Treatment of status epilepticus and prolonged QT after massive intentional bupropion overdose with lidocaine.

Bupropion is an atypical antidepressant often used in the treatment of depression, tobacco cessation, seasonal affective disorder, and off label for ADHD. Its primary mechanism of action is by blocking dopamine and norepinephrine reuptake and it is structurally similar to amphetamines. Toxic effects include, most notably and classically, seizures as well as tachycardia, agitation, nausea and vomiting, QT prolongation, QRS widening, hypertension/hypotension. It has a narrow therapeutic window with maximal daily dosing being 450 mg daily. We are reporting the case of a 14-year-old female who ingested 15 g of extended-release bupropion resulting in agitation, status epilepticus, prolonged QT devolving into pulseless Ventricular Tachycardia and briefly V Fib, requiring a total of 5 cardioversions and 1 defibrillation. The QT interval eventually narrowed after supportive care and lidocaine drip. The patient was able to be extubated just two days later with full cognitive function and echocardiogram without cardiac dysfunction. Seizure and cardiotoxicity (including prolonged QT) have been previously described with massive bupropion overdoses. To our knowledge, deterioration to Ventricular Tachycardia and Ventricular Fibrillation with successful treatment and shortening of QT interval with lidocaine bolus and drip has not been reported. Cardiotoxicity related to bupropion has previously been primarily supportive and avoidance of QT prolonging antiarrhythmics such as amiodarone, and at times requiring VA ECMO. Lidocaine has previously been used in tox cases to shorten QT intervals. The hope is for this information to be helpful to other EM and Critical Care providers when placed in similarly difficult circumstances.