Abstract Introduction Despite bupropion’s common use and favorable risk profile, overdose can lead to rapid neurotoxicity and life-threatening cardiotoxicity. Early recognition and proactive supportive management are essential. We present a successful case of managing bupropion overdose, including early use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Case Presentation A 39-year-old male with depression was brought to the emergency department (ED) 8.5 hours following intentional ingestion of 13.5 grams of bupropion extended-release tablets, with an unwitnessed seizure before arrival. Initial presentation noted hypertension, tachycardia, and confusion, with workup revealing anion-gap metabolic acidosis (venous pH 7.17) and lactic acidosis (13.57 mmol/L). Ethanol level was mildly elevated (15 mg/dL) and urine toxicology positive for benzodiazepines (administered in ED for prior seizure). Initial electrocardiogram (ECG) revealed sinus tachycardia with QRS 104 msec and QTc 504 msec. In the ICU, repeat ECG showed QRS prolongation to 112 msec, which was refractory to IV sodium bicarbonate as expected. At hour 15.5 post-ingestion, he developed status epilepticus and was intubated for airway protection with subsequent shock and bradycardia, requiring vasopressors. He then converted into ventricular tachycardia with new left bundle branch block-like morphology alongside persistent shock. He was cannulated to VA-ECMO at hour 17 given concern for impending hemodynamic collapse and cardiac arrest. Echocardiogram showed left ventricular ejection fraction (LVEF) decline from 67% to 45-50% post-cannulation. He was maintained on VA-ECMO and norepinephrine with serial ECGs showing bradycardia and QTc prolongation. Following close monitoring for stability, he was decannulated at hour 60, weaned off vasopressors with normalization of ECG intervals by hour 80, and extubated with LVEF recovery at hour 90. He had full neurologic recovery and was transferred to the medical floor with psychiatric follow-up, and discharged home on hospital day 19. Discussion Without an antidote, treating bupropion toxicity relies on early recognition and management of seizures, arrhythmias, and hemodynamic support for cardiogenic shock to stabilize patients through a reversible cause of hemodynamic deterioration. VA-ECMO serves as a bridge to recovery by allowing for drug metabolism, though initial reports involve cannulation following refractory shock and arrest, which may lead to prolonged complications despite neurologic and cardiac recovery. Our experience adds to the few published cases of early cannulation prior to needing extracorporeal cardiopulmonary resuscitation (ECPR), driven by proactive multidisciplinary management upon initial signs of instability, with hopes that it offers insight into the early use of VA-ECMO in bupropion toxicity to reduce long-term complications and improve outcomes. This abstract is funded by: None
Wang et al. (Fri,) studied this question.