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BACKGROUND
Epsom salts contains the active compound magnesium sulfate, which is medically used for the treatment of eclampsia, asthma and cardiac arrhythmias. When the serum concentration rises above therapeutic values serious toxicity may occur, including cardiac arrest. The National Poisons Information Service provides expert toxicology advice, invaluable when patients are critically ill and unresponsive to initial treatment.
CASE PRESENTATION
A 46-year-old woman deliberately ingested approximately 2 kg of Epsom salts in a suicide attempt. Approximately 2 h after ingestion she presented to the emergency department complaining of difficulty standing and shortness of breath, having collapsed and vomited in the bathroom at home.
Initial Glasgow Coma Scale (GCS) was 13/15 (eye 3 motor 6 verbal 4), non-invasive blood pressure 125/65 mm Hg, pulse 56 beats/min, and respiratory rate 15/min. Physical examination demonstrated generalised limb weakness, hypotonia, and reduced deep tendon reflexes.
INVESTIGATIONS
An electrocardiogram revealed sinus bradycardia that progressed to first degree atrioventricular block within 30 min of presentation. Blood results were normal other than serum magnesium concentration of 9.7 mmol/l, potassium 2.9 mmol/l, and glucose 8.9 mmol/l. Chest x ray revealed radiological evidence of aspiration.
TREATMENT
In addition to supportive treatment, intravenous fluids and oxygen, 10 ml of 10% calcium gluconate was given to counteract the myocardial depressant effects of the magnesium. There was no improvement. A bradydysrhythmia developed with a heart rate of 20-30 beats/min. Blood pressure was stable throughout. The heart rate responded to 0.5 mg of atropine. During this time the patient's GCS had fallen to 3/15. A rapid...