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Antiarrhythmic Storm: Cardiac Arrest Following Propafenone Intoxication
Session:
Sessão Melhores Casos Clínicos
Speaker:
André Lobo
Congress:
CPC 2024
Topic:
P. Other
Theme:
37. Miscellanea
Subtheme:
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Session Type:
Prémios, Registos e Sessões Especiais
FP Number:
---
Authors:
Andre Lobo; Fábio Nunes; Lino Santos; Ricardo Fontes-Carvalho
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Introduction: Propafenone, a class IC antiarrhythmic sodium-channel blocker, is primarily used to treat atrial fibrillation. Sodium-channel blocker overdose is a rare occurrence that can lead to seizures, hypotension, prolonged QRS, and ventricular arrhythmias, possibly resulting in cardiac arrest. Currently, there is no standardized algorithm for its management. We present a case of cardiac arrest following propafenone intoxication.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Case Report: A 17-year-old patient with cerebral palsy and a history of cannabis use presented to the ER 6 hours after voluntary ingestion of 1500 mg of propafenone and 300 mg of sertraline. At the ER, he suffered a brief seizure. Initial evaluation revealed a GCS of 14, BP 79/55 mmHg, pulse 80 bpm, and lab results indicating mild metabolic acidosis with hyperlactatemia (2.4 mmol/L). ECG showed sinus rhythm, first-degree AV block (PR: 214 ms), and widened QRS (180 ms). Bedside echocardiography showed moderate biventricular systolic function impairment. Fluids were administered, and the patient was closely monitored.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Subsequently, the patient evolved rapidly with a new seizure, QRS widening, and cardiac arrest. CPR was initiated, and after 10 minutes without ROSC, the decision was made to implement Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO). During transport for the hemodynamic lab, sodium bicarbonate was administered as an off-label antidote to sodium channel blockade. Shortly after, and while cannulation was still being performed for VA-ECMO, ROSC was achieved 31 minutes after CPR began. The decision was made to still progress to ECMO support. The patient was transferred to the pediatric ICU. Follow-up ECG and echocardiography showed complete normalization of electrical and mechanical changes in the following days. VA-ECMO was discontinued on the third day, with successful extubation on the fourth. The patient was transferred to the pediatric ward with total cardiovascular recovery and no superior neurological deficits (normal cerebral CT scan)</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">While subsequent evaluations revealed no superior neurological deficits, motor impairment of the inferior members was noted. A spinal anterior infarction, likely related to ECMO implantation, was diagnosed. The patient is currently undergoing neuromuscular rehabilitation.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Conclusion: Propafenone intoxication can precipitate severe cardiovascular toxicity. In this case, the use of sodium bicarbonate as an off-label antidote, coupled with prompt referral to VA ECMO, led to a successful outcome. Case reports of similar cases also suggest a role for intravenous lipid emulsion in these cases of propafenone intoxication. We present this case as we believe it is essential to disseminate these antidotes to rare but ominous sodium channel blocker intoxications.</span></span></p>
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