sodium-bicarbonate and Tachycardia--Ventricular

In the setting of flecainide toxicity, supraventricular tachycardia can manifest as a bizarre right or left bundle branch block, sometimes with a northwest axis, and can easily be mistaken for ventricular tachycardia leading to inappropriate therapy. We conducted a comprehensive literature review for cases of flecainide toxicity. We found 21 articles of flecainide toxicity in adult patients in which 22 ECG tracings were published. In patients with flecainide toxicity and QRS duration ≤ 200 ms, the ECGs were more likely to show RBBB, visible P waves (p = 0.03), and shorter QT (p = 0.02) and QTc intervals (p = 0.004). With QRS duration > 200 ms, the ECGs were more likely to show LBBB, loss of P waves, a northwest axis (p = 0.01), and longer QT and QTc intervals. Deaths were reported only in patients with QRS duration >200 ms, and the outcome of death or requirement for mechanical circulatory support was more prevalent in patients with a QRS duration > 200 ms [2/13 (15.4 %) vs. 6/10 (60 %), p = 0.04]. In patients with access to the medication, flecainide toxicity should be suspected with: (1) broad QRS, (2) RBBB morphology with QRS ≤ 200 ms; RBBB or LBBB morphology with QRS ≥ 200 ms (3) HR out of proportion to the degree of hemodynamic instability. The duration of the QRS interval is prognostic, with mortality and the requirement for mechanical circulatory support being more common in patients with a QRS > 200 ms.

Topics: Anti-Arrhythmia Agents; Disease Management; Electrocardiography; Flecainide; Humans; Male; Middle Aged; Sodium Bicarbonate; Tachycardia, Ventricular

Topics: Animals; Antidepressive Agents, Tricyclic; Antidotes; Aspirin; Heart Failure; Humans; Hypokalemia; Injections, Intravenous; Sodium Bicarbonate; Tachycardia, Ventricular

Diphenhydramine toxicity commonly manifests with antimuscarinic features, including dry mucous membranes, tachycardia, urinary retention, mydriasis, tachycardia, and encephalopathy. Severe toxicity can include seizures and intraventricular conduction delay. We present here a case of a 23-year-old male presenting with recurrent seizures, hypotension and wide complex tachycardia who had worsening toxicity despite treatment with sodium bicarbonate. The patient was ultimately treated with intravenous lipid emulsion therapy that was temporally associated with improvement in the QRS duration. We also review the current literature that supports lipid use in refractory diphenhydramine toxicity.

Topics: Antidotes; Diphenhydramine; Drug Overdose; Drug Therapy, Combination; Fat Emulsions, Intravenous; Histamine H1 Antagonists; Humans; Hypertonic Solutions; Male; Sodium Bicarbonate; Tachycardia, Ventricular; Young Adult

Topics: Aged; Atrial Flutter; Diagnosis, Differential; Dose-Response Relationship, Drug; Female; Flecainide; Humans; Renal Insufficiency; Risk Adjustment; Risk Factors; Sodium Bicarbonate; Tachycardia, Supraventricular; Tachycardia, Ventricular; Voltage-Gated Sodium Channel Blockers

Unintentional poisonings are a global health problem frequently resulting in hospital admissions. Propafenone is a class 1C antiarrhythmic drug used in the second-line management of supraventricular and ventricular arrhythmias and, when unintentionally ingested, can lead to severe and life-threatening poisoning. We describe a case of a 3-year-old male patient unintentionally ingesting 300 mg (20 mg/kg) of propafenone and presenting with ventricular tachycardia with QT prolongation. Two boli of intravenous hypertonic sodium bicarbonate (total amount of 3 mEq/kg), followed by 3-hours continuous infusion of 1 mEq kg h sodium bicarbonate, were able to restore the clinical conditions of the patient. With this case report, we aim to highlight the existing challenge in the therapeutic management of propafenone intoxication that finds intravenous hypertonic bicarbonate to be a useful tool also in pediatric population.

