Intralipid emulsion treatment as an antidote in lipophilic drug intoxications: a case series Sebnem Eren Cevik MD, Tanju Tasyurek MD, Ozlem Guneysel MD PII: DOI: Reference:
S0735-6757(14)00342-8 doi: 10.1016/j.ajem.2014.05.019 YAJEM 54302
To appear in:
American Journal of Emergency Medicine
Received date: Revised date: Accepted date:
7 February 2014 12 May 2014 14 May 2014
Please cite this article as: Cevik Sebnem Eren, Tasyurek Tanju, Guneysel Ozlem, Intralipid emulsion treatment as an antidote in lipophilic drug intoxications: a case series, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.05.019
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Intralipid emulsion treatment as an antidote in lipophilic drug intoxications: a case series
T
Short running head: Intralipid emulsion treatment drug intoxications
RI P
Authors:
SC
1. Sebnem EREN CEVIK, MD; Umraniye Training and Research Hospital Department of Emergency Medicine, Istanbul / Turkey
NU
2. Tanju TASYUREK, MD; Umraniye Training and Research Hospital Department of Emergency Medicine, Istanbul / Turkey
MA
3. Ozlem GUNEYSEL, MD, Associate Professor; Dr Lutfi Kirdar Kartal Education and Research Hospital, Department of Emergency Medicine, Istanbul / Turkey
Key words: Intralipid emulsion treatment, intoxications, antidote
PT
ED
Meetings: 1st International Critical Care and Emergency Medicine Congress, Istanbul, Turkey; November 6-8 2013 (as a poster presentation)
CE
Acknowledgements: I would like to express my great appreciation to Emine Gaffari, Ozlem Tosun Giritli and Seckin Bahar Sezgin for sharing the data of their patients.
AC
Conflict of interest: None
Financial Support Received: None Corresponding Author: Sebnem EREN CEVIK
Umraniye Training and Research Hospital Department of Emergency Medicine Istanbul / Turkey E-mail:
[email protected]
Phone:
+90 216 632 1818 – (1426)
Mobile:
+90 533 495 7520
ACCEPTED MANUSCRIPT
T
Intralipid emulsion treatment as an antidote in lipophilic drug intoxications: a case series
RI P
Abstract
SC
Intravenous lipid emulsion (ILE) is a life saving treatment in lipophilic drug intoxications. Not only does ILE have demonstrable efficacy as an antidote to local anesthetic toxicity, it is also
NU
effective in lipophilic drug intoxications.
MA
Our case series involved ten patients with ingestion of different types of lipophilic drugs. ILE treatment improved Glasgow Coma Scale or blood pressure and pulse rate or both according to
ED
the drug type. Complications were observed in two patients (minimal change pancreatitis and probable ILE treatment-related fat infiltration in lungs).
PT
In our case series, ILE was used for different lipophilic drug intoxications to improve
CE
cardiovascular and neurologic symptoms. According to the results, it was stated that ILE treatment is a life saving agent in lipophilic drug intoxications and it can be used in unconscious
ingestion.
AC
patients who have cardiac and/or neurologic symptoms but no history of a specific
drug
ACCEPTED MANUSCRIPT Introduction Intravenous lipid emulsion (ILE) is a life saving treatment in lipophilic drug intoxications. The
RI P
T
history of ILE treatment is not so far. The first report of the successful utilization of lipid emulsion to counteract a drug toxidrome was in 1962, whereby researchers demonstrated an enhanced
SC
recovery from barbiturate induced neurological depression in rats.
