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A woman in her 50s with a medical history of depression, rheumatoid arthritis, hypertension, and pulmonary eosinophilia presented to a rural hospital with acute agitation following an overdose. She arrived drowsy with a blood pressure (BP) of 80/44 mm Hg. Naloxone was ineffective; she was subsequently intubated and started on an infusion of epinephrine, 0.25 µg/kg/min, and sedated with diazepam, 150 mg. She was transferred by helicopter to a tertiary care center. En route she suffered cardiac arrest secondary to reported ventricular fibrillation (VF), (not recorded), with return of spontaneous circulation after 10 chest compressions without defibrillation. On arrival the patient continued to experience refractory hypotension with systolic blood pressures (SBP) in the 70s. The patient received a bolus of 20% intravenous fat emulsion (IFE), 100 mL, with immediate hemodynamic improvement; her blood pressure 5 minutes after the IFE bolus was 115/66 mm Hg. An electrocardiogram (ECG) was obtained (Figure 1).
Cole JB, Stellpflug SJ, Smith SW. Refractory Hypotension and “Ventricular Fibrillation” With Large U Waves After Overdose . JAMA Intern Med. 2016;176(7):1007-1009. doi:10.1001/jamainternmed.2016.2065