1
|
Tang KB, Simpson MD, Burns MM. Evolving trends of pharmaceutical poisonings associated with QRS complex prolongation. Clin Toxicol (Phila) 2024; 62:574-582. [PMID: 39194962 PMCID: PMC11421585 DOI: 10.1080/15563650.2024.2390138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 07/23/2024] [Accepted: 08/03/2024] [Indexed: 08/29/2024]
Abstract
INTRODUCTION Tricyclic antidepressants often cause drug-induced QRS complex prolongation in overdose but are now less commonly prescribed. We sought to determine, among a contemporary cohort of patients, the pharmaceuticals independently associated with QRS complex prolongation in acute overdose. METHODS We performed secondary analysis of data from the Toxicology Investigators Consortium (ToxIC) Core Registry. We included adult patients presenting from January 2016 through March 2023 with acute or acute-on-chronic pharmaceutical exposures. The primary outcome was QRS complex prolongation >0.12 s. Secondary outcomes included cardiac arrest, death, ventricular dysrhythmia, intensive care unit admission, initiation of vasopressors, and treatment with sodium bicarbonate. We used a multivariable logistic regression model with QRS complex prolongation as the outcome and individual pharmaceuticals of interest as independent variables. We assessed yearly trends of the contribution of relevant pharmaceuticals to QRS complex prolongation since 2016. RESULTS Of 11,945 patients in the total cohort (median age 37 years, 6,652 [55.7%] female), 366 (3.1%) developed QRS complex prolongation. Of 9,417 patients included in the model, 290 (3.1%) developed QRS complex prolongation. Amitriptyline, nortriptyline, doxepin, imipramine, noxiptiline, bupropion, flecainide, carvedilol, propranolol, diphenhydramine, and lamotrigine poisonings were independent predictors of QRS complex prolongation. Flecainide poisoning conferred the greatest odds of QRS complex prolongation (OR 574.1; 95% CI: 88.3-12,747). The contribution of tricyclic antidepressants to QRS complex prolongation decreased from 38.8% to 17.6% of all patients with QRS complex prolongation from 2016 to 2022. In 2022, the proportion of QRS complex prolongation from diphenhydramine (20.6%) surpassed that of tricyclic antidepressants. DISCUSSION This study provides insights into contemporary pharmaceutical poisoning associated with QRS complex prolongation. Tricyclic antidepressants remain clinically relevant exposures but are no longer the most common cause of drug-induced QRS complex prolongation. CONCLUSIONS Bupropion, diphenhydramine, and antidysrhythmics are increasingly common causes of QRS complex prolongation, each associated with numerous severe outcomes in poisoning. Greater safety measures to protect patients from cardiovascular toxicity from these pharmaceuticals are warranted.
Collapse
Affiliation(s)
- Katherine B Tang
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michael D Simpson
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michele M Burns
- Harvard Medical Toxicology, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
2
|
Li Z, Niu K, Zhou C, Wang F, Lu K, Liu Y, Xuan L, Wang X. Multifunctional cardiac microphysiological system based on transparent ITO electrodes for simultaneous optical measurement and electrical signal monitoring. LAB ON A CHIP 2024; 24:1903-1917. [PMID: 38385159 DOI: 10.1039/d3lc00908d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Drug-induced cardiotoxicity is a significant contributor to drug recalls, primarily attributed to limitations in existing drug screening platforms. Traditional heart-on-a-chip platforms often employ metallic electrodes to record cardiomyocyte electrical signals. However, this approach hinders direct cardiomyocyte morphology observation and typically yields limited functionality. Consequently, this limitation may lead to an incomplete understanding of cardiomyocyte characteristics. To address these challenges, we introduce a multifunctional cardiac microphysiological system featuring transparent indium tin oxide electrodes. This innovative design aims to overcome the limitations of conventional heart-on-a-chip systems where metal electrodes interfere with the observation of cells and increase the difficulty of subsequent image processing of cell images. In addition to facilitating optical measurement combined with image processing capabilities, this system integrates a range of electrodes with diverse functionalities. These electrodes can realize cellular electrical stimulation, field potential monitoring, and impedance change tracking, enabling a comprehensive investigation of various cardiomyocyte traits. To demonstrate its versatility, we investigate the effects of four cardiac drugs with distinct pharmacological profiles on cardiomyocytes using this system. This platform provides a means for quantitatively and predictively assessing cardiac toxicity, which could be applied to conduct a comprehensive evaluation during the drug discovery process.
