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A 22-year-old man, on long-term methadone maintenance (125 mg daily), with a history of intermittent heroin abuse, came to the Emergency Department (ED) after ingesting 250 mg of methadone. He was lethargic on presentation. Vital signs were: temperature 36.2 °C; respiratory rate 10/min; heart rate 50/min; blood pressure 104/62 mmHg; and room air oxygen saturation 99%. A rapid beside glucose determination was 90 mg/dl. His physical examination was significant for lethargy, “pinpoint” pupils and bradycardia, but was otherwise normal. No “track marks” or other stigmata of parenteral drug abuse were found. The cardiac monitor demonstrated sinus bradycardia. Toxicology was consulted. Clinically, this patient demonstrated a toxidrome consistent with opioid intoxication. An IV was established and a 12-lead EKG was performed, demonstrating sinus bradycardia (HR: 51/min) with a markedly prolonged QTc (516 ms). A total of 0.6 mg intravenous naloxone, 0.2 mg every 5 minutes, was given with restoration of a normal mental status. A CBC of differential, basic metabolic panel, and serum calcium and magnesium levels were normal. A urine drug screen (UDS) was positive for methadone, benzodiazepine, and cocaine metabolite(s).

Case files of the Drexel University medical toxicology fellowship: Methadone-induced QTc prolongation