Refractory Hypotension

ID: 51 y/o ♀; new immigrant; found unconscious in her apartment by her daughter, and was brought in by EMS.

HPI: Daughter went to visit her; found her on the floor, non-responsive, but breathing; called 911; no suicide note; no empty pill containers around; as per daughter long-standing depression, worse after immigration; regained consciousness in the ER, and denied suicidal attempt or intentional overdose; ⊘ trauma; ⊘ hemoptysis; ⊘ hematuria; ⊘ hematemesis; ⊘ melena/hematochezia; 

⊘ incontinence. 

PMH: Depression, HTN, DM-II; no prior suicide attempts;

Meds: Atenolol; nifedipine; metformin; atorvastatin; citalopram; ⊘ anticoagulants/antiplatelets; 

All: NKDA 

SH: New immigrant; language barrier; lives alone; ⊘ drugs; ⊘ ETOH;

E/O: responsive to voice; NAD; ⊘ ill/toxic; ⊘ obvious bleeding;

BP: 56/p  P: 45  R: 11  Sat: 94% RA  Temp: 36.4 ℃

CBG: 6.1

ABCDE: 100% O₂ by mask; 2 large bore IVs; NS 2L IV bolus; CBCD, Rapid Metabolic Panel (RMP), Lactate, ETOH level; acetaminophen and salicylate levels; Venous Blood Gas (VBG); ECG; continuous cardiac monitoring; respiratory therapist and ICU were paged; no signs of trauma in the rapid primary survey (RPS).

HEENT: ⊘ tongue biting. 

CVS: Bradycardia; otherwise unremarkable. 

Resp: AE=AE; bilat. clear fields. 

Abdo: protuberant; BS active; soft; ⊘ peritoneal.

Neuo: Pupils 3mm, symmetric, reactive, ⊘ RAPD; 

moves limbs ✗ 4; ⊘ focal.

Skin: cold extremities; not diaphoretic. 

BP refractory to NS 2 Lit IV bolus; lab results normal; 

ECG: sinus brady @45 with 1st º AV block. 

I/P: beta blocker overdose was suspected; BP responded to glucagon 3mg IV bolus then 3mg/h IV infusion,and D50W 50ml bolus + insulin 60U IV push; insulin infusion 0.5U/kg/h + dextrose 1g/kg/h as D10W were started; CBG repeated q15min; electrolytes repeated q30min; was admited to ICU after initial resuscitation;  

Discussion⁽¹⁾: 

The “toxidrome-oriented” physical examination: 

1. vital signs
2. LOC
3. pupil size and position
4. mucous membranes
5. skin temperature and moisture
6. bowel sounds
7. assessment of motor tone

DDx of hypotension + bradycardia cased by overdose:

1. Beta-blockers (associated w HYPOglycaemia)
2. CCBs (associated w HYPERglycaemia)
3. Digoxin (GI Sx, ECG ▵s)
4. clonidine
5. cholinergics

The empiric use of the so-called “coma cocktail” (dextrose, oxygen, naloxone, and thiamine) is no longer recommended in pt presenting with non-traumatic ↓LOC.

Reference: 

1. http://www.uptodate.com/contents/initial-management-of-the-critically-ill-adult-with-an-unknown-overdose?source=search_result&search=betablocker+poisoning&selectedTitle=2%7E9