Not only does ILE have demonstrable efficacy as an antidote to local anesthetic toxicity, its
NU
spectrum of use now clearly lies beyond this to encompass the treatment of other lipid soluble
MA
drug toxidromes (1). Methods
ED
We present a case series involving ten patients admitted to our emergency department with
PT
different lipophilic drug intoxications and administered ILE treatment during six months period. All of the patients were administered ILE as an antidote in the treatment of drug intoxication. In
CE
our Emergency Department the patient-focused data were recorded in a central computerized database. The medical records consist of history, vital signs, physical examination, laboratory
AC
tests, medical treatment and follow-up information. Each patient’s record was retrieved from the database and carefully abstracted by one of the authors to a data sheet which was designed for this study. The variables were defined as patient’s blood pressure, pulse rate, Glasgow Coma Scale (GCS), the time period between initial ILE infusion and improvement of signs and symptoms, laboratory tests and observed complications. Retrieved medical records included all of the information that was determined as variables. Two points or more increase in GCS was admitted as an improvement. On the other hand, systolic blood pressure above 90 mmHg or diastolic blood pressure above 60 mmHg was admitted as an improvement in blood pressure; pulse rate between 60 and 100 beats/min; or if tachycardic 20% or above decrease in pulse rate was determined as an improvement in pulse rate. Additionally, troponin level above 0.02 ng/mL
ACCEPTED MANUSCRIPT was admitted as an elevation according to the threshold of laboratory kits. The aim to review this case series is to denominate effectiveness and complications of ILE
RI P
T
treatment as an antidote in lipophilic drug intoxications other than local anesthetics. Case Report
SC
Case 1
NU
A 51-year-old woman with altered mental status presented to Emergency Department (ED). At the time of arrival her Glasgow Coma Scale (GCS) was 10 (E3V2M5); blood pressure was
MA
110/72 mmHg and pulse rate was 82 beats/min. Her pupils were isocoric and there was eye divergence (simultaneous outward movement of both eyes, away from each other). ECG, the
ED
other system examinations and blood tests were normal. From the records and the history, it
PT
was learned that she ingested 925 mg [potentially toxic dose which is greater than 5 mg/kg (2)] amitriptyline. Because of the fact that control blood pressure was 90/60 mmHg, the
CE
administration of an ILE was considered. ILE was administered at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 4300 mL). An hour after initial ILE dose, her GCS
Case 2
AC
was 14 (E4V4M6), divergence regressed and blood pressure improved to normal ranges.
A 24-year-old, unconscious woman was admitted to ED. From the history, it was learned that she took a total amount of 875 mg (greater than 5mg/kg) amitriptyline.
Her GCS was 7
(E1V1M5). Her blood pressure was 147/91 mmHg, and pulse rate was 143 beats/min. Her pupils were isocoric, and there was eye divergence (Figure 1). ECG revealed sinus tachycardia. Other system examinations and blood tests were normal. ILE treatment was started at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 3400 mL). After 45 minutes, pulse rate regressed to 101 beats/min. GCS improved to 9 (E2V2M5). Divergence also
ACCEPTED MANUSCRIPT regressed.
T
Case 3
RI P
A 32-year-old woman took 475 mg [potentially toxic dose which is greater than 450 mg (3)] metoprolol succinat as a suicide attempt an hour before she was admitted to our ED. GCS was
SC
15 (E4V5M6). Her blood pressure was 95/65mmHg, and pulse rate was 52 beats/min. ECG revealed sinus bradycardia. ILE treatment was started at dose 100 mL bolus and 0.5 mL/kg/min
NU
infusion for two hours (total dose of 3100 mL). Her bradycardia and her blood pressure
MA
increased in two hours after the ILE treatment. Her urine colour was red, but it was not because of hematuria (Figure 2). However, on the follow-up she had no pathological signs and symptoms, she was discharged after a 24 hours of hospitalization and psychiatry consultation. 4
ED
days after the administration of the drugs she again applied to ED with an abdominal pain
PT
reverberating to her back. In her blood tests pathological resullts were as follows: WBC:32.300 K/uL, amylase:249 U/L and lipase: 438 U/L. Additionally, urine test revealed urinary system
CE
infection. According to these results, she was hospitalized with the diagnosis of minimal change
Case 4
AC
pancreatitis. On the second day of the hospitalization, these blood values regressed.
