Journal of Medical Toxicology

, Volume 10, Issue 3, pp 307–310 | Cite as

Asystole Immediately Following Intravenous Fat Emulsion for Overdose

  • Jon B. Cole
  • Samuel J. Stellpflug
  • Kristin M. Engebretsen
Observation (Case Reports)


Use of intravenous fat emulsion (IFE) for the treatment of poisoned patients in extremis is increasing. Little literature exists describing failures and complications of IFE. We describe two cardiac arrests temporally associated with IFE. A 50-year-old woman presented after ingesting 80 total tablets of metoprolol 25 mg and bupropion 150 mg. Bradycardia and hypotension were refractory to calcium salts, catecholamines, and high dose insulin (HDI). With a pulse of 40/min and mean arterial pressure (MAP) of 30 mmHg, 100 mL of 20 % IFE was given; within 30 s, brady-asystolic arrest occurred. Pulses returned after 3 min of CPR. The patient died on hospital day 4 of multisystem organ failure (MSOF). A 53-year-old man presented after ingesting of 3,600 mg of diltiazem and 1,200 mg of propranolol. Bradycardia and hypotension were refractory to calcium salts, catecholamines, HDI, bicarbonate, and atropine. With a pulse of 30/min and a MAP of 40 mmHg, 150 mL of 20 % IFE was given; within 1 min, a brady-asystolic arrest occurred. Pulses returned after 6 min of CPR. The patient died on hospital day 7 of MSOF. Reported cases of IFE failures or potential complications are sparse. This report adds only case experience, not clarity. We report two cardiac arrests that were temporally associated with IFE.


Intravenous fat emulsion Cardiac arrest Poisoning Shock Resuscitation 


  1. 1.
    Stellpflug SJ, Harris CR, Engebretsen KM, Cole JB, Holger JS (2010) Intentional overdose with cardiac arrest treated with intravenous fat emulsion and high dose insulin. Clin Toxicol 48:227–229CrossRefGoogle Scholar
  2. 2.
    Stellpflug SJ, Fritzlar SJ, Cole JB, Engebretsen KM, Holger JS (2011) Cardiotoxic overdose treated with intravenous fat emulsion and high-dose insulin in the setting of hypertrophic cardiomyopathy. J Med Toxicol 7(2):151–153PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Geib AJ, Liebelt E, Manini AF (2012) Toxicology Investigators’ Consortium (ToxIC). Clinical experience with intravenous lipid emulsion for drug-induced cardiovascular collapse. J Med Toxicol 8(1):10–14PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Cave G, Harvey M (2009) Intravenous lipid emulsion as antidote beyond local anesthetic toxicity: a systematic review. Acad Emerg Med 16:815–824PubMedCrossRefGoogle Scholar
  5. 5.
    Jamaty C, Bailey B et al (2010) Lipid emulsions in the treatment of acute poisoning: a systematic review of human and animal studies. Clin Toxicol 48:1–27CrossRefGoogle Scholar
  6. 6.
    Sirianni AL, Osterhoudt KC, Calello DP, Muller AA, Waterhouse MR, Goodkin MB, Weinberg GL, Henretig FM (2008) Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med 51(4):412–415PubMedCrossRefGoogle Scholar
  7. 7.
    Weinberg GL (2011) Intravenous lipid emulsion: why wait to save a life? Emerg Med Austral 23(2):113–115CrossRefGoogle Scholar
  8. 8.
    ACMT Position Statement (2011) Interim guidance for the use of lipid resuscitation therapy. J Med Toxicol 7(1):81–82CrossRefGoogle Scholar
  9. 9.
    Murray DB, Bateman DN (2011) Use of intravenous lipids. Not yet in all overdoses with failed resuscitation. BMJ : 342:d2265Google Scholar
  10. 10.
    Buckley NA, Dawson AH (2013) The intralipid genie is out of the bottle-spin and wishful thinking. Anaesth & Int Care 41(2):154–156Google Scholar
  11. 11.
    Bologa C, Lionte C, Coman A, Sorodoc L (2013) Lipid emulsion therapy in cardiodepressive syndrome after diltiazem overdose—case report. Am J Emerg Med. Jul 31(7): 1154.e3-4Google Scholar
  12. 12.
    Meehan TJ, Gummin DD, Kostic MA, Cattapan SE, Waghray R, Bryant SM (2009) Beta blocker toxicity successfully treated with intravenous fat emulsion: a case series. Clin Toxicol 47(7):735, abstract #163Google Scholar
  13. 13.
    Package Insert, Lopressor, Novartis Pharmaceuticals, March 2013Google Scholar
  14. 14.
    Minton NA, Goode AG, Henry JA (1987) The effect of a lipid suspension on amitriptyline disposition. Arch Toxicol 60:467–479PubMedCrossRefGoogle Scholar
  15. 15.
    Cave G, Harvey M, Quinn P, Heys D (2013) Hypertonic sodium bicarbonate versus intravenous lipid emulsion in a rabbit model of intravenous flecainide toxicity: no difference, no sink. Clin Toxicol 51:394–397CrossRefGoogle Scholar
  16. 16.
    Dunn C, Bird SB, Gaspari R (2012) Intralipid fat emulsion decreases respiratory failure in a rat model of parathion exposure. Acad Emerg Med 19(5):504–509PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Perichon D, Turfus S, Gerostamoulos D, Graudins A (2013) An assessment of the in vivo effects of intravenous lipid emulsion on blood drug concentration and haemodynamics following oro-gastric amitriptyline overdose. Clin Toxicol 51:208–215CrossRefGoogle Scholar
  18. 18.
    Perichon D, Turfus S, Graudins A (2013) Intravenous lipid emulsion does not improve hemodynamics or survival in a rodent model of oral verapamil poisoning. Clin Toxicol 51:277, abstract #53Google Scholar
  19. 19.
    Lange DB, Schwartz D, DaRoza G, Gair R (2012) Use of intravenous lipid emulsion to reverse central nervous system toxicity of an iatrogenic local anesthetic overdose in a patient on peritoneal dialysis. Ann Pharmacother Dec 46:e37CrossRefGoogle Scholar
  20. 20.
    Niiya T, Litonius E, Petaja L, Neuvonen PJ, Rosenberg PH (2010) Intravenous lipid emulsion sequesters amiodarone in plasma and eliminates its hypotensive action in pigs. Ann Emerg Med 56(4):402–408PubMedCrossRefGoogle Scholar
  21. 21.
    Carreiro S, Blum J, Jay G, Hack JB (2013) Intravenous lipid emulsion alters the hemodynamic response to epinephrine in a rat model. J Med Toxicol 9(3):220–225PubMedCrossRefGoogle Scholar
  22. 22.
    Pentel P, Peterson CD (1980) Asystole complicating physostigmine treatment of tricyclic antidepressant overdose. Ann Emerg Med 9(Nov):588–590PubMedCrossRefGoogle Scholar

Copyright information

© American College of Medical Toxicology 2014

Authors and Affiliations

  • Jon B. Cole
    • 1
  • Samuel J. Stellpflug
    • 2
  • Kristin M. Engebretsen
    • 2
  1. 1.Hennepin Regional Poison Center, Department of Emergency MedicineHennepin County Medical CenterMinneapolisUSA
  2. 2.Clinical Toxicology Service, Department of Emergency MedicineRegions HospitalSaint PaulUSA

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