Collapse
Affiliation(s)
- Zhangjie Li
- Department of Micro/Nano Electronics, School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China.
| | - Kai Niu
- Department of Micro/Nano Electronics, School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China.
| | - Chenyang Zhou
- Department of Micro/Nano Electronics, School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China.
| | - Feifan Wang
- Department of Micro/Nano Electronics, School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China.
| | - Kangyi Lu
- Department of Micro/Nano Electronics, School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China.
| | - Yijun Liu
- Department of Micro/Nano Electronics, School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China.
| | - Lian Xuan
- Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Xiaolin Wang
- Department of Micro/Nano Electronics, School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, 200240, China.
- Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, 200240, China
- National Key Laboratory of Advanced Micro and Nano Manufacture Technology, Shanghai Jiao Tong University, Shanghai, 200240, China
- National Center for Translational Medicine (Shanghai) SHU Branch, Shanghai University, Shanghai, 200444, China
| |
Collapse
|
3
|
Ösken A, Aydın E, Özcan KS, Yaylacı S. Evaluation of Electrocardiographic Parameters and the Presence of Interatrial Block in Patients with Mad Honey Intoxication. Cardiovasc Toxicol 2021; 21:772-780. [PMID: 34125412 DOI: 10.1007/s12012-021-09668-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/08/2021] [Indexed: 11/25/2022]
Abstract
Mad honey intoxication (MHI) is a food-induced clinical condition that usually presents with cardiovascular symptoms and can lead to life-threatening arrhythmias if not diagnosed and treated early. No data exist in the literature on the presence of interatrial block (IAB) after food intoxication. In our study, we sought to investigate atrioventricular electrocardiography (ECG) parameters and determine the frequency of IAB in patients with MHI. In total, 76 patients diagnosed with MHI were included in our retrospective study. Twelve-lead ECGs were performed and participants were divided into two groups according to the presence of IAB in the reference ECG. The P maximum (Pmax), P minimum (Pmin), P dispersion (Pdisp), T peak to T end (Tp-Te) interval and QT dispersion (QTdisp) values were compared between the two groups. IAB was detected in 28 (35.5%) of 76 MHI patients included in the final analysis. Pmax duration (122 ± 8; p < 0.001) and PD (69 ± 11; p < 0.001) were significantly higher in the IAB ( +) group. During regression analysis, Pmax [odds ratio (OR) 1.158, 95% confidence interval (CI) 1.036-1.294; p = 0.010] and Pd (OR 1.086, 95% CI 1.001-1.017; p = 0.046) were independently associated with IAB. Pmax and Pd area under the receiver operating characteristic curve values for IAB prediction were 0.926 (95% CI 0.841-1,000; p < 0.001) and 0.872 (95% CI 0.765-0.974; p < 0.001), respectively. ECG changes are common in patients presenting with MHI. These patients need to be followed up clinically in terms of progression to arrhythmic events that may occur in the future.
Collapse
Affiliation(s)
- Altuğ Ösken
- Department of Cardiology, Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Tibbiye street, No:13, Haydarpasa, Istanbul, Turkey.
