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.