Supplemental data.
Suppl. Figure 1. Clinical case presentation. Time line of mean arterial pressure (MAP) and major therapeutic interventions (i.e., cardiopulmonary resuscitation [CPR] and drug administration; IVP = intravenous bolus). A 16 year-old previously healthy girl weighing 75 kg ingested ten verapamil (240 mg Extended Release), three quinapril (5 mg), three trazodone (50 mg), and an unknown number of loratadine (10 mg) tablets. She was immediately transferred by EMS to an Emergency Department where blood pressure (BP) was 126/87 mm Hg and heart rate (HR) was 87bpm. No gastrointestinal decontamination was performed. Four and a half hours after ingestion she ambulated to the bathroom. BP was noted to be 80/40 mmHg and HR 72 bpm. One liter of normal saline (NS) and one gram of calcium chloride were administered. She was then transferred to our institution, receiving two more liters of NS during transportl. Approximately six hours after ingestion, BP was 78/32 mmHg and HR was 66 bpm (Fig. 1A). EKG revealed first degree AV Block with a PR of 224 msec. One liter of NS and one gram of calcium chloride were administered, with a transient stabilization of BP (Fig. 1A). Thirty minutes later, decreasing sensorium required endotracheal intubation (Fig. 1A). The patient’s BP continued to drop despite administration of catecholamine pressors, glucagon and insulin. Repeated episodes of pulselessness required intermittent chest compression from eight to 11 hours after ingestion (Fig. 1A). Eleven hours after ingestion, one liter of intravenous lipid emulsion (ILE, 20%, 75cc/kg) was administered over one hour. Within ten minutes of initiating the ILE, BP was 97/44 mmHg and HR 93 bpm; 18 min after starting ILE, BP was 109/54 mmHg and remained stable thereafter (Fig. 1A). No further ILE was administered. The patient was extubated six hours after ILE administration and had no neurological impairment when discharged. There were no adverse events from the ILE. The patient was transferred to psychiatry the following day, approximately 28 hours after receiving the ILE. The patient’s plasma total verapamil concentrations at seven, 14 and 20 hours post-ingestion were 2.78, 2.91 and 0.42 µM (therapeutic 0.11 - 0.45 µM). Concentrations of the active metabolite norverapamil were 0.8, 1.55 and 0.39 µM respectively, measured by gas chromatography/mass spectrometry (GC/MS). As expected, the serum was lipemic following ILE. The patient’s plasma triglycerides (TG) prior to ILE administration were 132 mg/dL, and after assay re-calibration against ILE-derived TG were calculated at 670 and 296 mg/dL at 3 and 8 hours post ILE, corresponding to a serum ILE concentration of 0.8 and 0.25% vol%, respectively. The patient’s plasma calcium was relatively constant (8.1, 7.8 and 9.2 mg/dL respectively) as determined colorimetrically on a Beckman-Coulter DxC800 (reference range 8.5 – 10.5 mg/dL). Comprehensive drug screening was positive only for verapamil, norverapamil and two other verapamil metabolites, and trazodone. Quinapril and loratidine were not detected.