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Extended release potassium salts overdose and endoscopic removal of a pharmacobezoar: a case report
Contents lists available at Toxicology Reports Extended release potassium salts overdose and endoscopic removal of a pharmacobezoar: A case report nón Jorge Guillermo , Pérez Hernández Juan Carlos , Bautista Albiter Mayré Ivonne , Terán Flores Herminio , Ramírez Pérez Rubén a Jefe del Centro Toxicológico Hospital Angeles Lomas, Vialidad de la Barranca No. 14, Colonia Valle de las Palmas, Huixquilucan, Estado de México CP 52787, Mexico b Adscrito al Centro Toxicológico Hospital Angeles Lomas, Vialidad de la Barranca No. 14, Colonia Valle de las Palmas, Huixquilucan, Estado de México CP 52787, Mexico c Residente de Toxicología Hospital Angeles Lomas, Vialidad de la Barranca No. 14, Colonia Valle de las Palmas, Huixquilucan, Estado de México CP 52787, Mexico Background: Reported cases of potassium overdoses have shown that this condition could Received 7 February 2014 generate several morbidities, mainly related to cardiac dysrhythmias even with fatal out- Received in revised form 4 April 2014 comes in some cases.
Accepted 4 April 2014 Potassium salts in extended release tablets could form pharmacobezoars if a large amount Available online 22 May 2014 is ingested. In relation to the above, when the patient has a pharmacobezoar, clinical ﬁnd- ings may be delayed and may persist.
The techniques available for removal of a pharmacobezoar are whole bowel irrigation (WBI), endoscopy or in some surgery as a decontamination method has shown promising results.
Extended release potassium salts Case report: A 42 year old woman, who intentionally ingested 100 tablets of extended release potassium chloride, 50 mg of clonazepam and an undisclosed amount of ethanol, presented with metabolic acidosis, hyperlactatemia and sinus tachycardia 2 h after ingestion. Gastric lavage and activated charcoal were applied initially, speciﬁc measures were not neces- sary. However, a transcutaneous pacemaker was placed. Because of her background, we considered a pharmacobezoar and an endoscopy were performed to remove 99 tablets of potassium that were isolated or forming concretions.
Discussion: The readily available techniques to remove a pharmacobezoar are whole bowel irrigation (WBI) and endoscopy; nevertheless there is not a consensus about their relative merits. Our patient was treated by endoscopy because we found on the X-ray a conglom- erate of radiopaque images suggesting a pharmacobezoar. In this case we did not have any adverse effect.
Conclusions: We consider that endoscopy could be an effective and safe method to remove a drug bezoar from the stomach in uncomplicated patients.
2014 he Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license ( ∗ Corresponding author. Tel.: +52 1 55 52465056; mobile: +52 1 55 19177028.
E-mail addresses: (P.T.J. Guillermo), (P.H.J. Carlos), (B.A.M. Ivonne), (T.F. Herminio), (R.P. Rubén).
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P.T.J. Guillermo et al. / Toxicology Reports 1 (2014) 209–213 Extended release potassium salts are indicated in induced or acquired hypokalemic conditions. The potas- sium overdose could generate hyperkalemic states, espe- cially if the patient has impaired renal function or if there has been a large ingestion of salts (toxic dosage: 2 mEq/kg) a patient presents a large ingestion of extended release potassium tablets, clinical manifestations could be delayed even more than 24 h and concretions could be formed in the stomach. Concretions complicates the decon- tamination by gastric lavage, so that after this procedure in these patients, it is possible to ﬁnd tablets remaining in the stomach, even in 88.2% of cases The great absorption that follows to a massive ingestion of potassium salts causes myocardial conduction distur- bances and metabolic acidosis.
The correct technique for gastrointestinal decontami- nation in cases of massive overdose of extended-release tablets is not well established, nowadays, toxicologists con- tinue to consider use of whole bowel irrigation (WBI), endoscopy or even surgery to evacuate tablet remaining from the stomach Fig. 1. Abdominal radiography with multiple radioopacities in the stom-
ach (red arrow).
2. Case report
A 42 year old woman with history of borderline person- ality disorder and a suicide attempt with potassium salts (50 tablets) one year earlier presented to the emergency room after intake of 100 tablets of extended release potas- sium chloride (1000 mEq), 50 mg of liquid clonazepam, and an undisclosed amount of ethanol at home.