Topics: Administration, Intravenous; Anti-Arrhythmia Agents; Child, Preschool; Electrocardiography; Humans; Male; Propafenone; Sodium Bicarbonate; Tachycardia, Ventricular

Topics: Amitriptyline; Antidepressive Agents, Tricyclic; Cardiotoxicity; Drug Overdose; Electrocardiography; Heart Rate; Humans; Infusions, Intravenous; Male; Middle Aged; Predictive Value of Tests; Sodium Bicarbonate; Tachycardia, Ventricular

We report a case of a 74-year-old lady admitted to the emergency department with a very broad QRS complex caused by flecainide intoxication due to acute renal failure. Appropriate recognition of the ECG changes and symptoms provoked by flecainide intoxication permitted quick directed treatment with intravenous administration of high dose sodium bicarbonate, which resolved the QRS elongation.

Topics: Accidental Falls; Aged; Anti-Arrhythmia Agents; Drug Overdose; Electrocardiography; Fatigue; Female; Flecainide; Humans; Sodium Bicarbonate; Tachycardia, Ventricular; Treatment Outcome

Topics: Action Potentials; Administration, Intravenous; Aged; Anti-Arrhythmia Agents; Electrocardiography; Female; Flecainide; Heart Rate; Humans; Sodium Bicarbonate; Tachycardia, Ventricular; Time Factors

Ventricular tachycardia (VT) is life-threatening subgroup of wide QRS complex tachycardia (WCT). VT is usually associated with structural heart diseases, but it can occur in the absence of any cardiovascular diseases. Adverse cardiac effect of sodium bicarbonate in healthy subjects is not well described. A 30-year-old healthy man with excessive intake of sodium bicarbonate-related VT is presented. He was using sodium bicarbonate during last 2 months to lose weight. He has no risk factors and any cardiovascular or systemic diseases. After intravenous administration of amiodarone, tachycardia ended and his rhythm converted to sinus rhythm with normal electrocardiogram. Patient is asymptomatic, and no VT was observed without any medications at 1 year of follow-up.

Topics: Action Potentials; Adult; Anti-Obesity Agents; Electrocardiography; Heart Conduction System; Heart Rate; Humans; Male; Sodium Bicarbonate; Tachycardia, Ventricular; Treatment Outcome

Lacosamide treats partial seizures by enhancing slow inactivation of voltage-gated sodium channels. The described cardiac toxicity of lacosamide in the literature to date includes atrioventricular blockade (PR prolongation), atrial flutter, atrial fibrillation, sinus pauses, ventricular tachycardia and a single cardiac arrest. We report a second case of cardiac arrest following an intentional lacosamide overdose.. A 16 year-old female with a seizure disorder was found unresponsive in pulseless ventricular tachycardia after intentionally ingesting 4.5 g (76 mg/kg) lacosamide, 120 mg (2 mg/kg) cyclobenzaprine and an unknown amount of levetiracetam. Exact time of ingestion was unknown. Her initial electrocardiogram (ECG) demonstrated sinus tachycardia at 139 beats per minute, QRS duration 112 ms, and terminal R-wave in lead aVR > 3 mm. Despite treatment with 150 mEq of sodium bicarbonate, she had persistent EKG findings eight hours after presentation. Her serum lacosamide concentration nine hours after presentation was elevated at 22.8 μg/mL, while serum cyclobenzaprine concentration was 16 ng/mL (therapeutic: 10-30 ng/mL), and serum levetiracetam concentration was 22.7 μg/mL (therapeutic: 12-46 μg/mL). On hospital day three, ECG demonstrated resolution of the terminal R-wave with QRS of 78 ms. The patient recovered without physical or neurologic sequelae.. The patient's lacosamide, cyclobenzaprine and levetiracetam overdose was associated with QRS prolongation and terminal right axis deviation--suggesting sodium channel blockade as a likely etiology for her cardiac arrest. Cyclobenzaprine has potential for sodium channel blockade and ventricular dysrhythmias although cardiac toxicity due to cyclobenzaprine alone is rare. The combination of cyclobenzaprine with lacosamide may have resulted in cardiovascular collapse. In conclusion, overdose of lacosamide combined with therapeutic concentrations of sodium channel blocking xenobiotics may cause cardiac conduction delays and cardiac arrest.

