A curious method to commit suicide

ABSTRACT

Objective: The COVID-19 pandemic has generated an increase in anxiety-depressive disorders throughout society, with an evident impact on children and adolescents, further precipitated by limitations in social activities during confinement. The increase in home isolation with abuse of new technologies, often far from parental control, involves risky situations such as the case we present. Case report A 19-year-old man diagnosed with major depressive disorder, with psychiatric admissions since July 2019 for overdose with suicidal intent was home treated with methylphenidate 40mg, mirtazapine 15mg and vortioxetine 10mg. In August, the patient was searching for information on the Internet about euthanasia and suicide without pain in different pages and Internet forums. He bought two products online (by Amazon) that seemed effective for this purpose: a kilogram packet of sodium nitrate and a bottle of antifreeze. Finally, he decided on the first option due to the risk of suffering after ingesting antifreeze. On August 26 (400 pm), he ate a tablespoon (80 mg) of sodium nitrate. He developed dyspnea and feeling overwhelmed so he decided to informed his family of what he had done and an ambulance was called. He was transferred to hospital and given oxygen. At 700 pm in the emergency department he was noted to have a greyish coloration (“hot dead” appearance) with poor respiratory mechanics, tachycardic, tachypneic, with signs of peri-arrest blood pressure 96/50mmHg, heart rate 145 bpm, respiratory rate 30/min, oxygen saturations 70%. He also had uncoordinated movements, and could not obey orders. The patient was sedated for intubation and mechanical ventilation. An arterial blood gas analysis performed after intubation showed pH 7.35, pO2 165mmHg, pCO2 24mmHg, base excess -10.4, bicarbonate 14.5 mEq/L, potassium 3.1 mmol/L, methemoglobin 83%, carboxyhemoglobin 1.4%, lactate 13.3mmol/L. Methylene blue 1% (75mg intravenously) and activated charcoal by nasogastric tube were administered (after intubation). Later, he was admitted to the intensive care unit (920 pm). Physicians from this unit decided to administrate hydroxocobalamin (5 g intravenously at 00.39 am). The patient was extubated and discharged from the intensive care unit 36 hours after his admission to the department of Internal Medicine, without clinical complications;later he was transferred to Psychiatry Department. Conclusion: The toxic mechanism of sodium nitrate is related to the generation of methemoglobin. This patient survived a potentially lethal methemoglobin level following intentional ingestion of sodium nitrate with prompt administration of an antidote.