15-year-old with intentional ingestion of grandparent’s heart rhythm medication

Case

I’m calling from the ER and I have a 15-year-old female that has just been brought in by paramedics for a drug overdose. She is responsive to pain but non-communicative. This is her second suicide attempt according to the family. She lives with her grandparents and apparently they found her in her room surrounded by empty bottles of her grandfather’s heart medication. I’m not sure what she has taken but her heart rate is only 40 bpm. Her blood pressure is low at 92/50 and she responds to pain and stimuli but she’s non-communicative. I have poison control on the other line but given that there’s heart medication involved, I reached out to you as well. Any idea what I should do from here?

What am I thinking?

This call is unfortunately becoming all too common. My initial thoughts are focused on how to support the child and calling poison control in the event of an intentional ingestion is absolutely the right first call. We should start with supportive care of the patient and make sure that she is stable while following instructions from poison control. The next thought is to gain some understanding of the type of medication taken and how much was taken. Given the low heart rate and blood pressure, my concern is that of a calcium channel blocker or β-blocker overdose.

History and physical

A focused history is often required in the aftermath of an intentional ingestion patient with an emphasis on what may have been ingested. The ingested medications may be prescribed for the individual who took the overdose but may also be medications used by other family members as described in the scenario. Trying to determine what pills were taken and how much of them will provide a concentrated approach to treatment. Past medical history to include medication history and other medical diagnoses may help with drug–drug interactions and systemic findings such as renal or hepatic impairment. As treatment is focused on supportive care, physical exam would be concentrated on demonstrating hemodynamic stability. Frequent recording of the vital signs including heart rate and blood pressure with attention to perfusion of the extremities via pulse and capillary refill should be the key. With ingestion of antiarrhythmic drugs, any evidence for shock is likely to be cardiac in origin.