Hypothermic overdose, not all bad?
A 51-year-old woman presented to the emergency department (ED) in the evening following an intentional overdose of alcohol and her psychiatric medication and was not seen for the previous 24 h. She was found unresponsive at home on the kitchen floor by her parents who had been trying to contact her who then called the ambulance service to her flat. She was lying with her face down and had blood on her face and it was presumed by the paramedics that she had fallen and may have rolled on the floor as there was blood smears on the floor. She was supine on the floor and surrounded by empty packets of medication and two empty wine bottles. It was estimated from the dates on the packets and missing pills that she had taken 5800 mg of quetiapine and 240 mg of citalopram. Paramedics reported that they read the thermostat in her flat read 10°C.\nParamedics brought the patient to the ED and her Glascow Coma Scale as eight with agonal respirations, pulse of 56/min, blood pressure of 55/35 mmHg, and a core temperature of 24°C. Her ears, nose, and mouth were covered with blood from her nose. There were no other external injuries and the remainder of the exam was unremarkable.\nArterial blood gas demonstrated a pH-7.05, pCO2-55 mmHg, pO2-107 mmHg, Bicarb - 15 mmol/L, and Lactate - 11 mmol/L. Full blood count and electrolytes were unremarkable. Cardiac enzymes were not performed. The electrocardiogram (ECG) demonstrated multiple axis changes with increased QRS, prolonged QTc, ventricular ectopic beats, and Osborne (J) waves []. Chest X-ray demonstrated right lower lobe infiltrate suggesting aspiration. Toxicology showed an ethanol concentration of 21 mmol/L and paracetamol of < 30 μmol/L. computed tomography (CT) scans of her head and c-spine were normal.\nIn the ED, the patient was intubated and ventilated with warmed humidified oxygen. An orogastric tube was inserted and 200 ml of blood was aspirated, likely from swallowed blood as there was no other evidence of gastrointestinal bleeding or internal injury found during her hospital course. She was given 200 mmols of sodium bicarbonate, 2 g of magnesium sulfate, 4.4 mmols of calcium gluconate, and a low-dose adrenaline infusion of 0.5 mg/h. Management of hypothermia included removal of clothing, warming blanket, active warming with warmed intravenous normal saline and warmed bladder, and gastric lavage. An indwelling rectal thermometer was placed and her core temperature rose approximately 0.5°C an hour until it reached 38°C.\nA Her body temperature returned to normal over the next day and her vital signs returned to normal. She was extubated 24 h later and was treated for aspiration pneumonia. She recovered completely except for numbness in her left leg. She was transferred to the psychiatric ward after 72 h of medical admission as she had admitted to this being a suicide attempt.