Topics: Acetamides; Adolescent; Amitriptyline; Anticonvulsants; Drug Interactions; Drug Overdose; Electrocardiography; Epilepsy; Female; Heart Arrest; Humans; Lacosamide; Levetiracetam; Piracetam; Risk Factors; Sodium Bicarbonate; Sodium Channel Blockers; Sodium Channels; Suicide, Attempted; Tachycardia, Ventricular; Treatment Outcome

Flecainide is a class 1C antiarrhythmic drug especially used for the management of supraventricular arrhythmia. In overdose cases, flecainide can induce life treating ventricular arrhythmias and cardiogenic shock. We report the case of a 72-year-old woman admitted to our intensive care unit for a regular monomorphic wide complex tachycardia (QRS duration 240 ms, right bundle branch block and superior axis morphology) without apparent P waves. Clinical examination showed slight left congestive heart failure signs without cardiogenic shock. An intravenous bolus of 10 mg adenosine 5'-triphosphate (ATP) was ineffective to stop the tachycardia. The diagnosis of ventricular tachycardia induced by flecainide overdose was considered. 500 mL of intravenous 84‰ sodium bicarbonate was administrated. The patient's QRS narrowed immediately and 12-lead ECG showed sinus rhythm. Blood samples confirmed the flecainide overdose and the clinical status progressively improved.

Topics: Adenosine Triphosphate; Aged; Anti-Arrhythmia Agents; Bundle-Branch Block; Electrocardiography; Female; Flecainide; Humans; Injections, Intravenous; Sodium Bicarbonate; Tachycardia, Ventricular; Treatment Outcome

Topics: Alkalosis; Antacids; Diagnosis, Differential; Drug Overdose; Gastritis; Gastrointestinal Agents; Heartburn; Humans; Male; Medicine, Traditional; Middle Aged; Self Medication; Severity of Illness Index; Sodium Bicarbonate; Tachycardia, Ventricular; Treatment Outcome

Intravenous fat emulsion (IFE) is emerging as a novel antidote in clinical toxicology. Its current usage is extending beyond local anaesthetic toxicity into management of severe toxicity from some lipophilic drugs. We present a 51-year-old woman with severe bupropion toxicity whose haemodynamic status transiently improved after IFE. Serum analysis demonstrated an increase in serum concentration of hydroxybupropion, an active metabolite of bupropion, after IFE administration, lending support to one of the proposed mechanisms of IFE. A 51-year-old woman presented to the emergency department with generalised tonic-clonic convulsions lasting approximately 30 sec., and a wide complex rhythm on her ECG that was suggestive of myocardial sodium channel blockade. Despite sodium bicarbonate therapy, the patient developed profound hypotension refractory to high-dose norepinephrine. IFE was administered with haemodynamic improvement over the course of 30 min., followed by a significant decrease in norepinephrine requirement. The patient had an episode of ventricular tachycardia 24 hr after presentation, and received a second infusion of IFE. Analysis of serum for a panel of myocardial sodium channel blocking drugs revealed that significant bupropion ingestion had occurred. Bupropion poisoning may produce life-threatening clinical effects, and IFE may be considered in cases of severe haemodynamic instability. Further studies would be instrumental in determining the optimal clinical situations for utilisation of IFE.

Topics: Antidotes; Bupropion; Eating; Electrocardiography; Fat Emulsions, Intravenous; Female; Humans; Hypotension; Middle Aged; Sodium Bicarbonate; Tachycardia, Ventricular

