Amlodipine/insulin/metoprolol tartrate
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Various toxicities and overdose: case report A 51-year-old man developed bradycardia, hypotension, vomiting, depressed level of consciousness and increase in serum creatinine level following an overdose of amlodipine and metoprolol tartrate for suicide attempt. Additionally, he developed hypokalaemia during treatment with insulin for hypotension and bradycardia. The man, who had history of alcohol dependence and hypertension, presented to the rural hospital approximately 2 hours after the ingestion of approximately 40 tablets, mixture of metoprolol tartrate 25mg and his wife’s amlodipine 5mg for suicide attempt. On presentation, he was alert, but was vomiting. Vital signs revealed bradycardia and hypotension with heart rate of 50–60 bpm and systolic BP (SBP) of 100 mmHg. The man was started on treatment with calcium gluconate and IV bolus of insulin 1 U/kg followed by IV infusion of insulin at 1 U/kg/hour. Prior to the insulin bolus, his blood glucose was 124 mg/dL. Hence, glucose [dextrose] solution was administered along with the insulin bolus. Additionally, glucose infusion was also initiated. Thereafter, he was transferred to the tertiary care hospital. Prior to the transfer, he was intubated by the flight medics due to depressed level of consciousness. Intubation was accomplished suxamethonium chloride [succinylcholine] and etomidate. On arrival to the tertiary care hospital (4 hours postingestion), his heart rate was 38 bpm and BP was 79/49mm Hg. Within 15 minutes of arrival, his BP reached to a nadir of 55/45mm Hg with heart rate of 30 bpm. Hence, insulin was titrated up by 1 U/kg/hour every 15 minutes to a maximum of 10 U/kg/hour over 2 hours after the arrival (6 hours post-ingestion). Following this, an improvement in his SBP to 80–90mm Hg was observed. Approximately 20 minutes after arrival, he was also started on epinephrine infusion. During the titration of insulin, his blood glucose level was checked every 15 minutes. When his dose reached to 10 U/kg/hour, his blood glucose was checked every 30–60 minutes. From 11 hours post-ingestion, his glucose was titrated down. For remaining high-dose insulin course, 50% of glucose was infused. High-dose insulin and epinephrine infusion was continued until he stabilised (approximately 30 hours postingestion). During high-dose insulin infusion, his serum potassium was monitored every hour. He had only on episode of hypokalaemia, which occurred when he presented to the tertiary facility. This episode of hypokalaemia was treated with IV potassium. During the remaining course of insulin therapy, he had no additional episodes of hypokalaemia. From 30–32 hours postingestion, epinephrine was weaned, while insulin was weaned from 33–39 hours post-ingestion. The total duration of his high-dose insulin therapy was approximately 37 hour. Approximately, 27 hours post-ingestion, increase in creatinine level (2.57 mg/dL) was observed, which normalised 50 hours after the ingestion. Evidence of hepatic injury was not observed. After discontinuation of highdose insulin, infu
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