Severe bradycardia and prolonged hypotension in ciguatera

TY Chan
2013 Singapore medical journal  
C a s e R e p o r t e120 consumed could not be identified as the entire fish had been consumed. By the time the patient arrived at the hospital, which was 4.5 hours post ingestion, he had vomited twice and passed loose stools seven times. His pulse rate and blood pressure was 46 beats per minute (bpm) and 75/54 mmHg, respectively. On examination, there was mild epigastric tenderness. Muscle power, light touch and pain sensation in the patient's four limbs were normal. Electrocardiogram (ECG)
more » ... wed sinus bradycardia (heart rate 46 bpm) ( Fig. 1) . He was given 0.6 mg atropine and 1,000 mL 0.9% saline intravenously at full rate, followed by 500 mL every six hours. Five minutes after the administration of atropine and saline, the patient's pulse rate increased from 51 bpmto 82 bpm and his blood pressure increased from 93/51 mmHg to 120/72 mmHg. After another 5-25 minutes had passed, his heart rate and blood pressure further increased to 100-120 bpm and 133-140/77-92 mmHg, respectively. 11.5-24 hours post ingestion, the patient experienced bradycardia (heart rate 53-57 bpm) and hypotension (blood pressure 75-86/34-46 mmHg) again, and was administered another 1,000 mL 0.9% saline intravenously at full rate. The patient was still hypotensive at 16-83 hours post ingestion, and thus required intravenous infusion of 0.9% saline/5% dextrose (500 mL, 4-6 hourly) and dopamine (2.5 μg/kg/min) to prevent his systolic blood pressure from dropping below 100 mmHg. On Day 1 of admission, intravenous metoclopramide (10 mg) and mannitol (1g/kg) over a duration of an hour, oral hyoscine butylbromide (10 mg) and intramuscular tramadol (75 mg) were prescribed. Plasma urea and creatinine concentrations on admission were 12.4 mmol/L (normal range 3.4-8.9 mmol/L) and 79 μmol/L (normal range 62-106 μmol/L), respectively, but decreased to 9.2 mmol/L and 71 μmol/L, and 3.9 mmol/L and Singapore Med J 2013; 54(6): e120-e122
doi:10.11622/smedj.2013095 pmid:23665698 fatcat:fu2cdbt4zjhlhktdseiopyhwmq