A 53-year-old woman with a history of depression, hypothyroid, migraine presented to the emergency department (ED) in intubated state initially resuscitated at local hospital shortly after taking 25 tablets of sustained release verapamil 120 mg (3 g). At the ED her heart rate was 30/min (junctional rhythm) with blood pressure almost unrecordable. She received two litres of crystalloids, 1mg of IV Adrenaline, 2mg IV Atropine, 100mg Auxisoda, IV calcium Gluconate, 9mg IV Glucagon and immediately shifted to cathlab for urgent TPI.
After that she was shifted to RITU with Adrenaline & Noradrenalin support with mechanical ventilator. HIE therapy was initiated with 25% dextrose and insulin infusions 10 units/hour. Glucagon infusion given at 5mg/hour. Empiric Meropenem, Teicoplanin due to leukocytosis of 29,000/mm3. Calcium chloride infusion was continued throughout this time to maintain an elevated ionized calcium level. Initially she developed severe lactic acidosis (lactate-13) which was gradually corrected with IV fluid resuscitation, maintaining perfusion pressure by triple ionotrope support and sodium bicarbonate infusion. The next day she became anuric and commenced on CVVHDF with no ultrafiltrate. She also developed GTCS for which Inj Meropenem was stopped, Zavicefta, Aztreonam, Polymyxin-B added and injection levipil started. As a result of the initial resuscitation and these interventions, she received massive fluid and her saturation started to fall with increased Pco2 leading to pulmonary oedema. So we started to give Ultrafiltrate slowly. Her renal function improved, urine output increased, and CVVHDF was discontinued after one day. On hospital day four, our patient regained heart rhythm with a heart rate of 65-70 bpm and transvenous pacing was discontinued. At this point, it was felt that she had overcome the acute effects of verapamil overdose, and her calcium, HIE therapy were discontinued. Her blood pressure started to normalize and gradually she was off vassopressor support and was extubated on Day seven successfully.
Our patient’s recovery was delayed by leukocytosis even after her blood pressure and renal failure had improved because she has grown MDR Klebsiella in her sputum for which she was given respected antibiotics for ten days. She slowly improved and was discharged from hospital post-ingestion day 12. At discharge she was alert and oriented with intact verbal function, was able to walk and was eager to be discharged. At the time of publication she has completed extensive physical rehabilitation and doing well at her home.
