(127) Cheating "Death": From Brain Death Mimicry to VA ECMO After Intentional Drug Overdose

Introduction: Intoxication is one of the most common confounders during brain death determination. The combination of absent brainstem reflexes and profound cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation is rare.

Description: 57-year-old female with a history of depression and seizures presented with an intentional drug overdose, possibly including chlordiazepoxide, propranolol, alcohol, and bupropion. Her GCS deteriorated to 3, necessitating intubation for airway protection. At this time, her pupil, corneal, and cough reflexes were present. She exhibited a tonic-clonic seizure and subsequently lost brainstem reflexes (pupil, cough, gag, corneal, oculocephalic). Activated charcoal was not indicated. Despite glucagon and calcium infusions, she progressed to cardiogenic shock, requiring multiple vasopressors and inotropes. Toxicology tests showed the presence of ethanol and urine benzodiazepine, and a significantly elevated hydroxybupropion level (2596.1 ng/ml) was reported days later. An ECHO showed severely reduced LVEF ( < 20%) and moderately reduced RV function. Swann-Ganz catheter indicated a Cardiac Index of 1L/min/m2. A repeat CT head was unremarkable, but her neurologic exam remained out of proportion to her imaging. She had no reported cardiac arrest or hypoxic event. After multidisciplinary consideration, she was cannulated for VA ECMO. In 2 days, she regained brainstem reflexes, and after 4 days of ECMO support, her cardiogenic shock resolved, and she was decannulated. She developed acute renal failure due to ATN and temporarily required CVVH, transitioning to iHD. She was discharged to an inpatient psychiatric facility. On follow-up, her neurologic, cardiac, and renal functions had returned to pre-illness levels, and she was enjoying activities that would otherwise not have been possible.

Discussion: Bupropion overdose is one of the most common brain death mimickers. Though the mechanism is unclear, most patients in case reports, even those with complications like status epilepticus and cardiogenic shock (even with reported cardiac arrest), were able to recover to their neurologic baseline. It is crucial to identify potential reversibility of the neurologic exam due to intoxication confounders when considering invasive life-sustaining measures such as ECMO.