Polymyoclonus, ventricular fibrillation and Takotsubo after accidental spinal injection of tranexamic acid.
BMJ Case Rep
; 16(7)2023 Jul 18.
Article
em En
| MEDLINE
| ID: mdl-37463777
ABSTRACT
Several factors have been identified as contributing to medication administration errors, including look-alike, sound-alike (LASA) errors. LASA errors are important causes of serious adverse events arising from spinal injection of tranexamic acid, which can be confused with ampoules of local anaesthesia.We present a case of accidental injection of 250 mg of tranexamic acid rather than prilocaine during spinal anaesthesia. The patient developed lower extremities myoclonus, followed by generalised convulsions and ventricular fibrillation, that was reverted within 6 min. Severe cardiogenic shock requiring both inotropic and vasopressor therapy followed, along with a classic apical ballooning pattern on echocardiography and elevated myocardial injury markers, indicating Takotsubo cardiomyopathy. The patient's condition progressively improved to full recovery, and she was discharged from hospital after 1 month with no neurological deficit or cardiac dysfunction.To our knowledge, this is the 28th reported case of accidental spinal injection of tranexamic acid. We present a brief review of previously published cases.
Palavras-chave
Texto completo:
1
Coleções:
01-internacional
Base de dados:
MEDLINE
Assunto principal:
Ácido Tranexâmico
/
Cardiomiopatia de Takotsubo
/
Mioclonia
Tipo de estudo:
Diagnostic_studies
/
Prognostic_studies
Limite:
Female
/
Humans
Idioma:
En
Revista:
BMJ Case Rep
Ano de publicação:
2023
Tipo de documento:
Article
País de afiliação:
Portugal