| | - Ercan Aydın
- Department of Cardiology, Trabzon Vakfıkebir State Hospital, Trabzon, Turkey
| | - Kazım Serhan Özcan
- Department of Cardiology, Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Tibbiye street, No:13, Haydarpasa, Istanbul, Turkey
| | - Selçuk Yaylacı
- Department of Internal Medicine, Sakarya University Faculty of Medicine, Sakarya, Turkey
- Department of Internal Medicine, Fındıklı State Hospital, Rize, Turkey
| |
Collapse
|
4
|
Nearly Fatal Hydroxychloroquine Overdose Successfully Treated with Midazolam, Propofol, Sodium Bicarbonate, Norepinephrine, and Intravenous Lipid Emulsion. Case Rep Emerg Med 2021; 2021:8876256. [PMID: 33968450 PMCID: PMC8081608 DOI: 10.1155/2021/8876256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 03/31/2021] [Accepted: 04/03/2021] [Indexed: 12/14/2022] Open
Abstract
Background In the context of the current COVID-19 pandemic, there has been renewed interest in the drug hydroxychloroquine. However, clinicians should be aware of the dangers of hydroxychloroquine intoxication, an insufficiently studied condition. Case Report. We present a case of autointoxication with 20 g hydroxychloroquine in a 35-year-old woman. Cardiac monitoring showed ventricular arrhythmias for which high-dose midazolam and propofol were initiated, resulting in a brief normalization of the cardiac rhythm. Because of the reoccurrence of these arrhythmias, intravenous lipid emulsion was administered with fast cardiac stabilization. Treatment with continuous norepinephrine, potassium chloride/phosphate, and sodium bicarbonate was initiated. On day 6, she was extubated and after 11 days, she was discharged from the hospital without complications. Conclusion Since high-quality scientific evidence is lacking, treatment options are based on experience in chloroquine toxicity. Activated charcoal is advised if the patient presents early. Sedation with diazepam, early ventilation, and continuous epinephrine infusion are considered effective in treating severe intoxication. Caution is advised when substituting potassium. Despite the lack of formal evidence, sodium bicarbonate appears to be useful and safe in case of QRS widening. Intravenous lipid emulsion, with or without hemodialysis, remains controversial but appears to be safe. As a last resort, extracorporeal life support might be considered in case of persisting hemodynamic instability.
Collapse
|
5
|
Don't Throw the Sodium Bicarbonate Out with the Correlation. J Med Toxicol 2021; 17:317-318. [PMID: 33852108 DOI: 10.1007/s13181-021-00838-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/06/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022] Open
|
6
|
Brown G, Jang W, Peets A, Ramanathan K. Phenytoin-Induced Cardiac Conduction Abnormalities. JOURNAL OF CARDIAC CRITICAL CARE TSS 2020. [DOI: 10.1055/s-0040-1718986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractPhenytoin possesses electrophysiological effects consistent with those of the Vaughan–Williams 1B classification. As such, phenytoin may widen the QRS complex but would not be expected to result in QTc prolongation or ST elevation. The reported case demonstrates these unexpected electrophysiological effects with supratherapeutic concentrations of phenytoin when no other potential cause could be elucidated. No contributing factors present in the case, compared with previously published reports of electrophysiological effects of supratherapeutic phenytoin concentrations, could be elucidated. The report suggests that clinicians should monitor for potential conduction abnormalities in patients with elevated phenytoin concentrations.
Collapse
Affiliation(s)
- Glen Brown
- Pharmacy Department, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Wesley Jang
- Critical Care Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Adam Peets
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Krishnan Ramanathan
- Division of Cardiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
7
|
Suffredini JM, Rutland J, Akpunonu P, Baum R, Catanzaro J, Elayi CS. Flecainide Toxicity Resulting in Pacemaker Latency and Intermittent Failure to Capture. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1279-1283. [PMID: 31467262 PMCID: PMC6735620 DOI: 10.12659/ajcr.916370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Patient: Female, 91 Final Diagnosis: Flecainide toxicity Symptoms: Bradycardia Medication: Flecainide Clinical Procedure: — Specialty: Cardiology
Collapse
Affiliation(s)
- John M Suffredini
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Joshua Rutland
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Peter Akpunonu
- Department of Emergency Medicine, University of Kentucky, Lexington, KY, USA
| | - Regan Baum
- Department of Emergency Medicine, University of Kentucky, Lexington, KY, USA
| | - John Catanzaro
- Division of Cardiology, University of Florida - Jacksonville, Jacksonville, FL, USA
| | - Claude S Elayi
- Division of Cardiology, University of Florida - Jacksonville, Jacksonville, FL, USA
| |
Collapse
|
8
|
Arens AM, Kearney T. Adverse Effects of Physostigmine. J Med Toxicol 2019; 15:184-191. [PMID: 30747326 DOI: 10.1007/s13181-019-00697-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 01/12/2019] [Accepted: 01/17/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Physostigmine is a tertiary amine carbamate acetylcholinesterase inhibitor. Its ability to cross the blood-brain barrier makes it an effective antidote to reverse anticholinergic delirium. Physostigmine is underutilized following the publication of patients with sudden cardiac arrest after physostigmine administration in patients with tricyclic antidepressant (TCA) overdoses. We completed a narrative literature review to identify reported adverse effects associated with physostigmine administration. DISCUSSION One hundred sixty-one articles and a total of 2299 patients were included. Adverse effects occurred in 415 (18.1%) patients. Hypersalivation (206; 9.0%) and nausea and vomiting (96; 4.2%) were the most common adverse effects. Fifteen (0.61%) patients had seizures, all of which were self-limited or treated successfully without complication. Symptomatic bradycardia occurred in 8 (0.35%) patients including 3 patients with bradyasystolic arrests. Ventricular fibrillation occurred in one (0.04%) patient with underlying coronary artery disease. Of the 394 patients with TCA overdose, adverse effects were described in 14 (3.6%). Adverse effects occurred in 7.7% of patients treated with an overdose of an anticholinergic agent compared with 20.6% of patients with non-anticholinergic agents. Five (0.22%) fatalities were identified. CONCLUSIONS In conclusion, significant adverse effects associated with the use of physostigmine were infrequently reported. Seizures were self-limited or resolved with benzodiazepines, and all patients recovered neurologically intact. Physostigmine should be avoided in patients with QRS prolongation on EKG, and caution should be used in patients with a history of coronary artery disease and overdoses with QRS prolonging medications. Based upon our review, physostigmine is a safe antidote to treat anticholinergic overdose.
