The Utility of Ecmo and Intraaortic Balloon Pumps in Lipophilic Beta Blocker and Bupropion Overdose

Abstract

Patient: Female, 21 year old Final Diagnosis: Cardiogenic shock due to ingestion Symptoms: Encephalopathy, seizures Medication: Propranolol, Bupropion Clinical Procedure: ECMO, Intraaortic Balloon Pump Specialty: Critical Care, Toxicology Background Combined massive ingestion of Beta Adrenergic Blocking Medications (BBs), Calcium Channel Blockers (CCBs), and behavioral modulators can be dangerous due to their cardiotoxicity leading to hypotension and severe refractory cardiogenic shock. Beta blockers can cause serious myocardial depression by decreasing calcium influx into cells. Some beta blockers exhibit sodium channel blockade, while others cross the blood brain barrier due to their lipophilicity causing CNS toxicity. Behavioral modulators, specifically Bupropion, cause significant cardiac depression as well by acting as a potential cardiac gap junctions blocker and therefore decreasing intercellular communication. Case Report We present a case of combined massive drug ingestion leading to severe refractory cardiogenic shock where invasive mechanical support was implemented. Patient was a 21-year-old female who presented after polyingestion in a suicide attempt. Patient took a large amount of propranolol and bupropion. She initially presented in cardiogenic shock, and seizing. She was intubated for airway protection, started multiple vasopressors, and high - dose insulin. Despite multiple therapies, she continued to deteriorate and her ejection fraction continued to worsen, at which point she was cannulated for Extracorporeal Membrane Oxygenation (ECMO) and an Intraaortic Balloon Pump (IABP) for refractory cardiogenic shock. She was in the intensive care unit for multiple weeks. Her cardiac function improved and she was able to be weaned off the mechanical support devices and vasopressors. She was discharged to a rehab facility with a good neurological outcome. Conclusion The use of ECMO contributed to the overall outcome of our patient. ECMO has a direct impact on drug pharmacokinetics. ECMO can be used to alter drug levels based on altering clearance as well as direct extraction from the circuit. Based on these results, implementation of early ECMO should be considered in patients with massive overdoses in refractory cardiogenic shock.