Abstract
IntroductionMassive intentional verapamil overdose is a toxic ingestion which can cause multiorgan system failure and has no currently known antidote.Case PresentationThe patient is a 41-year-old Caucasian woman who ingested 19.2 g of sustained release verapamil in a suicide attempt. Our patient became hypotensive requiring three high-dose vasopressors to maintain arterial pressure. She also developed acute respiratory failure, bradycardic ventricular rhythm necessitating continuous transvenous pacing, and anuric renal failure. Our patient was treated with intravenous calcium, bicarbonate, hyperinsulinemic euglycemic therapy and continuous venovenous hemodialysis without success. On the fourth day after hospital admission continuous intravenous lipid therapy was initiated. Within three hours of beginning lipid therapy, our patient's vasopressor requirement decreased by half. Within 24 hours, she was on minimal vasopressor support and regained an underlying junctional rhythm. After three days of lipid infusion, she no longer required inotropic agents to maintain blood pressure or pacing to maintain stable hemodynamics.ConclusionsIntravenous fat emulsion therapy may be an effective antidote for massive verapamil toxicity.
Highlights
Massive intentional verapamil overdose is a toxic ingestion which can cause multiorgan system failure and has no currently known antidote.Case Presentation: The patient is a 41-year-old Caucasian woman who ingested 19.2 g of sustained release verapamil in a suicide attempt
Intravenous fat emulsion therapy may be an effective antidote for massive verapamil toxicity
We report the successful use of intravenous lipid therapy to reverse the systemic effects of severe verapamil toxicity and we review the literature relating to this complex problem
Summary
Calcium channel blockers are commonly prescribed for hypertension and rate control of atrial fibrillation, but can be highly toxic in large quantities. Her chest X-ray and physical exam were consistent with significant volume overload from her multiple infusions and resuscitation, and a furosemide infusion was started Her central venous pressure at this time ranged from 22 to 46 mmHg. On hospital day three, she developed a thrombosis of her right radial artery at the site of an arterial catheter and was started on intravenous heparin. Urine output increased, and CVVH was discontinued At this point, it was felt that she had overcome the acute effects of verapamil overdose, and her calcium, HIE therapy and intravenous lipids were discontinued. It was felt that she had overcome the acute effects of verapamil overdose, and her calcium, HIE therapy and intravenous lipids were discontinued Her blood pressure normalized and her heart rhythm was sinus tachycardia with a rate into the 110s. At the time of publication she has completed extensive physical rehabilitation and will soon be returning home to be with her family
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