Abstract
BACKGROUND ß-blocker and calcium channel blocker overdose typically manifests with bradycardia and hypotension. Progression to refractory shock may occur in cases of severe toxicity, requiring vasopressor support. Methylene blue is a nitric oxide synthase inhibitor that can be used in vasoplegic shock refractory to vasopressor therapy. This report describes a case of refractory shock treated with methylene blue as rescue therapy after an overdose of multiple prescribed antihypertensive agents. CASE REPORT A 47-year-old woman was admitted after a suicide attempt involving an overdose of a ß-blocker and a combination of a calcium channel blocker and an angiotensin receptor blocker. She was initially hemodynamically stable; however, she developed sudden-onset bradycardia, hypotension, and progressive shock while in the emergency department. Initial management included atropine, calcium gluconate, glucagon, a high-dose dextrose-insulin infusion, and 3 vasopressors. Despite these interventions, she displayed profound hypotension and shock. Due to persistent refractory vasodilatory shock, a bolus of methylene blue was administered within 48 h of intensive care unit admission, resulting in a substantial and rapid improvement in blood pressure, as well as successful weaning from vasopressors within 72 h after administration. CONCLUSIONS This case indicates that methylene blue can serve as a rescue therapy option for managing refractory vasoplegic shock induced by overdose of antihypertensives, including calcium channel blockers, ß-blockers, and angiotensin receptor blockers. It contributes to the growing body of evidence supporting the use of methylene blue in refractory vasoplegia.