A 32-year-old woman had taken an unknown amount of fluoxetine hydrochloride, alprazolam and nifedipine tablets. Her GCS was 8 (E4V5M6). Her blood pressure was 70/50mmHg, and pulse rate was 48 beats/min. ECG revealed sinus bradycardia. She was administered 0.2 mg flumazenil and her GCS improved to 11. Due to hypotension and bradycardia, ILE treatment was started at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 3700 mL). However, two hours after initiating ILE, her blood pressure and pulse rate were 105/70 mmHg and 85 beats/min respectively, her level of consciousness did not change. After the effect of flumazenil decreased, her GCS again regressed to 8. After the administration of ILE,
ACCEPTED MANUSCRIPT flumazenil administration was repeated, however the same result with the initial administration was not achieved. It was considered to be due to the effect of ILE on flumazenil which is a weak
T
lipophilic base. Her urine color was red (same as Case 3). Because of the fact that her GCS did
RI P
not change, she was transported to an intensive care unit. Two days after the ILE treatment, anterior-posterior chest radiography revealed diffuse infiltration (Figure 3a) and there was
SC
ground-glass opacity probable releated with ILE treatment in the thorax computed tomography (CT) (Figure 4a,b,c,d). She was suffering from coughing and chest pain. Her oxygen saturation
NU
was 97% in room air and respiratory system examination was normal. On the third day of the
MA
ILE treatment, chest radiography signs regressed significantly (Figure 3b). Case 5
ED
A 28-year-old man had taken a total amount of 2400 mg (which is greater than maximum daily
PT
dose 800 mg) quetiapine an hour before he was admitted to ED. GCS was 13 (E3V5M5). His blood pressure was 95/50 mmHg, and pulse rate was 144 beats/min. ECG revealed sinus
CE
tachycardia. ILE therapy was initiated at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 3580 mL).. Two hours after the ILE treatment, hypotension and tachycardia
Case 6
AC
regressed and GCS improved to 15 (E4V5M6).
A 18-year-old woman with a history of epilepsy had taken an unknown amount of lamotrigine 100 mg tablets and sertraline 50 mg tablets an hour before she was admitted to ED. Her GCS was 12 (E4V2M5), she was agitated, disoriented and non-cooperated. Her vital signs and ECG were normal. In neurological examination, there was vertical nystagmus and myoclonia. ILE therapy was initiated at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 3100 mL). In the first hour of ILE infusion, she started to answer the questions with disfasia and in the sixth hour, GCS was 15 and her speech was minimal dysarthric.
ACCEPTED MANUSCRIPT Case 7 A 17-year-old man with a history of bonsai use was admitted to ED. GCS was 9 (E2V2M5). His
RI P
T
blood pressure was 90/50 mmHg and pulse rate was 120 beats/min. ECG revealed tachycardia. Her pupils were miotic. ILE treatment was started due to hypotension and tachycardia at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 4000 mL). Two hours after
SC
the treatment, his blood pressure and pulse rate increased to normal levels and his GCS
NU
improved to 14.
MA
Case 8
A 24-year-old confused, disoriented woman was admitted to our ED with amitriptyline
ED
intoxication an hour after taking the drugs. From the history, it was learned that she had taken 520 mg (greater than 5 mg /kg) amitriptyline. Her GCS was 12 (E2V5M5). Her blood pressure
PT
was 80/60 mmHg, pulse rate was 125 beats/min, and temperature was 38.5 C°. Her pupils were
CE
mydriatic, pupillary light reflex was bilateral (+). Her speech was dysarthric. ECG revealed sinus tachycardia. ILE treatment was started at dose 100 mL bolus and 0.5 mL/kg/min infusion for
AC
two hours (total dose of 3400 mL). An hour after the beginning of the ILE treatment, her blood pressure started to increase (120/75mmHg), and pulse rate started to decrease (88 beats/min). Five hours later, her GCS was 14.