Collapse
Affiliation(s)
- Ann M Arens
- Minnesota Poison Control System, Minneapolis, MN, USA. .,Hennepin Healthcare, Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, MC-R2, Minneapolis, MN, 55415, USA.
| | - Tom Kearney
- California Poison Control System, San Francisco Division, San Francisco, CA, USA.,San Francisco School of Pharmacy, University of California, San Francisco, CA, USA
| |
Collapse
|
9
|
Role of ECMO in life threatening intoxication. THE EGYPTIAN JOURNAL OF CRITICAL CARE MEDICINE 2018. [DOI: 10.1016/j.ejccm.2018.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
10
|
Fadhlillah F, Patil S. Pharmacological and mechanical management of calcium channel blocker toxicity. BMJ Case Rep 2018; 2018:bcr-2018-225324. [PMID: 30150339 PMCID: PMC6119390 DOI: 10.1136/bcr-2018-225324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2018] [Indexed: 11/04/2022] Open
Abstract
Cardiovascular instability associated with calcium channel blocker toxicity comprises a small percentage of overdose presentations, yet they are associated with a high mortality rate. We detail the management of a 64-year-old man who took an intentional overdose of 840 mg nimodipine. We include the treatment he received and highlight the scarcity of evidence behind the use of gastric decontamination, calcium, glucagon, intravenous lipid emulsion, high-dose insulin therapy, sodium bicarbonate, vasopressors and methylene blue in calcium channel blocker toxicity. Additionally, the article explores the use of electrical pacing and venoarterial extracorporeal membrane oxygenation (VA-ECMO). Following successful weaning of VA-ECMO, the patient was successfully extubated but remained neurologically impaired due to hypoxic-ischaemic brain injury, critical care polyneuropathy and renal failure requiring dialysis. He has cerebral performance category 3; he has mild cognitive impairment but able to perform some activities of daily living independently and communicate his thoughts and needs. He requires no respiratory or cardiovascular support.
Collapse
Affiliation(s)
- Fiqry Fadhlillah
- Emergency Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Shashank Patil
- Emergency Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
11
|
Wong OF, Chan YC, Lam SK, Fung HT, Ho JKY. Clinical Experience in the Use of Intravenous Lipid Emulsion in Hydroychloroquine and Chloroquine Overdose with Refractory Shock. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791101800410] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hydroxychloroquine overdose is a rare condition and often results in severe cardiovascular toxicities. We report 2 cases of fatal hydroxychloroquine overdose (1 patient had co-ingestion of chloroquine). Both patients developed refractory cardiovascular collapse and cardiac arrest soon after the drug overdose. Both of them were treated with high dose adrenaline and diazepam. However, they deteriorated rapidly despite the treatments. In view of similar toxicological profile of hydroxychloroquine to other lipophilic cardiotoxic medications, intravenous lipid emulsion was given as the last resort but both of them died eventually. Based on the clinical experience from these 2 cases, Intravenous lipid emulsion is not effective in reversing the cardiotoxic effects of hydroxychloroquine and chloroquine overdose.
