A teenage girl who took a large quantity of tablets with suicidal intent

The patient was a young woman who on several occasions had been hospitalised for intoxication and given general anaesthesia for endotracheal intubation and gastric lavage as an emergency indication. Following one such episode about a year before the event in question, the patient developed a severe subglotic stenosis after extubation. It was not possible to determine whether the stenosis was congenital or due to frequent intubation. The patient had not undergone tracheostomy. The stenosis was successfully treated with laser resection, which resulted in a higher threshold for subsequent intubation since pressure from the inflation cuff on the tube is associated with recurrence (1).

Immediately prior to the admission in question, in the space of one hour, the patient had broken open a medicine cabinet, cut herself with a razorblade and ingested up to 64 sustained-release tablets of 50 mg quetiapine, 90 sustained-release tablets of 300 mg bupropion, 30 sustained-release tablets of 150 mg bupropion, 56 tablets of 10 mg aripiprazole and 150 mL aripiprazole oral solution (1 mg/mL) as well as an unknown quantity of paracetamol tablets. She arrived at the Emergency Department about one hour after ingestion. At that time she was seemingly awake and alert and had a GCS (Glasgow coma scale) score of 15, but was uncooperative and did not want gastric lavage or any other treatment.

Clinical examination revealed superficial cuts to the skin, but otherwise findings were relatively unremarkable. Her blood pressure was 144/81 mmHg, pulse was regular at 121 bpm, pulse oximetry (SpO₂) was 97 % on room air, respiratory rate was 18 breaths per minute, and aural temperature was 36.4°C. Her pulse fell to 77 bpm during conversation. Blood tests were normal apart from serum paracetamol at 239 µmol/L (therapeutic range 30–130) and venous blood gas analysis results which were pH 7.38 (reference range 7.35–7.45), PvCO₂ 4.61 kPa (5.2–6.5), bicarbonate 20.5 mmol/L (21–27), base excess −4.6 (0 ±3) and lactate 3.0 mmol/L (< 2.5). ECG revealed normal axis, sinus rhythm, heart rate 90 bpm (50–100) and PQ interval 151 ms (120–210) with narrow QRS complexes of 93 ms (< 120). Corrected QT interval was 384 ms (380–470), and ST segments were unremarkable.

Following unsuccessful attempts to perform gastric lavage in the patient without general anaesthesia, in consultation with local secondary on-call doctors and a secondary on-call doctor at the Poison Information Centre it was decided to perform intubation for gastric lavage under general anaesthesia. There were no technical complications with the procedure, but no tablets were recovered, only small pink particles in a total of 2.5 L administered and aspirated fluid. Treatment with intravenous acetylcysteine infusion was initiated for paracetamol poisoning (15 g over 1 hour, followed by 5 g over 4 hours and then 10 g over 16 hours), and the patient was transferred to the intensive care unit for observation in case of development of tachycardia, QT interval abnormalities, electrolyte imbalances, seizures or hyperthermia.

In the intensive care unit, the patient had normal sinus rhythm with a heart rate of 50–90 bpm and blood pressure of 120/55 mmHg. Her blood pressure fell slightly following treatment with propofol (3.5 mg/kg/min intravenously) and remifentanil (0.15 µg/kg/min intravenously), leading to initiation of treatment with low-dose noradrenaline (0.04 µg/kg/min intravenously). The patient had good hourly diuresis and a temperature of 36.3–36.8°C. The second measurement of serum paracetamol, performed about four hours after ingestion, found levels of 133 µmol/L, and the acetylcysteine infusion was stopped. Blood gas analysis now revealed pH 7.37, PvCO₂ 5.0, bicarbonate 21 mmol/L, base excess −3, lactate 1.7 mmol/L, sodium 141 mmol/L (136–146), potassium 4.4 mmol/L (3.5–5.0), chloride 109 mmol/L (97–107), calcium 1.29 mmol/L (1.20–1.35) and glucose 6.5 mmol/L (4.0–6.0). Her ECG was unchanged.

The patient was extubated after approximately eight hours, at which point her pulse increased rapidly to 150 bpm and her temperature to 37.4°C. She developed severe motor restlessness, as well as visual and auditory hallucinations, headache, nausea and dizziness. She alternated between being lucid in conversation and whispering to people in the room, and between lashing out physically, being extremely anxious and somnolent. Treatment with midazolam (1 mg intravenously) was tried, and a few seconds later the patient had a transient generalised tonic-clonic seizure with cessation of breathing for 40 seconds. The patient then had a few smaller, transient seizures and trembling, and vomited shiny mucus twice.

Blood samples were now taken to measure serum levels of bupropion and quetiapine. The third and last measurement of serum paracetamol was < 70 µmol/L. Three hours after the first seizure and thirteen hours after ingestion, the patient vomited whole tablets, clearly recognisable as modified-release bupropion (7). Following a short period of observation and discussion, the patient was reintubated and gastroscopy was performed. Several clumps of tablets were found, particularly in the fundus of the stomach. Over 50 tablets were removed after several passes with a polyp snare (Roth Net) (Figure 1). Activated charcoal was administered via a gastric tube at this point.

After gastroscopy, the patient was in continuous sinus rhythm (90 bpm), and her temperature and blood pressure returned to normal with no need for vasopressors. She remained sedated and intubated for a total of two days. EEG on day 1 showed no signs of epileptiform activity. Abdominal CT revealed areas of high attenuation in the stomach and duodenum, which could represent sparse residues or disintegrating tablets. Another dose of charcoal was administered, but there were no more signs or symptoms of intoxication.

Blood sample analysis results for quetiapine taken eleven hours after ingestion came back showing serum levels of 423 nmol/L (100–800). The patient also had transient hypokalaemia with lowest potassium levels of 3.0 mmol/L, as well as myoglobin elevated to 267 µg/L (< 50) and CK elevated to 3,608 U/L (35–210).

On day 2, the patient was awakened and extubated. She was calm and in a relatively good condition, but slightly hoarse. Following laryngoscopic assessment by the otolaryngologist, two doses of hydrocortisone (100 mg intravenously) were administered for soft tissue swelling, which resolved well without any further action. The patient was observed on the ward, with no signs of deterioration of the stenosis or post-intoxication sequelae, until being discharged for psychiatric treatment on day 6. The day after discharge, the result of the blood sample analysis for hydroxybupropion taken 11 hours after ingestion came back. The analysis showed serum levels of 16,061 nmol/L (500–4,000), quantified at the Department of Clinical Pharmacology at St Olav's Hospital, Trondheim University Hospital.