She recognized this as a new suicide attempt and pre- sented with somnolence, tachycardia and exhalation of ethanol odor 2 h after ingestion. Her vital signs were: blood pressure 130/90 mm Hg, pulse was 97 beats/min, respira- tions were 22 breaths/min, temperature was 36.5 ◦C, and oxygen saturation was 98% on room air.
A 12 lead electrocardiogram demonstrated sinus tachy- cardia with normal QRS duration and unaltered T-waves.
Potassium level was 3.9 mmol/L, blood gas analysis revealed pH 7.25, HCO3 17.5 mEq/L and lactate 4.9 mmol/L.
A standard toxicological screen was negative for all agents.
Ethanol level was 90.80 mg/dl. Finally a plain ﬁlm of the abdomen showed multiple opacities in the region of the stomach (Other agents, including acetaminophen Fig. 2. Endoscopic removal of the tablets.
and salicylates were reported to be absent.
A venous access was placed. After that, a gastric lavage A total of 99 of the 100 tablets that were either isolated with a 20-french orogastric tube (maximum size in our hos- or forming concretions were removed with an endoscopic pital) was performed. However, no tablets were recovered during this procedure. Also, a single dose of activated char- After gastric decontamination, clinical outcome was sat- coal was performed in order to treat a possible coingestant.
isfactory, pharmacological correction of acidosis was not Anti-hyperkalemic measures were not necessary at that needed and she did not develop hyperkalemia or cardio- time. However, a transcutaneous pacemaker was placed.
vascular impairments. The patient was intubated for the Given her background and the gastric lavage that was procedure and extubated 18 h later. After that, she was ineffective, an abdominal radiography was performed in discharged to the psychiatry service 48 h later.
order to identify the location of the tablets. The radiography showed multiple radiopacities in the stomach and the pos- sibility of a pharmacobezoar was considered. Consultation with the gastroenterology service was done to request an The potassium excess could be absorbed by the intra- endoscopy for removal of the suspected pharmacobezoar.
cellular compartment to maintain serum levels under
P.T.J. Guillermo et al. / Toxicology Reports 1 (2014) 209–213 Fig. 3. Removed tablets.
5.5 mEq/L, but unfortunately this mechanism is saturable We considered the high risk of massive absorption with this context, potassium serum levels over 6.0 mEq/L hemodynamic implications and started management with should be considered risky and need to be treated immedi- airway protection, placement of a pacemaker and decon- ately there is no clear relationship between tamination by endoscopy Furthermore, our patient the serum level and heart rhythm disturbances, we know had a history of a previous suicide attempt with 50 tablets that the risk of dysrhythmias is increased if rapid absorp- of extended release potassium salts. She developed hyper- tion of potassium occurs kalemia, metabolic acidosis and hyperacute T waves, and Many drugs are capable to form concretions as in was hospitalized seven days in an intensive care unit. In the case of amitriptyline, salicylates, carbamazepine, iron, the second attempt, even though the patient increased potassium salts and other extended release preparations, the ingestion to 100 tablets of the same drug, she did not with or without an enteric coat develop any complication and was discharged two days The gastric decontamination is an essential procedure after ingestion. We strongly concur that if a pharmacobe- in the treatment of patients with an oral drug overdose; zoar is suspected endoscopy should be considered in order however, the appropriate technique to remove a bezoar is to avoid a massive absorption On the other hand, the multiple introductions of the The gastric lavage and activated charcoal administra- endoscope could increase the risk of airway injuries and tion have both been demonstrated to be poorly effective on aspiration of gastric content that, in our case, patients with pharmacobezoars. Moreover, in Mexico there the equipment was introduced eighteen times and no com- are no orogastric tubes with a recommended diameter to plications were presented. For this reason, we consider the remove extended release tablets (36–40 Fr).
endoscopic removal of bezoars a therapeutical option for Nowadays, the available techniques to remove phar- macobezoars include: WBI (only small size bezoars), endoscopy and surgical extraction. In this context, the Case development.
main factors to consider before selecting a decontamina- tion technique are: drug toxicity, pharmacobezoar size and location, clinical condition of the patient and availability of the resources (polyethylene glycol, operating room, etc.) Parenteral solutions Not Anti hyperkalemic Despite the fact that WBI has been demonstrated in some reports be safe and to improve the clinical condition of these patients, at this time there is no strong evidence of its efﬁcacy. It requires several hours to clarify the efﬂuent, (after endoscopy) also, it is necessary to have a normal bowel function and it could not be effective if a big bezoar exists in the stom- ach. In the case of perforation, intestinal occlusion, active bleeding, hemodynamic instability or vomiting, the WBI are contraindicated in the case of a potassium salts overdose, one of the most important causes of morbid- Not Anti hyperkalemic ity is the cardiac rhythm disturbance with hemodynamic measures. Transcutaneous instability, which limits the use of WBI.