Case 9 A 18-year-old woman was admitted to ED. GCS was 8 (E4V2M4). Her blood pressure was 50/30 mmHg, pulse rate was 188 beats/min, and temperature was 38.0°C. Her pupils were bilateral mydriatic. She was agitated. ECG revealed sinus tachycardia. In neurological examination, there was dyskinesia. In blood gases, pH was 6.8 mL/dL and 60 mEq bolus
ACCEPTED MANUSCRIPT sodium bicarbonate was administered. ILE treatment was started on the fifteenth minute of her arrival to ED, due to suspicion of drug intoxication, at dose 100 mL bolus and 0.25 mL/kg/min
T
infusion. However, we were not able to get a drug ingestion history from the family. Twenty
RI P
minutes after the initiation of ILE, her mydriasis regressed, blood pressure increased to 90/60 mmHg and 120/70 mmHg respectively and pulse rate also decreased to value of 144 beats/min.
SC
Control pH in the blood gases was 7.01 mL/dL. Thirty minutes after the arrival, she had respiratory depression. She was intubated with propofol and rocuronium. After the intubation,
NU
gastric lavage and activated charcoal were applied. After the transport to intensive care unit
MA
(ICU), empty amitriptyline and alpha lipoic acid boxes were found by the family at home. In the ICU, dopamine and sodium bicarbonate infusion was started. Due to hypotension, noradrenaline was started and due to metabolic acidosis, sodium bicarbonate infusion was
ED
continued. For the reason that ILE treatment was not continued in the ICU, the patient was
PT
administered only total of 500 mL ILE in ED. On the follow-up, troponin-I increased to 9.24 ng/mL on the first day, and >50.000 ng/mL on the second day. On the second day of the
CE
ingestion, cardiac arrest occurred. She did not answer cardiopulmonary resuscitation and she
Case 10
AC
was admitted as exitus.
A 23-year-old woman with an unknown amount of amitriptyline intoxication was admitted to ED. GCS was 8 (E2V1M5). Her blood pressure was 160/95 mmHg, and pulse rate was 109 beats/min. Her pupils were isochoric and there was eye divergence. ECG revealed sinus tachycardia. ILE treatment was initiated at dose 100 mL bolus and 0.25 mL/kg/min infusion for two hours (total dose of 1750 mL). An hour after starting ILE therapy, GCS improved to 13 (E3V4M5). On the follow-up, CKMB mass and troponin-I values elevated to 4.2 ng/mL (reference value:
S0735-6757(14)00342-8 doi: 10.1016/j.ajem.2014.05.019 YAJEM 54302
To appear in:
American Journal of Emergency Medicine
Received date: Revised date: Accepted date:
7 February 2014 12 May 2014 14 May 2014
Please cite this article as: Cevik Sebnem Eren, Tasyurek Tanju, Guneysel Ozlem, Intralipid emulsion treatment as an antidote in lipophilic drug intoxications: a case series, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.05.019
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Intralipid emulsion treatment as an antidote in lipophilic drug intoxications: a case series
T
Short running head: Intralipid emulsion treatment drug intoxications
RI P
Authors:
SC
1. Sebnem EREN CEVIK, MD; Umraniye Training and Research Hospital Department of Emergency Medicine, Istanbul / Turkey
NU
2. Tanju TASYUREK, MD; Umraniye Training and Research Hospital Department of Emergency Medicine, Istanbul / Turkey
MA
3. Ozlem GUNEYSEL, MD, Associate Professor; Dr Lutfi Kirdar Kartal Education and Research Hospital, Department of Emergency Medicine, Istanbul / Turkey
Key words: Intralipid emulsion treatment, intoxications, antidote
PT
ED
Meetings: 1st International Critical Care and Emergency Medicine Congress, Istanbul, Turkey; November 6-8 2013 (as a poster presentation)
CE
Acknowledgements: I would like to express my great appreciation to Emine Gaffari, Ozlem Tosun Giritli and Seckin Bahar Sezgin for sharing the data of their patients.
AC
Conflict of interest: None
Financial Support Received: None Corresponding Author: Sebnem EREN CEVIK
Umraniye Training and Research Hospital Department of Emergency Medicine Istanbul / Turkey E-mail:
[email protected]
Phone:
+90 216 632 1818 – (1426)
Mobile:
+90 533 495 7520
ACCEPTED MANUSCRIPT
T
Intralipid emulsion treatment as an antidote in lipophilic drug intoxications: a case series
RI P
Abstract
SC
Intravenous lipid emulsion (ILE) is a life saving treatment in lipophilic drug intoxications. Not only does ILE have demonstrable efficacy as an antidote to local anesthetic toxicity, it is also
NU
effective in lipophilic drug intoxications.
