Verapamil overdose: case report and review of the literature.

OBJECTIVE: To report the presentation and controversies regarding therapy of an 18-year-old man following a life-threatening ingestion of verapamil. CASE SUMMARY: An 18-year-old man ingested large quantities of dipyridamole, trimethoprim/sulfamethoxazole, amoxicillin, and verapamil. He presented to an outlying hospital and was initially conscious. Soon thereafter, the patient had a seizure; he required intubation, developed cardiac conduction abnormalities, and became hypotensive. The patient required pharmacologic pressors and a pacemaker for transfer to our institution. At our institution, vigorous fluid resuscitation, cardiac pacing, and careful attention to acid/base and electrolyte management provided the basis of therapy. The patient recovered without deficit and was discharged from the intensive care unit five days later. DISCUSSION: Current controversies regarding the management of verapamil overdose are reviewed. Removal of the drug by gastric lavage is a mainstay of therapy. Administration of syrup of ipecac is contraindicated. Although specific recommendations for calcium dosing in the overdose situation have not been rigorously studied, maintenance of a normal serum ionized calcium concentration is suggested. An exogenous catecholamine, rather than dopamine, may be the drug of choice for treating hypotension. Cardiopulmonary bypass provides a method for drug removal in cases of severe toxicity; however, this invasive method requires further study. Management of fluid/electrolyte, acid/base, and ventilation abnormalities is required to treat large ingestions of verapamil. Treatment guidelines for critical care clinicians are provided.

Hepatoxicity with encephalopathy associated with aspirin therapy in rheumatoid arthritis.

Encephalopathy secondary to aspirin-induced hepatoxicity developed in three patients with JRA. In each patient clinical and biochemical resolution occurred after discontinuing the drug, but toxicity appeared on rechallenge. Liver biopsies in two patients showed mild nonspecific changes. Acute hepatic decompensation and encephalopathy may occur as a consequence of aspirin hepatoxicity in JRA and justify sequential observations of liver function tests and salicylate levels in such patients.