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Posted: March 18th, 2022
History:A 33-year-old woman arrives at the emergency department, visibly distressed, with complaints of fever and diarrhea. She tearfully admits to ingesting 20 enalapril tablets approximately 30 minutes before arrival. She insists she is not currently suicidal and has taken no other medications. The pills belonged to her father.
Past Medical History (PMH): None.
Physical Examination:
Temperature: 100.8°F
Heart Rate: 100 bpm
Respiratory Rate: 18 breaths per minute
Blood Pressure: 80/40 mm Hg
General: Awake and alert, but visibly upset.
HEENT: No abnormalities noted.
Pulmonary: Clear breath sounds, no respiratory distress.
Cardiovascular: Regular heart rate and rhythm, no murmurs.
Abdomen: Soft, non-tender.
Neurologic: Cranial nerves II-XII intact, normal muscle strength.
1. What Are the Signs and Symptoms of an ACE Inhibitor Overdose?
Overdosing on ACE inhibitors like enalapril is typically not life-threatening but can lead to several notable symptoms, primarily related to blood pressure regulation and kidney function. The most common symptoms include:
Hypotension (low blood pressure): Can lead to dizziness, fainting, or even shock in severe cases.
Diarrhea and nausea: Gastrointestinal distress is common in overdose scenarios.
Angioedema: Although rare, swelling of the lips, tongue, or throat can occur, leading to potential airway obstruction.
Hyperkalemia (elevated potassium levels): Can cause muscle weakness, irregular heart rhythms, and, in extreme cases, cardiac arrest.
Drug fever and rash: Some patients may experience fever and skin irritation as a reaction to the overdose.
2. How Should the Hypotension Be Managed?
The primary concern in this patient is her low blood pressure (80/40 mm Hg). Management should be tailored to improving circulation and preventing organ damage. The key interventions include:
Positioning: Laying the patient supine with legs elevated to promote blood flow to vital organs.
Intravenous (IV) Fluids: Rapid administration of isotonic saline or lactated Ringer’s solution to restore intravascular volume.
Vasopressors: If fluid resuscitation is insufficient, medications such as norepinephrine or dopamine may be used to maintain blood pressure.
Monitoring: Continuous assessment of blood pressure, heart rate, kidney function, and electrolytes, especially potassium levels.
3. How Do Angiotensin-Converting Enzyme (ACE) Inhibitors Work?
ACE inhibitors function by blocking the conversion of angiotensin I to angiotensin II, a powerful vasoconstrictor responsible for raising blood pressure. By inhibiting this process, ACE inhibitors:
Reduce blood vessel constriction, leading to lower blood pressure.
Decrease sodium and water retention, which helps manage hypertension and heart failure.
Increase bradykinin levels, which can lead to vasodilation but also contribute to side effects such as coughing and angioedema.
Conclusion
This patient’s enalapril overdose has resulted in symptomatic hypotension, requiring immediate fluid resuscitation and careful monitoring. While ACE inhibitor overdoses are usually not fatal, complications like severe hypotension, hyperkalemia, and angioedema must be anticipated and managed accordingly. Given her emotional distress, a psychiatric evaluation should also be considered to ensure her overall well-being.
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