Propafenone and valsartan overdose with cardiovascular deterioration managed with lipid emulsion and high dose insulin: a case report

This is a case of a 23-year-old female who presented to the emergency department (ED) comatose after ingesting 7.8 g of propafenone and 11.7 g of valsartan. Upon arrival to the ED, the patient had seizures and required intubation. Several boluses of sodium bicarbonate were given as well as a continuous infusion to normalize QRS intervals. Norepinephrine and intravenous lipid emulsion (ILE) therapy were initiated. In the intensive care unit (ICU), the patient experienced persistent seizures and a 5-minute period of pulseless ventricular tachycardia. Subsequently, hyperinsulinemic-euglycemic therapy (HIET) was initiated. The patient received a 1 unit/kg intravenous bolus of regular insulin followed by a continuous infusion starting at 1 unit/kg/hr. Norepinephrine infusion was weaned off after 27 h of HIET. Within 48 h of presentation, the patient was transferred out of the ICU. This case exhibits the successful management of a mixed overdose with propafenone and valsartan utilizing a multimodal approach. In addition to supportive care, the patient received sodium bicarbonate, HIET, ILE and vasopressors to manage the cardiovascular collapse associated with these toxicities.