Reanimationspflichtigkeit und protrahierte Kardiodepression nach suizidaler Metoprolol/Ramipril-Intoxikation

We report about a 53-year-old female patient, who tried to commit suicide by swallowing 100 tablets of metoprolol (9.5 g) and 20 pills each containing 5 mg ramipril and 25 mg hydrochlorothiazide. She was found unconscious in cardiogenic shock without measurable blood pressure and sinusbradycardia. A sufficient blood pressure could be maintained using excessive doses of epinephrine (> 150 μg/min) and norepinephrine (>400 μ/min). Serum levels of metoprolol and ramipril were more than 100-fold above therapeutic levels. The ECG showed sinus rhythm and intermittent incomplete right bundle branch block. Initial left ventricular function was severely impaired (ejection fraction: 11%), but returned to normal values within 2 days. The patient developed pneumonia and acute renal failure. She recovered completely and was discharged to receive further psychiatric treatment 12 days after admission. Therapeutic strategies of /?-blocker poisoning are discussed.