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Competing Interests: Competing interests: None declared.

Complications related to methamphetamine use and abuse are common presentations seen in the emergency department. Standard management focuses on addressing the central nervous system and cardiovascular effects with the use of sedation and hemodynamic support. We describe a case report of a patient with methamphetamine toxicity and subsequent severe cardiomyopathy refractory to conventional management that responded to cardiovascular support with extracorporeal membrane oxygenation therapy (ECMO). A 22-year-old female was admitted in severe cardiogenic shock following intravenous administration of methamphetamine and oral fentanyl use. Despite aggressive treatment with benzodiazepines, intravenous fluids, vasopressors, vasodilators, antibiotics and inotropes, the patient's clinical status deteriorated, and she suffered a cardiac arrest. The patient was successfully resuscitated, and following the return of spontaneous circulation, ECMO was initiated. After 82 hours the patient was successfully weaned from ECMO with the recovery of her left ventricular function and no neurologic sequelae. The patient developed leg ischemia requiring embolectomy and open repair as a complication of ECMO cannulation. In our case, ECMO was used successfully in treating severe cardiac dysfunction from acute methamphetamine-induced cardiomyopathy and was used as a bridge to recovery. The complications seen in this patient emphasize the potential risks associated with this intervention and highlight the need for careful patient selection.

Intentional insulin overdose may lead to severe and refractory hypoglycemia. Exogenous dextrose administration is the mainstay of therapy for these patients and is effective in most cases. However, in patients with a functional pancreas, exogenous dextrose administration may precipitate endogenous insulin release leading to rebound hypoglycemia. We describe a case report of a 41-year-old woman who injected 300 units of insulin aspart with suicidal intent. Her initial blood glucose was 2.3 mmol/L (41 mg/dL). Over the next 12 hours, she experienced recurrent hypoglycemic episodes despite 10% dextrose infusions and 14 ampoules of 50% dextrose. Our patient experienced complications, including peripheral edema, related to the large volumes of intravenous dextrose required to attempt to maintain euglycemia. Octreotide, a somatostatin analogue, may help prevent dextrose-induced hypoglycemia and improve the management in select insulin overdose patients; large infusion volumes resulted in significant peripheral edema. Treatment with octreotide was initiated 12.5 hours post-injection and was followed by a stabilization of blood glucose concentration in this non-diabetic patient.