aminend
Warlock
- May 24, 2020
- 747
Description
A man in his mid-20s called Emergency Medical Services (EMS) to report that he ingested 25 g of sodium nitrite in a suicide attempt. The paramedics found the patient somnolent with systolic blood pressure 110 mm Hg, heart rate 130 bpm, oxygen saturation 79% with notable cyanosis and diaphoresis. EMS reported a scale and white powder at the scene. He was intubated after a tonic-clonic seizure, developed ventricular fibrillation, defibrillated at 200 J, and Cardiopulmonary Resuscitation (CPR) was initiated as the cardiac rhythm degraded to pulseless electrical activity. Intravenous medications administered included 2.5 mg epinephrine 1:10 000, 1 g calcium chloride, 100 mEq sodium bicarbonate 8.4% and 5 g hydroxocobalamin.The patient was transported to the emergency department (ED) with ongoing CPR. On hospital arrival in the ambulance bay, the paramedics were given 100 mg methylene blue to administer intravenously as they did not have the antidote in their ambulance. During the primary survey in the ED, he was in asystole, with end-tidal CO2 12 mm Hg and blue-grey discolouration of the skin. The patient received intravenous 2 mg epinephrine, 1 g calcium chloride, 50 mEq sodium bicarbonate 8.4%, 50 mg methylene blue and 125 mL intralipid. Arterial blood gas was obtained with notable brown-black appearance (figure 1) and pH 7.03, PCO2 87 mm Hg, PaO22 mm Hg, bicarbonate 22 mmol/L, lactate 30 mmol/L. The haemoglobin was 12.4 g/dL with 28.8% methaemoglobin (reference range 0.4%–1.5%). Resuscitation was ceased 50 min after the initial arrest. Postmortem-combined nitrate and nitrite level was 5300 µmol/L (reference range 0–53) and autopsy revealed brown discolouration of muscle tissue consistent with methaemoglobinemia (figure 2).
