Reactions 1262 - 25 Jul 2009

O SAmitriptyline/citalopram overdose

Cardiogenic shock in an elderly patient treatedwith insulin: case report

A 65-year-old woman developed cardiogenic shock afteringesting an overdose of amitriptyline and citalopram[dosages not stated]; she was subsequently treated withhigh-dose insulin.

The woman had hypertension and depression and ahistory of suicide attempts and was known to be receivingcitalopram, atenolol, venlafaxine and enalapril. Afteringesting multiple drugs at an unknown time, she wasbrought to an emergency department and intubated;paramedics had found her unresponsive with anidioventricular rhythm and episodes of ventriculartachycardia. On arrival, she had a Glasgow Coma Score of3, an idioventricular rhythm with a QRS interval of 320 ms,BP of 79/43mm Hg and a HR of 70 beats/min. Hercondition deteriorated to pulseless electrical activity.

The woman received sodium bicarbonate, atropine,epinephrine [adrenaline] and calcium chloride. Palpablepulses returned but hypotension and bradycardiacontinued. She received glucagon, dextrose, insulin,normal saline, sodium bicarbonate and norepinephrine[noradrenaline]. ECG showed a wide complex bradycardiawith a QRS interval of 200ms and a QTc interval of646 msec. She was transferred to an ICU within 2 hours.She received vasopressin. An ECG showed an ejectionfraction of 55% and mild left ventricular hypertrophy. Onday 2, her cardiac output was 4 L/min with a low calculatedcardiac index of <2.5 L/min/m2. At this time, about12 hours after her arrival, higher insulin doses were usedbecause of concern about ischaemic extremities, reducedperipheral perfusion, inadequate inotropic function andurine output of 0.6 mL/kg/h. She responded, starting withimproved extremity warmth and capillary refill time. After36 hours of an insulin infusion ≥ 500 units/hr, the infusionwas weaned to maintain MAP >65mm Hg. Her course wascomplicated by pulmonary emboli. She recovered to a stateconsistent with residual mild anoxic injury and wasdischarged for transitional care. Her combinedamitriptyline and nortriptyline level was 1528 ng/mL andher citalopram concentration was 197 ng/mL. It wasrevealed in the ICU that she had access to amitriptyline.Venlafaxine and atenolol concentrations were within thetherapeutic range.Holger JS, et al. High dose insulin in toxic cardiogenic shock. Clinical Toxicology47: 303-307, No. 4, Apr 2009 - USA 801146575

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Reactions 25 Jul 2009 No. 12620114-9954/10/1262-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved