another ECG case…

The Case.

I was superficially involved in this case of a 32 year old suicidal patient who ingested two full packets of Solian (amisulpride) (~ 24 grams) approximately 90 minutes prior to arrival to ED.

On initial assessment he was GCS 12/15 & had a systolic BP of 115 mmHg.

This is his ECG….

amisulpride ECG

[DDET Amisulpride Toxicity…]


Amisulpride – What is it ?

a benzamide neuroleptic (atypical antipsychotic) with high affinity for the dopamine (specifically D2-2) receptor. 

    • used for acute & chronic schizophrenia (both negative & positive symptoms)
    • unlike other neuroleptics, it has minimal affinity for 5HT, alpha, H1 or cholinergic receptors.

Dose-based Risk Assessment.

      • < 8g = mild-moderate sedation, mild anticholinergic features.
        • QT prolongation & torsades are reported (in as little as 4.6g ingestion)
      • 8-15g = Increasing sedation & depressed level of consciousness.
        • Cardiotoxicity includes hypotension, QRS & QT prolongation, bundle-branch blocks & torsades.
      • > 15g = Significant risk of delayed coma & cardiotoxicity…

Signs & Symptoms.

      • Mild-Moderate: Mydriasis, lethargy, drowsiness and sedation, bradycardia, agitation, hyperthermia and extrapyramidal symptoms.
      • Severe toxicity: Seizures, coma, hypotension, and QTc prolongation. Torsades & VT are reported in intentional overdose.


[DDET Management…]


  • Resuscitation area / full cardiorespiratory monitoring.
      • Patients may require intubation / mechanical ventilation
      • Minimum of 16 hours telemetry mandated for ingestion >4g
  • Decontamination (oral activated charcoal) is recommended for > 4 grams in previous 4 hours.
      • No antidote.
      • Enhanced elimination not useful
  • Control of QT / risk of Torsades
      • Magnesium (2g IV over 1-2 minutes, repeat x1 –> infusion of 0.5-1.0g / hour)
      • Chemical or electrical atrial overdrive pacing.
  • Correct electrolyte abnormalities (specifically hypomagnesaemia, hypokalaemia & hypocalcaemia)


As a rule; all ingestions > 4 grams should be monitored for at least 16 hours and until all ECG intervals are normal….

  • Asymptomatic adults with inadvertent/minor exposure may be monitored at home.
  • Significant/deliberate amisulpride overdose are observed for at least 16 hours after ingestion.
    • Continuous cardiac monitoring and serial ECGs.
    • If no dysrhythmias or QT prolongation at 16hrs –> discharged after psychiatric evaluation.
  • Dysrhythmias or QT prolongation on ECG –> intensive care setting for continuous cardiac monitoring and treatment.


[DDET As for our patient…]

ECG:  Sinus rhythm @ 83bpm. Normal axis. PR ~200ms. QRS ~120ms. QTc ~560ms !!!

His management (after discussion with our Toxicology gurus) included;

  • Intubation
  • NG tube w/ activated charcoal administration
      • Two further doses of charcoal
  • MgS04 (20mmol x2)
  • Isoprenaline infusion with target HR >100 bpm
      • Dropped QT down to ~500msec

He survived his first night in the ICU….


[DDET References]
  1. Murray L, Daly F, Little M & Cadogan M. Toxicology Handbook. 2nd Edition. Elsevier 2011.
  2. Isbister GK et al. Amisulpride deliberate self-poisoning causing severe cardiac toxicity including QT prolongation and torsades de pointes. Med J Aust 2006; 184 (7): 354-356.
  3. Isbister GK, Balit CR, Macleod D, Duffull SB. Amisulpride overdose is frequently associated with QT prolongation and torsades de pointes. J Clin Psychopharmacol. 2010 Aug;30(4):391-5.
  4. http://lifeinthefastlane.com/book/toxicology/amisulpride/
  5. Micromedex 2.0 (Toxicology Summary) “SULPIRIDE AND RELATED AGENTS”
  6. http://lifeinthefastlane.com/ecg-library/basics/qt_interval/


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