1. More Than A Gesture Michael D. Schwartz, MD Centers for Disease Control/ ATSDR/Georgia Poison Center (Fellowship Sponsor: Oak Ridge Institute for Science & Education, Department of Energy)

2. “There are No Interesting Cases after 3 A.M.” 47 y/o female who ingested “a lot” of her medication –0300: Woke up and went to living room –0310: Mother got up and found her with empty bottle Schizophrenia Takes Depot Haloperidol, diphenhydramine, X Denies drugs/ETOH; does smoke ER: Patient took 10 of DPH…but 100 of X

3. Initial ED Course EMS: Refused AC/C, stable, NSR BP 120/80, P=70, T=36. 1, RR/Sat=16/100% PE: Normal pupils, cardiac, pulm., abd. Neuro: “I want to die.” FSBS = 100 EKG #1 shows NSR=70, normal intervals, no acute changes

4. Patient’s last normal ECG for a while

5. “I Want to Die” At the conclusion of the physical exam: the patient suddenly experienced pulseless ventricular tachycardic arrest Shocked into sinus & restoration of pulse with the aid of a handy LifePak nearby. Georgia Poison Center called

6. Post-Arrest Pulse 60, BP 70/50 (dopamine 20 mcg), Intubated, A-line, C-line, NG, AC/C ABG: 7.51/19/356/15/100% –K + 1.0 mEq/L Post-arrest EKG: LBBB, QRS 236 msec, QT 528 msec

7. Post-Arrest ECG #2

8. Labs Urine Toxicology screen: Negative APAP/ASA: Negative CBC: normal 140 105 12 178Ca = 8.7, Mg = 2.3 1.3 18 1.2 Cardiac enzymes: normal Serum Osm: normal, Lactate: normal LFTs: normal

9. Tox Attending: “I’m not sure Sodium Bicarbonate is such a good idea…” K + = 1.3 NaHCO 3 = Dead QT = Long QRS = Wide

10. What’s A Fella/ow to Do? Switched from dopamine to norepinephrine 4 mcg/min, BP = 130/70 “Potassium-in-Every-Orifice” Method: K=1.8 Magnesium 4 gm IV prophylaxis for TdP Patient’s HR holding at 82 300 cc 3% NaCl infused rapidly Toxicology Fellow’s HR = 220-Age

11. ECG #3 (2 minutes of hot salt)

12. ECG #4 (completion of hot salt)

13. ECG #5 (after conversion)

14. ECG #6 (ICU Day 1) QRS 80 msec, QT 396 msec, K = 4.6, norepinephrine D/C’d

15. A laboratory result was reported