MA
Our case series involved ten patients with ingestion of different types of lipophilic drugs. ILE treatment improved Glasgow Coma Scale or blood pressure and pulse rate or both according to
ED
the drug type. Complications were observed in two patients (minimal change pancreatitis and probable ILE treatment-related fat infiltration in lungs).
PT
In our case series, ILE was used for different lipophilic drug intoxications to improve
CE
cardiovascular and neurologic symptoms. According to the results, it was stated that ILE treatment is a life saving agent in lipophilic drug intoxications and it can be used in unconscious
ingestion.
AC
patients who have cardiac and/or neurologic symptoms but no history of a specific
drug
ACCEPTED MANUSCRIPT Introduction Intravenous lipid emulsion (ILE) is a life saving treatment in lipophilic drug intoxications. The
RI P
T
history of ILE treatment is not so far. The first report of the successful utilization of lipid emulsion to counteract a drug toxidrome was in 1962, whereby researchers demonstrated an enhanced
SC
recovery from barbiturate induced neurological depression in rats.
Not only does ILE have demonstrable efficacy as an antidote to local anesthetic toxicity, its
NU
spectrum of use now clearly lies beyond this to encompass the treatment of other lipid soluble
MA
drug toxidromes (1). Methods
ED
We present a case series involving ten patients admitted to our emergency department with
PT
different lipophilic drug intoxications and administered ILE treatment during six months period. All of the patients were administered ILE as an antidote in the treatment of drug intoxication. In
CE
our Emergency Department the patient-focused data were recorded in a central computerized database. The medical records consist of history, vital signs, physical examination, laboratory
AC
tests, medical treatment and follow-up information. Each patient’s record was retrieved from the database and carefully abstracted by one of the authors to a data sheet which was designed for this study. The variables were defined as patient’s blood pressure, pulse rate, Glasgow Coma Scale (GCS), the time period between initial ILE infusion and improvement of signs and symptoms, laboratory tests and observed complications. Retrieved medical records included all of the information that was determined as variables. Two points or more increase in GCS was admitted as an improvement. On the other hand, systolic blood pressure above 90 mmHg or diastolic blood pressure above 60 mmHg was admitted as an improvement in blood pressure; pulse rate between 60 and 100 beats/min; or if tachycardic 20% or above decrease in pulse rate was determined as an improvement in pulse rate. Additionally, troponin level above 0.02 ng/mL
ACCEPTED MANUSCRIPT was admitted as an elevation according to the threshold of laboratory kits. The aim to review this case series is to denominate effectiveness and complications of ILE
RI P
T
treatment as an antidote in lipophilic drug intoxications other than local anesthetics. Case Report
SC
Case 1
NU
A 51-year-old woman with altered mental status presented to Emergency Department (ED). At the time of arrival her Glasgow Coma Scale (GCS) was 10 (E3V2M5); blood pressure was
MA
110/72 mmHg and pulse rate was 82 beats/min. Her pupils were isocoric and there was eye divergence (simultaneous outward movement of both eyes, away from each other). ECG, the
ED
other system examinations and blood tests were normal. From the records and the history, it
PT
was learned that she ingested 925 mg [potentially toxic dose which is greater than 5 mg/kg (2)] amitriptyline. Because of the fact that control blood pressure was 90/60 mmHg, the
CE
administration of an ILE was considered. ILE was administered at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 4300 mL). An hour after initial ILE dose, her GCS
Case 2
AC
was 14 (E4V4M6), divergence regressed and blood pressure improved to normal ranges.
A 24-year-old, unconscious woman was admitted to ED. From the history, it was learned that she took a total amount of 875 mg (greater than 5mg/kg) amitriptyline.
