CASE REPORT
Case history
A 50-year-old married woman after a family struggle was referred to Shaheed Moddares Hospital in Save. Following the struggle, the patient got extremely agitated and the emergency medical service (EMS) reached and checked her blood sugar (BS) by finger and her BS was 65mg/dl, so the EMS injected two vials of 50ml Mg Sulfate 50% (25-gram of Mg sulfate each) instead of Dextrose 50% to the patient by mistake. Immediately after the injection, the patient got flushed and then she lost consciousness, so the EMS took her to the emergency ward of Shaheed Moddares Hospital. At the entrance to the emergency ward before any assessment, she became pulseless, and cardiac pulmonary resuscitation (CPR) was initiated for 10 minutes and was intubated, and her pulse came back, and then supportive care and diagnostic processes like hydration, ECG, and laboratory tests initiated. The patient’s companion mentioned no past medical history or kidney disease and no drug or supplement for usual consumption. On examination, the skin was flushed, no sweating, pupils were symmetric and dilated, heart, lung, and intestine sounds were normal, and the deep tendon reflexes (DTR) were hypoactive. Her blood pressure was 100/70 mmHg and her pulse rate was 110 beats per minute.
The primary laboratory test result was BS 484mg/dl, serum sodium 128 mEq/L, serum potassium 2.2 mEq/L, calcium 9.1mg/dl, phosphorus 3.2mg/dl, magnesium 4.9mEq/L Urea 38 mg/dl, Creatinine 1.33 mg/dl, Aspartate transaminase (AST) 85units/liter, Alanine transaminase (ALT) 107units/liter, Lactate dehydrogenase (LDH) 528units/liter, Troponin qualitative negative, CK-MB 21 IU/L, venous blood gas was PH: 7.14 pco2: 46.2 mmHg hco3: 15.4 mmHg.
Differential diagnosis
Internal medicine and cardiology consultation were requested in the emergency ward considering the laboratory result and ECG, which were hypermagnesemia, hypokalemia, and hyponatremia. the ECG rhythm was irregular (160 bpm), the P wave was flattered, ST-depression in V2-V6, I, and II, and ST-elevation in aVR was obvious (image 1).
Image 1- ECG before hemodialysis