Caffeine overdose
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Various toxicities: case report A 39-year-old man developed combativeness, agitation, diaphoresis, nausea, vomiting, supraventricular tachycardia, premature ventricular contractions, occasional bigeminy, hypokalaemia, high-anion gap metabolic acidosis, multiple metabolic derangements, mild rhabdomyolysis, renal failure and cardiovascular collapse following an intentional caffeine overdose and intoxication [time to reactions onsets not stated]. The man was brought to the hospital by emergency medical services following an intentional caffeine overdose. His HR was 260–280 beats/minute on arrival, and a narrow complex morphology was seen on the monitor. He was treated with midazolam because of combativeness. He was shifted to the emergency department (ED). In the ED, he was found to be diaphoretic, agitated, tachycardic and vomiting. He stated that approximately 1–2h prior to the ED arrival, he had ingested approximately 50g of over-the-counter caffeine tablets. Telemetry monitoring and frequent ECGs revealed supraventricular tachycardia with frequent premature ventricular contractions and occasional bigeminy. He was treated with esmolol for the uncontrolled and persistent tachycardia. He also required multiple doses of midazolam for agitation and trimethobenzamide to treat nausea and vomiting. Initial investigations revealed multiple laboratory abnormalities, high-anion gap metabolic acidosis, hypokalaemia and creatinine of 1.55 mg/dL. A serum caffeine level was also sent to an outside lab for processing. He received sodium bicarbonate with potassium repletion for correction of his multiple metabolic derangements. He developed renal failure and cardiovascular collapse. After consideration of the multiple options for therapy, urgent haemodialysis was elected due to the reported ingestion being well above the known lethal dose. He was admitted to the ICU and immediately started on a 4h haemodialysis session. During the haemodialysis session, his hemodynamics significantly improved and he was weaned off of esmolol. Later that evening, his initial pre-dialysis caffeine level was found to be well above lethal levels at 254 µg/mL. After the first dialysis session, a repeat caffeine level was found to be 130 µg/mL (49% decrease from baseline). The following morning another pre-dialysis treatment level was drawn and found to be 86 µg/mL. After a second haemodialysis session, the caffeine level dropped to 27.4 µg/mL (89% decrease from baseline). He received a total of three haemodialysis sessions, with his caffeine level ultimately returning to a normal level two days after admission. His hospital course was further complicated by mild rhabdomyolysis which improved after an unspecified IV fluid hydration. After the IV fluid hydration, an echocardiogram revealed no significant wall motion abnormalities and a normal left ventricular function with ejection fraction of 60-65%. He was shifted to the general medical floors 48h later. On hospital day 8, he was discharged to an inpatient psychiatric facility. Author comment: "
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