Her GCS was 7
(E1V1M5). Her blood pressure was 147/91 mmHg, and pulse rate was 143 beats/min. Her pupils were isocoric, and there was eye divergence (Figure 1). ECG revealed sinus tachycardia. Other system examinations and blood tests were normal. ILE treatment was started at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 3400 mL). After 45 minutes, pulse rate regressed to 101 beats/min. GCS improved to 9 (E2V2M5). Divergence also
ACCEPTED MANUSCRIPT regressed.
T
Case 3
RI P
A 32-year-old woman took 475 mg [potentially toxic dose which is greater than 450 mg (3)] metoprolol succinat as a suicide attempt an hour before she was admitted to our ED. GCS was
SC
15 (E4V5M6). Her blood pressure was 95/65mmHg, and pulse rate was 52 beats/min. ECG revealed sinus bradycardia. ILE treatment was started at dose 100 mL bolus and 0.5 mL/kg/min
NU
infusion for two hours (total dose of 3100 mL). Her bradycardia and her blood pressure
MA
increased in two hours after the ILE treatment. Her urine colour was red, but it was not because of hematuria (Figure 2). However, on the follow-up she had no pathological signs and symptoms, she was discharged after a 24 hours of hospitalization and psychiatry consultation. 4
ED
days after the administration of the drugs she again applied to ED with an abdominal pain
PT
reverberating to her back. In her blood tests pathological resullts were as follows: WBC:32.300 K/uL, amylase:249 U/L and lipase: 438 U/L. Additionally, urine test revealed urinary system
CE
infection. According to these results, she was hospitalized with the diagnosis of minimal change
Case 4
AC
pancreatitis. On the second day of the hospitalization, these blood values regressed.
A 32-year-old woman had taken an unknown amount of fluoxetine hydrochloride, alprazolam and nifedipine tablets. Her GCS was 8 (E4V5M6). Her blood pressure was 70/50mmHg, and pulse rate was 48 beats/min. ECG revealed sinus bradycardia. She was administered 0.2 mg flumazenil and her GCS improved to 11. Due to hypotension and bradycardia, ILE treatment was started at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 3700 mL). However, two hours after initiating ILE, her blood pressure and pulse rate were 105/70 mmHg and 85 beats/min respectively, her level of consciousness did not change. After the effect of flumazenil decreased, her GCS again regressed to 8. After the administration of ILE,
ACCEPTED MANUSCRIPT flumazenil administration was repeated, however the same result with the initial administration was not achieved. It was considered to be due to the effect of ILE on flumazenil which is a weak
T
lipophilic base. Her urine color was red (same as Case 3). Because of the fact that her GCS did
RI P
not change, she was transported to an intensive care unit. Two days after the ILE treatment, anterior-posterior chest radiography revealed diffuse infiltration (Figure 3a) and there was
SC
ground-glass opacity probable releated with ILE treatment in the thorax computed tomography (CT) (Figure 4a,b,c,d). She was suffering from coughing and chest pain. Her oxygen saturation
NU
was 97% in room air and respiratory system examination was normal. On the third day of the
MA
ILE treatment, chest radiography signs regressed significantly (Figure 3b). Case 5
ED
A 28-year-old man had taken a total amount of 2400 mg (which is greater than maximum daily
PT
dose 800 mg) quetiapine an hour before he was admitted to ED. GCS was 13 (E3V5M5). His blood pressure was 95/50 mmHg, and pulse rate was 144 beats/min. ECG revealed sinus
CE
tachycardia. ILE therapy was initiated at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 3580 mL).. Two hours after the ILE treatment, hypotension and tachycardia
Case 6
AC
regressed and GCS improved to 15 (E4V5M6).
A 18-year-old woman with a history of epilepsy had taken an unknown amount of lamotrigine 100 mg tablets and sertraline 50 mg tablets an hour before she was admitted to ED. Her GCS was 12 (E4V2M5), she was agitated, disoriented and non-cooperated. Her vital signs and ECG were normal. In neurological examination, there was vertical nystagmus and myoclonia. ILE therapy was initiated at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 3100 mL). In the first hour of ILE infusion, she started to answer the questions with disfasia and in the sixth hour, GCS was 15 and her speech was minimal dysarthric.