Taxus species are known to be toxic and may result in significant dysrhythmias. Treatment of taxus induced cardiac dysrhythmias is based largely on case reports. We describe a case of a 24-year-old male with Taxus cuspidate (yew berry) toxicity initially treated with amiodarone bolus and infusion and subsequently managed with sodium bicarbonate boluses and continuous infusion.. The patient was found at home by his parents with witnessed "seizure-like"activity 2 hours after reportedly chewing and swallowing 168 yew seeds. The initial prehospital rhythm strip demonstrated ventricular tachycardia (VT); the patient was hypotensive with fluctuating levels of alertness. Prehospital cardioversion was attempted without success. Staff at the local presenting emergency department (ED) consulted toxicology for management of the presumed yew berry ingestion, complicated by cardiac dysrhythmias and mental status change with seizure. Amiodarone 300-mg IV and diazepam 5-mg IV were given. Cardioversion was attempted 4 times without change in the wide complex tachycardia, presumed to be VT, at a rate of 166. An amiodarone drip at 1 mg/min was initiated. The patient was transferred to an intensive care unit (ICU) at a regional toxicology center. On arrival to the toxicology center the patient was alert and verbally appropriate without complaints. Initial heart rate was 76 and regular with premature ventricular contractions (PVCs). A wide complex tachycardia associated with hypotension recurred; however, normal mental status was maintained. A bolus of 100 mEq of sodium bicarbonate (NaHCO3) was given intravenously followed by sodium bicarbonate infusion at 37.5 mEq/hr. The amiodarone drip was discontinued. Subsequent electrocardiograms (EKG's) revealed a prolonged, but steadily narrowing QRS complex. Ultimately, the QRS complex closed to 92 ms, with a rate of 94, PR 154 and a QT/QTc of 390/487.. This case describes successful treatment of an isolated Taxus cuspidate (yew berry) ingestion with significant toxicity initially with amiodarone bolus and infusion. Due to lack of significant change in telemetry recordings with amiodarone, treatment with sodium bicarbonate bolus and infusion was initiated. While the QRS narrowed significantly temporally related to the bicarbonate, it is difficult to determine if correction of the cardiac dysrhythmias was solely due to the sodium bicarbonate, or the synergism of sodium bicarbonate and amiodarone, or possibly spontaneous improvement due to taxine clearance. One should use caution while drawing conclusions from a single case; however, based on the clinical improvement of this patient, both with EKG recordings and vital signs, this report would suggest that isolated Taxus cuspidate ingestion from yew berry plants can be treated with sodium bicarbonate.

Topics: Amiodarone; Anti-Arrhythmia Agents; Antidotes; Drug Therapy, Combination; Electrocardiography; Humans; Injections, Intravenous; Male; Plant Poisoning; Seizures; Sodium Bicarbonate; Tachycardia, Ventricular; Taxus; Treatment Outcome; Young Adult

A 19-year-old woman was brought by ambulance to the emergency department (ED) from a police holding cell. Less than 3 hours earlier, the patient had been a passenger in a car stopped for a traffic violation. As the police officer approached the car, the patient was noted to hurriedly stuff 2 plastic bags containing a white powdery substance into her mouth. On questioning, it was reported that the packets contained cocaine. Less than an hour after being taken to the police station, the patient was witnessed to have a generalized seizure. What is the pharmacological basis of acute cocaine intoxication? What are the cardiovascular manifestations of acute cocaine intoxication? What is the basis for using sodium bicarbonate in cocaine-induced wide-complex dysrhythmias? What is the basis for the use of lidocaine in cocaine-induced wide-complex dysrhythmias? Is there any evidence for the use of amiodarone to treat cocaine-induced wide-complex dysrhythmias?

Topics: Amiodarone; Anti-Arrhythmia Agents; Anticonvulsants; Antidotes; Arrhythmias, Cardiac; Charcoal; Cocaine; Electrocardiography; Emergency Medical Services; Female; Heart Arrest; Humans; Lidocaine; Lorazepam; Pulse; Seizures; Sodium Bicarbonate; Sympathomimetics; Tachycardia, Ventricular; Young Adult

Topics: Amitriptyline; Antidepressive Agents, Tricyclic; Child, Preschool; Humans; Hydrogen-Ion Concentration; Lidocaine; Magnesium Sulfate; Male; Sodium Bicarbonate; Tachycardia, Ventricular; Treatment Outcome; Turkey

Topics: Acidosis; Adult; Humans; Hypokalemia; Infusions, Intravenous; Male; Sodium Bicarbonate; Tachycardia, Ventricular

