(133) Bupropion Overdose Leading to Cardiogenic Shock Successfully Managed With VA ECMO

Introduction: Bupropion, an atypical antidepressant, is known for its minimal risk of sexual dysfunction and weight gain. However, rare cases of overdose have led to severe encephalopathy, which can mimic brain death, and profound cardiovascular collapse. This case report illustrates both events.

Description: 21-year-old male with a medical history of anxiety and depression presented following an intentional overdose of extended release bupropion, ingesting an unknown quantity of 300mg tablets. He was unresponsive, exhibited seizure-like activity, and was subsequently intubated. The patient had absent brainstem reflexes, absent motor response to tactile stimulation, and was not triggering the ventilator. Pupils were dilated and non-reactive. EEG revealed burst suppression while patient was observed to have intermittent myoclonic jerks. The initial bupropion level was 12,414ng/mL and ECG showed prolonged QTc and widened QRS prompting treatment with sodium bicarbonate and lipid emulsion infusion per poison control recommendations. He subsequently suffered cardiac arrest with monomorphic ventricular tachycardia. Echocardiography showed marked worsening of left ventricular (LV) function, near standstill. He was initiated on veno-arterial (VA) ECMO support then converted to VA-V ECMO due to lung injury. An Impella device was also placed to assist with LV venting. Patient’s bupropion levels gradually declined. After nine days of mechanical therapy, he was decannulated and regained full cardiac and neurologic recovery. Eventually he was transferred to inpatient psychiatry for ongoing care.

Discussion: Bupropion overdose is commonly associated with increased mortality due to cardiotoxic and neurotoxic effects. The initial neurologic exam can be misleading, and patients need time to recover. ECG abnormalities may prompt treatment with sodium bicarbonate or lipid emulsion. If cardiogenic shock ensures, VA ECMO may be lifesaving.