Reactions 1351 - 14 May 2011

O SImipramine overdose

Junctional escape rhythm and hypotension: casereport

A 15-year-old girl developed junctional escape rhythmand resistant hypotension following an intentionalimipramine [Tofranil] overdose.

The girl was admitted to the emergency department withvomiting and fatigue. Twelve hours prior, she had ingested12 tablets of imipramine 25mg (approximately 6 mg/kg) ina suicide attempt and had begun vomiting 2 hourspostingestion. Tricyclic antidepressants were positive onurine toxicological screening. Her BP and HR were70/30mm Hg and 45 bpm, respectively. Arrhythmia andbradycardia were evident on auscultation. Laboratoryanalysis revealed a haemoglobin, haematocrit and WBCcount of 10.5 g/dL, 31.9% and 13 200/mm3, respectively.Her glucose and creatinine levels were elevated, and herbicarbonate level was slightly reduced. An ECG revealedjunctional escape rhythm without atrial activity, low QRSvoltage, absence of P waves, a widened QRS complex, aprolonged QT interval and a right bundle-branch-likepattern.

A gastric lavage was performed, and IV fluids andcharcoal were administered. A sodium bicarbonateinfusion was initiated and the girl’s BP improved slightlyfollowing the initiation of dopamine. Her bradycardiapersisted despite treatment with atropine. Six hourspostadmission, her hypotension and junctional rhythmpersisted. Her BP normalised after placement of atemporary pacemaker. She had no urine output 24 hourslater, and her serum urea and creatinine levelsprogressively increased. Haemodialysis was performedfollowed by haemoperfusion. Her urea and creatininelevels normalised on day 3 and the pacemaker wasremoved. Repeat ECG revealed sinus bradycardia, awidened QRS complex and a right bundle branch-likepattern. On day 5, she was discharged withoutcomplication. No ECG abnormalities were detected onfollow-up.Sert A, et al. Temporary cardiac pacemaker in the treatment of junctional rhythmand hypotension due to imipramine intoxication. Pediatric Cardiology 32: 521-524,No. 4, Apr 2011. Available from: URL: http://dx.doi.org/10.1007/s00246-011-9914-y - Turkey 803054121

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Reactions 14 May 2011 No. 13510114-9954/10/1351-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved