Department of Internal Medicine, Newark Beth Israel Medical Center, Newark, NJ
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Critical Care I
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: Baclofen, a lipophilic GABA agonist, is commonly used in spastic movement disorders like multiple sclerosis(MS). Its use as a muscle relaxant provides symptomatic relief to patients. Adverse effects include hallucinations, hypotension, hypothermia, bradycardia, seizures, coma and death. We present a case of a pt w/ MS who overdosed on baclofen. An unusual therapy historically used in veterinary medicine, intravenous lipid emulsion, was administered after her presentation with favorable results.
CASE PRESENTATION: A 76 y/o AAF w/ HTN, schizophrenia and MS presented to the ED after a failed suicide attempt. The pt was convinced she heard multiple gunshots and voices repeatedly telling her that her husband had killed himself. In response, she ingested nearly 40 tabs of baclofen. Her husband found her approx 12 hrs later and called EMS. She arrived unresponsive, bradycardic and hypotensive; she was subsequently intubated. EKG showed sinus bradycardia. Atropine was given with no response and the pt was then started on an epinephrine drip. With the decreased response to atropine and epinephrine, it was decided to give the pt a 20% lipid emulsion. Within two hours, the heart rate improved and epinephrine was weaned off, though mental status remained unchanged. CT head was negative. EEG demonstrated subclinical seizures and the pt was started on anti-epileptic therapy. On day three, pt began to open her eyes spontaneously, respond to pain and track objects. By day five, she began to follow commands and show marked improvement in neurological function. She was subsequently extubated and discharged to a rehab facility with baseline neurological status.
DISCUSSION: The pharmacokinetics of baclofen estimates the half-life in overdose can approach 34 hours, possibly explaining the delay in return to baseline mental status. Having failed standard resuscitation protocols, including the use of atropine and epinephrine, a lipid infusion is a reasonable effort in acute management of lipophilic drug overdoses. A significant improvement was seen in heart rate and blood pressure, however due to prolonged time from ingestion to presentation, it is unknown if the lipid infusion would have been more beneficial if she presented earlier.
CONCLUSIONS: In the setting of known toxicity to baclofen, limited data is available regarding treatment. There are animal studies and few human based case reports that have demonstrated an improvement in clinical signs with the use of lipid infusion in the setting of a lipophilic drug toxicity with cardiovascular collapse. More research is warranted for the use of lipid infusion for the treatment of baclofen overdose.
Reference #1: Fernandez et al. The use of IV Lipid Emulsion as an Antidote in Veterinary Toxicology. J o Vet Em and Crit, 21: 309-320.
Reference #2: Bildik et al. Baclofen Intoxication. Turk J Em Med 2010;10(2):86-89.
Reference #3: Geib et al. Clinical Experience with IV Lipid Emulsion for Drug-Induced Cardiovascular Collapse. J Med Tox 2012; Mar 8(1) 10-14.
DISCLOSURE: The following authors have nothing to disclose: Amee Sodha, Habib Nazir, Mariza De Brito, Marc Lindner, Katherine Chiapaikeo-Poco, Ryan Hill, Jason Manzella, Joshua Lee, Nancy Holder, Nadeem Ali, Pratik Patel, Christina Migliore
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