pacemaker was removed P.T.J. Guillermo et al. / Toxicology Reports 1 (2014) 209–213 uncomplicated patients and should be performed early if the medical center is short of appropriate orogastric tubes This was a case of intentional potassium, ethanol and Gunja a case of a patient who ingested clonazepam overdose resulting in mild metabolic acidosis, 100 tablets of extended release potassium chloride with hyperlactatemia and sinus tachycardia at 2 h after inges- severe hyperkalemia 5 h after the ingestion Also, tion, without hyperkalemia and after utilizing endoscopy Saxena a case of a woman who ingested in order to remove 100 isolated tablets and forming phar- 16 mEq/Kg of potassium salts and developed severe hyper- macobezoars. In this case, the bezoar formation could lead kalemia with cardiac arrest in the ﬁrst hour after the to massive absorption of potassium and increase the risk of ingestion. Finally, Colledge another case with hyperkalemic disturbances. In addition to standard treat- an intake of approximately 100 tablets with hyperkalemia ments for hyperkalemia, this case report demonstrates and ventricular tachycardia demonstrating the effects of a the beneﬁt from endoscopy in extended-release potassium rapid absorption in massive ingestions of potassium salts.
bezoar formation, considering the hospital resources, time In our case, due to the early endoscopic removal of tablets, from the ingestion and clinical status of the patient. Also, the patient did not increase potassium serum levels and this study asks whether endoscopy should be used as an complications were not registered.
initial measure of decontamination in patients who have Reported cases.
Extended release KCl Charles et al. (1978) Illingworth (1980) Wide complex tachycardia Colledge et al. (1988) Hyperacute T waves, sinus tachycardia 110×.
Ventricular tachycardia 1st degree AV blockade, hyperacute T waves Peeters et al. (1998) 300 tabs (2.4 mmol) Abdominal distension. One month later gastric 20 tabs of extended Left ventricular heart release KCl (630 mg).
Bendoﬂurazide and Unaltered EKG. Nausea and vomiting, Asystole, death in gastric lavage 40 tabs of extended release KCl (8 mmol) Whitaker et al. (2000) Tachycardia (155×) 1st degree AV blockade.
Hyperacute T waves 100 tabs (10 mEq) Hyperacute T waves 20–30 tabs (10 mEq) Tachycardia, nausea, vomiting and diarrhea Asthenia and adinamia Tachycardia (100×) Tachycardia (124×) 10–20 tab (8 mmol) 4, 5, 6, 7, 8.
1, 5, 6, 7, 9, 11, 14.
Briggs Albert et al. (2013) Mildly peaked T waves 2, 3, 5, 6, 7, 8.
Pérez et al. (2013) Metabolic acidosis, hyperlactatemia and sinus tachycardia with normal T 1: gastric lavage; 2: whole bowel irrigation; 3: endoscopy; 4: hemodialysis; 5: calcium; 6: insulin/glucose; 7: sodium bicarbonate; 8: ␤-2 agonist; 9: ion exchange resin; 10: furosemide; 11: activated charcoal; 12: mannitol; 13: cardiac pacemaker and 14: advanced cardiac resuscitation.
P.T.J. Guillermo et al. / Toxicology Reports 1 (2014) 209–213 ingested a large quantity of tablets, particularly in centers where there is a lack of adequate tubes for gastric lavage We concur that in selected cases endoscopy could be used instead of gastric lavage as ﬁrst decontamination mea- sure, although, a clinical guideline for the use of endoscopy as a decontamination method still need to be created.
Cases of extended release potassium salts reported are summarized below ( Conﬂict of interest
The authors declare that they have no competing inter- Special thanks to Dr. Carlos Mitrani Boyle, gastroen- terologist and endoscopist who performed the procedure.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the online version, at
© SUPPLEMENT TO JAPI • FEBRUARY 2013 • VOL. 61 Management of Hypertension Goals of Therapy • In low risk patients, it is suggested to institute life style modifications and observe BP for a period of 2-3 months, he primary goal of therapy of hypertension should be before deciding whether to initiate drug therapy. effective control of BP in order to prevent, reverse or delay