ACCEPTED MANUSCRIPT Case 7 A 17-year-old man with a history of bonsai use was admitted to ED. GCS was 9 (E2V2M5). His
RI P
T
blood pressure was 90/50 mmHg and pulse rate was 120 beats/min. ECG revealed tachycardia. Her pupils were miotic. ILE treatment was started due to hypotension and tachycardia at dose 100 mL bolus and 0.5 mL/kg/min infusion for two hours (total dose of 4000 mL). Two hours after
SC
the treatment, his blood pressure and pulse rate increased to normal levels and his GCS
NU
improved to 14.
MA
Case 8
A 24-year-old confused, disoriented woman was admitted to our ED with amitriptyline
ED
intoxication an hour after taking the drugs. From the history, it was learned that she had taken 520 mg (greater than 5 mg /kg) amitriptyline. Her GCS was 12 (E2V5M5). Her blood pressure
PT
was 80/60 mmHg, pulse rate was 125 beats/min, and temperature was 38.5 C°. Her pupils were
CE
mydriatic, pupillary light reflex was bilateral (+). Her speech was dysarthric. ECG revealed sinus tachycardia. ILE treatment was started at dose 100 mL bolus and 0.5 mL/kg/min infusion for
AC
two hours (total dose of 3400 mL). An hour after the beginning of the ILE treatment, her blood pressure started to increase (120/75mmHg), and pulse rate started to decrease (88 beats/min). Five hours later, her GCS was 14.
Case 9 A 18-year-old woman was admitted to ED. GCS was 8 (E4V2M4). Her blood pressure was 50/30 mmHg, pulse rate was 188 beats/min, and temperature was 38.0°C. Her pupils were bilateral mydriatic. She was agitated. ECG revealed sinus tachycardia. In neurological examination, there was dyskinesia. In blood gases, pH was 6.8 mL/dL and 60 mEq bolus
ACCEPTED MANUSCRIPT sodium bicarbonate was administered. ILE treatment was started on the fifteenth minute of her arrival to ED, due to suspicion of drug intoxication, at dose 100 mL bolus and 0.25 mL/kg/min
T
infusion. However, we were not able to get a drug ingestion history from the family. Twenty
RI P
minutes after the initiation of ILE, her mydriasis regressed, blood pressure increased to 90/60 mmHg and 120/70 mmHg respectively and pulse rate also decreased to value of 144 beats/min.
SC
Control pH in the blood gases was 7.01 mL/dL. Thirty minutes after the arrival, she had respiratory depression. She was intubated with propofol and rocuronium. After the intubation,
NU
gastric lavage and activated charcoal were applied. After the transport to intensive care unit
MA
(ICU), empty amitriptyline and alpha lipoic acid boxes were found by the family at home. In the ICU, dopamine and sodium bicarbonate infusion was started. Due to hypotension, noradrenaline was started and due to metabolic acidosis, sodium bicarbonate infusion was
ED
continued. For the reason that ILE treatment was not continued in the ICU, the patient was
PT
administered only total of 500 mL ILE in ED. On the follow-up, troponin-I increased to 9.24 ng/mL on the first day, and >50.000 ng/mL on the second day. On the second day of the
CE
ingestion, cardiac arrest occurred. She did not answer cardiopulmonary resuscitation and she
Case 10
AC
was admitted as exitus.
A 23-year-old woman with an unknown amount of amitriptyline intoxication was admitted to ED. GCS was 8 (E2V1M5). Her blood pressure was 160/95 mmHg, and pulse rate was 109 beats/min. Her pupils were isochoric and there was eye divergence. ECG revealed sinus tachycardia. ILE treatment was initiated at dose 100 mL bolus and 0.25 mL/kg/min infusion for two hours (total dose of 1750 mL). An hour after starting ILE therapy, GCS improved to 13 (E3V4M5). On the follow-up, CKMB mass and troponin-I values elevated to 4.2 ng/mL (reference value:
