cinchonism high-dose diazepam, and administration of epineph- is characterized by decreased hearing acuity, tinnitus, rine are associated with reductions in mortality.2,3 vertigo, headache, nausea, vomiting, abdominal pain, IV diazepam at 2 mg/kg should be administered tachycardia, dystonia, and skin flushing. These effects over 30 minutes followed by 1 to 2 mg/kg/day for www.emedmag.com AUGUST 2010 | EMERGENCY MEDICINE 15 CASE STUDIES IN TOXICOLOGY FIGURE 2. ECG obtained after initiation of treatment. 2 to 4 days. Isolated animal studies suggest that of chloroquine. Activated charcoal should be admin- diazepam improves hemodynamic function and re- istered in patients with adequate protective airway duces mortality following chloroquine poisoning.3 reflexes or following intubation. It is possible that the effects of diazepam on cardiac Sodium bicarbonate should be administered in the function are due to its beneficial effects on myo- setting of QRS complex prolongation, whether the cardial benzodiazepine receptors.4 It is unknown ingestant is identified or unknown, with a goal of whether other benzodiazepines are as effective as reducing the duration to less than 100 ms.5 Although diazepam, though there is little reason to suspect sodium bicarbonate would be expected to counter- they are not. act the sodium channel antagonism and narrow the Epinephrine at 0.25 μg/kg/min should be ad- QRS complex, it also leads to hypokalemia and sub- ministered intravenously and titrated until a sys- sequent lengthening of the QT interval. The use of tolic blood pressure of 100 mm Hg is attained. Its sodium bicarbonate has been described as beneficial β1-adrenergic effects increase inotropy, improving in the management of chloroquine overdose in case myocardial function. Although other catechol- reports. However, no clinical trials have been per- amines, such as norepinephrine, may be as effica- formed. Patients who receive sodium bicarbonate for cious as epinephrine, the latter is more physiologi- a wide QRS complex in chloroquine overdose should cally logical. That is, the β1-receptor agonist activity undergo close monitoring of the QT intervals and of epinephrine raises the blood pressure through repletion of serum potassium. enhanced inotropy, while the α-receptor agonist Although more information could be gained from activity of norepinephrine increases it by causing prospective observational studies, the likelihood of peripheral vasoconstriction. This latter effect may carrying out such studies is low, given the relative be detrimental in the setting of a poorly contractile rarity of chloroquine poisoning. There may be ethi- ventricle. cal concerns over withholding the “standard of care” Given the potential for morbidity and mortality, treatment of epinephrine and diazepam and admin- orogastric lavage should be considered in patients istering a “novel” treatment, without any support for presenting with a recent potentially toxic ingestion clinical equipoise, to a very ill person. Therefore, the 16 EMERGENCY MEDICINE | AUGUST 2010 www.emedmag.com CASE STUDIES IN TOXICOLOGY TABLE. Sodium Channel Antagonists Class Examples QRS Widening Class IA antidysrhythmics Disopyramide, procainamide, quinidine Therapeutic effect Class IB antidysrhythmics Lidocaine, phenytoin, mexiletine Therapeutic effect Class IC antidysrhythmics Flecainide,
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