The use of sodium bicarbonate (SB) in cardiopulmonary resuscitation (CPR) is controversial. This study analyzes the effects of SB use on CPR outcome in the Brain Resuscitation Clinical Trial III (BRCT III), which was a multicenter randomized trial comparing high-dose to standard-dose epinephrine during CPR. Sodium bicarbonate use in BRCT III was optional.. The entire BRCT III database was reviewed. Analysis included only patients who arrested out of the hospital and whose time from collapse to initiation of ACLS was no longer than 30 min (total n = 2122 patients). Sodium bicarbonate use by the 16 participating study sites was analyzed. The study sites were divided according to their SB usage profile: 'low SB user' sites administered SB in less than 50% of CPRs and their first epinephrine to SB time exceeded 10 min; and 'high SB user' sites used SB in over 50% of CPRs and their first epinephrine to SB time was <10 min.. Sites' SB usage rates ranged between 3.1% and 98.2% of CPRs. Sodium bicarbonate usage rates correlated inversely with the sites' intervals from collapse (r = - 0.579 P = 0.018) from initiation of ACLS (r = - 0.685 P = 0.003) and from first epinephrine (r = - 0.611 P = 0.012) to SB administration. Mean ROSC rate in the 'high SB user' sites was 33.5% (CI = 30.0-37.0) compared to 25.7% (CI = 23.1-28.4) in the 'low SB user' sites. In the 'high SB user' sites, hospital discharge rate was 5.3% (CI = 3.6-7.0) compared to 3% (CI = 2.0-4.0) in the 'low SB user' sites, and 5.3% (CI = 3.6-7.0) had a favorable neurological outcome compared to 2.1% (CI = 1.2-3.0) in the 'low SB user' sites. Collapse to ACLS interval was 8.5 min (CI = 8.1-9.0) in the 'high SB user' sites compared to 10.2 min (CI = 9.8-10.6) in the 'low SB user' sites, and their ACLS to first epinephrine interval was 7.0 min (CI = 6.5-7.5) compared to 9.7 min (CI = 9.3-10.2). Multivariate regression analysis found that belonging to 'high SB user' sites independently increased the chances for ROSC (OR 1.36, CI 1.08-1.7) and for achieving a good neurological outcome (OR 2.18, CI 1.23-3.86).. Earlier and more frequent use of SB was associated with higher early resuscitability rates and with better long-term outcome. Sodium bicarbonate may be beneficial during CPR, and it should be subjected to a randomized clinical trial.

Topics: Acidosis; Aged; Brain; Buffers; Cardiopulmonary Resuscitation; Dose-Response Relationship, Drug; Emergency Medical Services; Epinephrine; Female; Heart Arrest; Humans; Male; Middle Aged; Randomized Controlled Trials as Topic; Sodium Bicarbonate; Sympathomimetics; Tachycardia, Ventricular; Treatment Outcome; Ventricular Fibrillation

We sought to compare the effects of hypertonic sodium chloride solution (HTS), sodium bicarbonate solution, and hyperventilation (HV) on severe tricyclic antidepressant (TCA) toxicity in a swine model.. Twenty-four mixed-breed, domestic swine of either sex were given an intravenous infusion of nortriptyline (NT) until development of both a QRS duration longer than 120 ms and a systolic blood pressure (SBP) less than or equal to 50 mm Hg. Animals were randomly assigned to 1 of 4 groups. On reaching toxicity, the control group received 10 mL/kg of 5% dextrose in water (D5W); the HTS group received 10 mL/kg of 7.5% NaCl solution (15 mEq Na+/kg); the NaHCO3 group received 3 mEq/kg of 8.4% sodium bicarbonate solution followed by enough D5W solution to equal 10 mL/kg of total volume; and the HV group was mechanically hyperventilated to maintain arterial pH between 7.50 and 7.60 and given 10 mL/kg of D5W.. The mean SBP 10 minutes after treatment was 54+/-18 mm Hg in the control group, 134+/-21 mm Hg in the HTS group, 85+/-19 mm Hg in the NaHCO3 group, and 60+/-12 mm Hg in the HV group (P<.05). Mean QRS duration 10 minutes after treatment was 144+/-38 ms in the control group, 80+/-14 ms in the HTS group, 105+/-38 ms in the NaHCO3 group, and 125+/-46 ms in the HV group (P<.05).. In this model of TCA, toxicity HTS was more effective than sodium bicarbonate. Hyperventilation had little effect. Sodium loading may be the most important factor in reversing TCA toxicity.

