Adrenaline overdose

Fatal anaphylaxis occurs mostly due to bronchial obstruction or cardiac arrest, but also disseminated intervascular coagulation as well as adrenalin overdose [2, 7, 21, 31]. When anaphylactic reactions are survived, long-lasting sequels are rare. However,... 

Fyfe AI, Daly PA, Dorian P, Tough J. Reversible cardiomyopathy after accidental adrenaline overdose. Am J Cardiol 1991 67(4) 318-9. 

Drug overdose Complications of adrenaline overdose potentially could last longer than expected. The following case is potentially important to draw an attention to such effects. 

Antidepressants are used in the treatment of neuropathic pain and headache. They include the classic tricyclic compounds and are divided into nonselective nor-adrenaline/5-HT reuptake inhibitors (e.g., amitriptyline, imipramine, clomipramine, venlafaxine), preferential noradrenaline reuptake inhibitors (e.g., desipramine, nortriptyline) and selective 5-HT reuptake inhibitors (e.g., citalopram, paroxetine, fluoxetine). The reuptake block leads to a stimulation of endogenous monoaminer-gic pain inhibition in the spinal cord and brain. In addition, tricyclics have NMDA receptor antagonist, endogenous opioid enhancing, Na+ channel blocking, and K+ channel opening effects which can suppress peripheral and central sensitization. Block of cardiac ion channels by tricyclics can lead to life-threatening arrhythmias. The selective 5-HT transporter inhibitors have a different side effect profile and are safer in cases of overdose [3]. 

Some solutions of drugs (e.g. local anaesthetics, epinephrine/adrenaline) for parenteral use are labelled in a variety of ways percentage, proportion, or weight in volume (e.g. 0.1%, 1 1000,1 mg per mL). Also, dilutions may have to be made by doctors at the time of use. Such drugs are commonly dangerous in overdose and great precision is... 

Acute overdose may be rapidly fatal without treatment and indeed has even been described as a means of suicide. (Chloroquine may now be bought from pharmacies in the UK without a prescription.) Puhnonciry oedema is followed by convulsions, cardiac arrh5dhmias and coma as little as 50 mg/kg can be fatal. These effects are principally due to the profound negative inotropic action of chloroquine. Diazepam was found fortuitously to protect the heart and adrenaline (epinephrine) reduces intraventricular conduction time this combination of drugs, given by separate i.v. infusions, improves survival. 

Overdose of sympathomimetics is treated according to rational consideration of mode and site of action (see Adrenaline, below). 

Accidental overdose with adrenaline occurs occasionally. It is rationally treated by propranolol to block the cardiac p effects (cardiac arrhythmia) and phentolamine or chlorpromazine to control the a effects on the peripheral circulation that will be prominent when the P effects are abolished. Labetalol (a + p block) would be an alternative. P-adrenoceptor block alone is hazardous as the then unopposed a-receptor vasoconstriction causes (severe) hypertension (see Phaeochromocytoma, p. 494). Use of antihypertensives of most other kinds is irrational and some may also potentiate the adrenaline. 

A 38-year-old white man with a history of coronary artery disease, myocardial infarction, coronary artery by-pass, alcoholism, and depression took a combined massive overdose of diltiazem and atenolol (24). He underwent cardiopulmonary resuscitation because of cardiac arrest bradycardia, hypotension, and oliguria followed and were resistant to intravenous pacing and multiple pharmacological interventions, including intravenous fluids, calcium, dopamine, dobutamine, adrenaline, prenalterol, and glucagon. Adequate mean arterial pressure and urine output were restored only after the addition of phenylephrine and transvenous pacing. He survived despite myocardial infarction and pneumonia. 

A 22-year-old woman took an overdose of propafenone (amount unknown) and developed tetany and then generalized convulsions requiring intravenous clonazepam (44). She had a low blood pressure and first-degree atrioventricular block associated with prolonged intraventricular conduction. She was intubated and given intravenous fluids, equimolar sodium lactate, dopamine, and adrenaline. Her cardiac conduction returned to normal. 

Quinuronium sulfate is a bitter, white to yellow, crystalline powder that is usually available as a stable 5% aqueous solution. This compound is effective in the treatment of B. caballi infections but is associated with relapses, making it more effective for premunition than for the elimination of infection. One treatment consists of two doses of a 5% solution of quinuronium sulfate, administered s.c. at 0.3mg/kg, 6h apart. Quinuronium sulfate has a narrow margin of safety and overdosing produces parasympathomimetic effects including tremors, salivation, urination and defecation. These signs usually respond to treatment with atropine, epinephrine (adrenaline) and calcium gluconate. The interval between treatments should not be shorter than 2 weeks and should preferably be 3 months because sensitization occurs, which results in shock, with a profound drop in blood pressure, and death. 

Because of our earlier observations that octopamine might be a neurotransmitter in insects but not vertebrates, several years ago we carried out an experiment to determine whether large doses of exogenous octopamine might exert detrimental behavioral effects in insects, analogous to what might happen if a vertebrate received an overdose of adrenalin or amphetamine. As a control, we decided to compare the activity of octopamine (chemically para-octopamine) with a positional isomer, meta-octopamine, which we found had little activity on insect adenylate cyclase (17). 

Drug overdose Life-threatening flecainide intoxication in a 2-year-old toddler occurred when syringes used for oral administration were accidentally reversed, producing a fivefold flecainide overdose 3 hours after drug administration he developed a bradycardia of 50/minute and had a cardiopulmonary arrest, requiring resuscitation and adrenaline, after which the bradycardia recurred, followed by a wide-complex tachycardia that converted rapidly to a narrow-complex tachycardia after bolus intravenous adrninistration of sodium bicarbonate [60 ]. He then remained hemo-dynamicaUy stable and in sinus rhjflhm. The serum flecainide concentration was 0.7 mg/1. 

The vasoconstrictor effect of adrenaline should cause hypertension. However, paradoxical hypotension has been reported in three patients with massive quetiapine overdose, in whom the blood pressure fell dramatically after infusion of adrenaline hemodynamic stability was restored when noradrenaline was substituted for adrenaline [67 ]. 

Hawkins DJ, Unwin P. Paradoxical and severe h5fpotension in response to adrenaline infusions in massive quetiapine overdose. Crit Care Resusc 2008 10(4) 320-2. 

A 3-year-old toddler developed multifocal atrial tachycardia following an iatrogenic overdose of adrenaline accidentally administered (i.v). His ECG showed wandering atrial pacemaker (P-waves with different origins and configurations) that persisted for at least 1 year. This event... 

---