Amaducci, Alexandra

Burket, Glenn

Cannon, Robert D., DO

Cook, Matthew D, DO

Day, Ryan

Enyart, Joshua, DO

Janssen, Jennifer, MS

Katz, Kenneth D, MD

Williams, Karl E, MD, MPH

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of Emergency MedicineLoperamide-Induced Torsades de Pointes: A CaseSeries (Poster).Kenneth D. Katz MDLehigh Valley Health Network, Kenneth_D.Katz@lvhn.orgRobert D. Cannon DOLehigh Valley Health Network, Robert_D.Cannon@lvhn.orgMatthew D. Cook DOLehigh Valley Health Network, Matthew_D.Cook@lvhn.orgAlexandra AmaducciLehigh Valley Health Network, Alexandra.Amaducci@lvhn.orgRyan DayLehigh Valley Health Network, Ryan.Day@lvhn.orgSee next page for additional authorsFollow this and additional works at: https://scholarlyworks.lvhn.org/emergency-medicinePart of the Emergency Medicine CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtKatz, K. D., Cannon, R. D., Cook, M. D., Amaducci , A. Day, R. Enyart, J. Burket, G. Janssen, J. Williams, K. (2017,March 30-April 2).Loperamide-Induced Torsades de Pointes: A Case Series (Poster). Poster Presented at: American College of Medical Toxicology, San Juan,PR.AuthorsKenneth D. Katz MD; Robert D. Cannon DO; Matthew D. Cook DO; Alexandra Amaducci; Ryan Day;Joshua Enyart DO; Glenn Burket; Jennifer Janssen MS; and Karl E. Williams MD, MPHThis poster is available at LVHN Scholarly Works: https://scholarlyworks.lvhn.org/emergency-medicine/480© 2017 Lehigh Valley Health NetworkThese cases illustrate the extreme and persistent toxicity associated with loperamide abuse and the need to treat ECG derangements aggressively, even in asymptomatic patients. CASE REPORT 1CASE DISCUSSIONINTRODUCTIONCASE REPORT 2A 39-year-old woman with Hepatitis C, depression and IVDA was transported to the ED after reported seizure-like activity. The patient experienced TdP in the ED and admitted to ingesting large amount of loperamide daily. An ECG demonstrated sinus rhythm 64 bpm, right axis deviation, PR interval 208ms, QRS interval 142ms and QTc 687 ms. She was administered IV magnesium, sodium bicarbonate, and later, isoproterenol. After ICU admission, the patient experienced no further TdP and was discharged on HD 6. Loperamide and desmethyl loperamide concentrations on HD 4 were undetectable and 27ng/mL, respectively.Figure 1. ED ECG#1, 28-year-old male.Figure 6. ED ECG #1, 39-year-old female. Figure 7. ECG #2, 39-year-old female. Figure 2. ED ECG#2, 28-year-old male.Figure 3. ED HD2, 28-year-old male.Figure 4. ECG HD3 showing Torsades de Pointes.Figure 5. EKG from HD4, associated with TdP episode requiring cardioversion.1Lehigh Valley Health Network, Allentown, Pennsylvania; 2Office of the Medical Examiner of Allegheny County, Pittsburgh, PennsylvaniaLoperamide-Induced Torsades de Pointes: A Case SeriesKenneth D. Katz, MD,1 Robert D. Cannon, DO,1 Matthew D. Cook, DO,1 Alexandra Amaducci, DO,1 Ryan Day, MD,1 Joshua Enyart, DO,1 Glenn Burket, DO,1 Jennifer Janssen, MS,2 Karl E. Williams, MD, MPH2Loperamide (Imodium TM) is an antidiarrheal opioid acting at the µ receptor agonist in high concentrations. Due to the US opioid epidemic, loperamide abuse and ensuing life-threatening toxicity has surfaced.  A 28-year-old man with a history of depression and heroin abuse presented to the ED with shortness of breath and lightheadedness. He admitted to ingesting large amounts of loperamide daily. His initial ECG demonstrated sinus rhythm 67 bpm, right axis deviation, undetectable PR interval, QRS 168ms and QTc 693ms. The patient was administered sodium bicarbonate and magnesium sulfate IV and admitted to the ICU. On HD 2, he developed persistent TdP. He was administered lidocaine and isoproterenol infusions, and a temporary, external pacemaker was placed for overdrive pacing. He was discharged in stable condition on HD 16 after all therapies were discontinued. Serum loperamide and desmethyl loperamide concentrations obtained on HD 1 measured 120ng/mL and 560ng/mL, respectively. Serum loperamide and desmethyl loperamide concentrations on HD 10 measured undetectable and 16ng/mL, respectively.The timing and duration of Torsades de Pointes (TdP) from loperamide toxicity is unpredictable and should be heeded with caution, even in asymptomatic patients and drug discontinuance.HYPOTHESIS:Two patients presenting with life-threatening TdP requiring lengthy hospital admissions for confirmed loperamide toxicity are discussed. Patient data were retrieved from the hospital’s EMR system.METHODS:

Loperamide-Induced Torsades de Pointes: A Case Series (Poster).

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1495&context=emergency-medicine

Loperamide-Induced Torsades de Pointes: A Case Series (Poster).

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