Topics: Animals; Antidepressive Agents, Tricyclic; Blood Pressure; Buffers; Disease Models, Animal; Electrocardiography; Female; Fluid Therapy; Glucose; Hydrogen-Ion Concentration; Injections, Intravenous; Male; Nortriptyline; Random Allocation; Respiration, Artificial; Saline Solution, Hypertonic; Sodium; Sodium Bicarbonate; Swine; Tachycardia, Ventricular

Flecainide occasionally produces incessant ventricular tachycardia that is difficult to treat. Reports of uncontrolled clinical studies have suggested a therapeutic role for hypertonic sodium bicarbonate (NaHCO3). To test this observation, spontaneous and pacing-induced arrhythmia canine models were designed. In the spontaneous model, flecainide was infused at 0.5 mg/kg/min until ventricular tachycardia occurred spontaneously. In the pacing-induced model, flecainide was infused at 1.0 mg/kg/min load (0.5 mg/kg/min maintenance) stepwise until the QRS was widened 50%, 75%, and 100%, with programmed ventricular stimulation at each step until ventricular arrhythmia was induced. Dogs who developed spontaneous arrhythmia were treated blindly with three doses of either NaHCO3 (3 mEq/kg/dose, with 1 minute between doses) or normal saline. Dogs who were induced in the second model were treated with the same three doses, 10 minutes apart, with programmed stimulation between each dose. Before unblinding in both protocols, dogs were classified as "responders" or "nonresponders" to therapy. In the spontaneous model, of 14 dogs with spontaneous ventricular tachycardia, all 7 dogs treated with NaHCO3 showed response, compared with only 1 of 7 dogs treated with saline (P < .01). Ventricular QRS complexes/min were reduced by NaHCO3 in that protocol. In the induced arrhythmia protocol, of 14 dogs with inducible arrhythmia, 6 of 7 responded to NaHCO3, and 1 of 7 responded to placebo (P < .05). In both protocols, arterial pH and the serum sodium concentration were increased by NaHCO3 but not by normal saline control treatment. QRS interval duration was shortened by NaHCO3 therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Animals; Cardiac Pacing, Artificial; Disease Models, Animal; Dogs; Electrocardiography; Flecainide; Hypertonic Solutions; Sodium Bicarbonate; Sodium Chloride; Tachycardia, Ventricular

Direct-air ventilation, external cardiac compression, and external defibrillation are established techniques for patients who unexpectedly develop cardiac arrest. The proper use of drugs can increase the incidence of successful resuscitation. Intracardiac adrenaline (epinephrine) acts as a powerful stimulant during cardiac standstill and, in addition, converts fine ventricular fibrillation to a coarser type, more responsive to electrical defibrillation. Routine use of intravenous sodium bicarbonate is recommended to combat the severe metabolic acidosis accompanying cardiac arrest. Lidocaine is particularly useful when ventricular fibrillation or ventricular tachycardia tends to recur. Analeptics are contraindicated, since they invariably increase oxygen requirements of already hypoxic cerebral tissues. The following acrostic is a useful mnemonic for recalling the details of the management of cardiac arrest in their proper order: A (Airway), B (Breathing), C (Circulation), D (Diagnosis of underlying cause), E (Epinephrine), F (Fibrillation), G (Glucose intravenously), pH (Sodium bicarbonate), I (Intensive care).

Topics: Acidosis; Arrhythmias, Cardiac; Bicarbonates; Brugada Syndrome; Cardiac Conduction System Disease; Critical Care; Drug Therapy; Electric Countershock; Epinephrine; Glucose; Heart Arrest; Heart Conduction System; Humans; Intensive Care Units; Lidocaine; Resuscitation; Sodium Bicarbonate; Tachycardia, Ventricular; Ventricular Fibrillation