SummaryA case of refractory hypotension following propanolol overdose is reported. Management included isoprenaline, glucagon and extracorporeal circulatory support using femoral vein-femoral artery bypass. The unreliability of neurological observations, especially unreactive pupils, in the presence of drug overdose is reiterated. Key wordsSympathetic nervous system, 8-adrenergic antagonists; propanolol. Complications. Case historyA 20-year-old woman was admitted to the Accident and Emergency Department having ingested approximately 50 of her mother's propanolol tablets (total 2 gm) and 10 Mersyndol tablets (paracetamol 45 mg, codeine 9.7 mg, doxylamine 5 mg). Three hours before admission, her mother reported that she was well. However, in the hour before admission, the daughter told friends of her action and they induced her to vomit. Some tablets were seen in the vomitus. After half an hour, she became drowsy and an ambulance was called. The ambulance crew found her unresponsive, with focal fitting, dilated but sluggishly reacting pupils, no recordable blood pressure and a slow capillary refill time, but she was breathing spontaneously. She was given oxygen by mask and transferred in the lateral decubitus position.Her past medical history included mild asthma as a child. She had no psychiatric history. She lived with her mother and had a 2-year-old child. Recent relationship problems with her boyfriend had precipitated her overdose.She was unrousable on admission, intermittently fitting and peripherally cyanosed. No pulses were palpable and blood pressure was unrecordable. The ECG showed a broad QRS complex and bradycardia of 40 beats per minute. Blood gases during resuscitation were pH 6.96, Paco, 4.72 kPa, Pao, 73.0 kPa, base deficit 20.7. Urea and electrolytes were normal. Blood glucose was 6.5 mmol/litre. Paracetamol level was 33 mmol/litre; no tricyclics were detected. Subsequently propanolol levels were found to be greater than 4589 ng/ml. She was initially oxygenated by mask ventilation, followed by tracheal intubation and ventilation with 100% oxygen. External cardiac massage was initiated and continued throughout her subsequent resuscitation (total of 4 hours). Gastric lavage was performed, but no tablets were recovered. Activated charcoal was instilled into the stomach. Clonazepam 1 mg was given to relieve seizure activity and atropine 1.2 mg was administered for bradycardia. During the first hour, she received two boluses of isoprenaline 200 pg followed by an infusion of 20 pg per minute and two boluses of adrenaline 1 mg, followed by an infusion of 25 pg per minute. She also received 2 litres of intravenous colloid. There was no improvement in her pulse or blood pressure, and her central venous pressure was 35 cmH20. Glucagon was given as it became available, to a total of 9 mg over 90 minutes. Her carotid pulse became intermittently faintly palpable following glucagon administration. Her ECG continued to show a bizarre broad complex bradycardia of 30 to 40 beats per minute. Transvenous cardiac pac...