Methods
Cardiopulmonary resuscitation (CPR) was commenced immediately by a nearby ambulance crew. Cardiac rhythm analysis revealed ventricular fibrillation. The patient was transferred to the emergency department with resuscitation ongoing. Intravenous adrenaline and amiodarone were given during the resuscitation attempt in accordance with Advanced Life Support (ALS) UK guidelines (6). Return of spontaneous circulation (ROSC) was achieved after 17 minutes. A total of seven biphasic defibrillations at 200J were administered during the resuscitation effort, with cardiac rhythms evolving from ventricular fibrillation to ventricular tachycardia to pulseless electrical activity (Table 1). A post-resuscitation 12 lead-ECG demonstrated an irregular broad complex rhythm (Figure 1). Arterial blood gases revealed a metabolic acidosis with a lactate of 5.8 mmol/L. Glasgow Coma Scale score was 3.
The patient underwent tracheal intubation and was ventilated in the emergency department. She remained hypotensive and suffered alternating bouts of wide complex tachy- and bradyarrhythmias, with the latter transiently responsive to an intravenous isoprenaline infusion. An intravenous adrenaline infusion was commenced due to extreme haemodynamic instability. The patient suffered a second cardiac arrest with cardiac rhythm analysis demonstrating asystole. ROSC was achieved after one minute of CPR and additional boluses of intravenous adrenaline.
An emergency oesophagogastroduodenoscopy (OGD) was performed at the bedside. Several tree leaves were seen in the gastric body which were successfully retrieved using a Roth net and aspiration. The gastric mucosa was then washed copiously and aspirated completely. The tree leaf residue was sent to the laboratory for analysis.
In attempts to mitigate the destabilising arrhythmogenic effects ofTaxa baccata, the patient received two 80 mg doses of intravenous digoxin specific antibody (Digibind), 100 mL of intravenous 8.4 percent sodium bicarbonate, 4 mmol of intravenous magnesium sulfate and an intravenous amiodarone infusion. Intravenous intralipid therapy was also administered, first as a 100 mL bolus and then as an infusion. 200mg of intravenous hydrocortisone was administered due to previous case reports indicating benefit when used in Yew tree overdose.
Despite these measures, the patient continued to suffer progressive haemodynamic instability and was thus referred emergently to the regional ECMO service. She was established on peripheral VA-ECMO approximately seven hours after Taxa baccata ingestion. Computed tomography (CT) imaging of the head, chest, abdomen and pelvis was unremarkable.