Christopher Coriasso, DO, MS
Critical Care Fellow
Mercy Hospital Saint Louis
Saint Louis, MO, United States
Disclosure information not submitted.
Ahmed Alsaei, MD
Mercy Hospital Saint Louis
Saint Louis, Missouri
Disclosure information not submitted.
Melinda Miller, MD
Critical Care Medicine
Mercy Hospital Saint Louis, United States
Disclosure information not submitted.
Michael Plisco, MD
Pulmonology, Critical Care Medicine
Mercy Hospital Saint Louis, United States
Disclosure information not submitted.
Title: Brain Death Mimicry and the Use of VA-ECMO following Polysubstance Overdose: A Case Report
Case Report Body
Introduction: The decision to offer extracorporeal membrane oxygenation (ECMO) is based on a risk/benefit assessment and the likelihood of a treatable underlying condition. Patients who exhibit signs of brain death following an intentional drug overdose, despite maximal medical therapy, may pose a dilemma for clinicians. An assessment to determine if a patient has a high likelihood of recovery such that bridging with ECMO should be offered is not always feasible in the setting of critical illness.
Description: We describe a 26-year-old male who presented to our hospital 1 hour after intentionally ingesting bupropion (27 grams), propranolol and amlodipine. The patient was initially bradycardic and drowsy but became progressively encephalopathic and hypotensive within a short interval of time. He was intubated for airway protection after suffering a clinically significant seizure. His physical exam became concerning for brain death after he was noted to have fixed dilated pupils, absent brainstem reflexes and lack of withdrawal to noxious stimuli. Despite supportive therapy with IV crystalloids, vasopressors, IV calcium, sodium bicarbonate, glucagon, and high insulin euglycemic therapy, the patient became increasingly unstable. The decision was made to initiate VA-ECMO despite a concerning neurological exam and burst suppression pattern on EEG. The patient’s condition gradually improved over several days, and his neurological exam returned to baseline. He was decannulated on day 7 and transferred from the ICU on day 15.
Discussion: This case highlights the potential role for VA-ECMO in refractory cardiogenic and vasoplegic shock due to bupropion, amlodipine and propranolol poisoning. Bupropion overdose mimicking brain death is infrequently reported but important to consider when treating patients who demonstrate signs of brain death on physical exam.There is no rapid serum diagnostic test for bupropion levels so obtaining history is key. Brain death diagnosis should not be pursued in the setting of normal cerebral imaging or incomplete evaluation of brain death prerequisites especially in the presence of drug intoxication. We suggest that early prognostication should be avoided in such cases, and enough time should be given for drug clearance prior to neurological forecasting.