Collapse
Affiliation(s)
| | - YC Chan
- Hong Kong Poison Information Centre, Room 2A, Block K, 130 Hip Wo Street, Kwun Tong, Kwoloon, Hong Kong
| | - SK Lam
- Tuen Mun Hospital, Accident and Emergency Department, Tsing Chun Koon Road, Tuen Mun, N.T., Hong Kong
| | - HT Fung
- Tuen Mun Hospital, Accident and Emergency Department, Tsing Chun Koon Road, Tuen Mun, N.T., Hong Kong
| | | |
Collapse
|
12
|
Reduce the risk of QT interval prolongation associated with targeted cancer therapy by using arrhythmic risk stratification and prevention strategies. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-017-0428-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
13
|
Verhoeven AR, Harris CR. Deadly Drug Ingestions. PHYSICIAN ASSISTANT CLINICS 2017. [DOI: 10.1016/j.cpha.2017.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
14
|
Cuni R, Parrini I, Asteggiano R, Conte MR. Targeted Cancer Therapies and QT Interval Prolongation: Unveiling the Mechanisms Underlying Arrhythmic Complications and the Need for Risk Stratification Strategies. Clin Drug Investig 2017; 37:121-134. [PMID: 27638052 DOI: 10.1007/s40261-016-0460-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The care and treatment of cancer patients has significantly changed in the last decade with a remarkable shift towards novel targeted therapies. These promising new drugs may represent effective and potentially life-saving therapeutic options in cancer patients, but are also emerging in the cardiotoxicity scenario for their arrhythmogenic potential due to their QT-prolonging activity. In this article we review the mechanisms underlying drug-induced QT interval prolongation and the classes of anticancer-targeted therapies most frequently responsible for this adverse event, with a particular focus on tyrosine kinase-targeting molecules. Since up to 49 % of serious adverse drug reactions (ADRs) and 58 % of potentially fatal ADRs may not appear on initial drug safety labels, we also review and discuss data from the post-marketing VigiBase® safety reporting system, the World Health Organization's global database of ADRs. Finally, we discuss arrhythmic risk stratification and prevention strategies in the complex multiple-risk setting of cancer patients, paying particular attention to drug-drug interactions with common antimicrobial, psychotropic and antiemetic supportive care, and we also provide an electrocardiographic QT monitoring algorithm for patients who are candidates for targeted cancer therapies.
Collapse
Affiliation(s)
- Rezarta Cuni
- Department of Cardiology, Azienda Ospedaliera Ordine Mauriziano, Largo Filippo Turati nr. 62, 10128, Turin, Italy.
| | - Iris Parrini
- Department of Cardiology, Azienda Ospedaliera Ordine Mauriziano, Largo Filippo Turati nr. 62, 10128, Turin, Italy
| | - Riccardo Asteggiano
- Azienda Sanitaria Locale Torino 2 and Torino 3, Out of Hospital Cardiology Service, Turin, Italy
| | - Maria Rosa Conte
- Department of Cardiology, Azienda Ospedaliera Ordine Mauriziano, Largo Filippo Turati nr. 62, 10128, Turin, Italy
| |
Collapse
|
15
|
Abstract
Sodium bicarbonate is a well-known antidote for tricyclic antidepressant (TCA) poisoning. It has been used for over half a century to treat toxin-induced sodium channel blockade as evidenced by QRS widening on the electrocardiogram (ECG). The purpose of this review is to describe the literature regarding electrophysiological mechanisms and clinical use of this antidote after poisoning by tricyclic antidepressants and other agents. This article will also address the literature supporting an increased serum sodium concentration, alkalemia, or the combination of both as the responsible mechanism(s) for sodium bicarbonate's antidotal properties. While sodium bicarbonate has been used as a treatment for cardiac sodium channel blockade for multiple other agents including citalopram, cocaine, flecainide, diphenhydramine, propoxyphene, and lamotrigine, it has uncertain efficacy with bupropion, propranolol, and taxine-containing plants.
Collapse
|
16
|
Abstract
The iboga alkaloids are a class of naturally occurring and synthetic compounds, some of which modify drug self-administration and withdrawal in humans and preclinical models. Ibogaine, the prototypic iboga alkaloid that is utilized clinically to treat addictions, has been associated with QT prolongation, torsades de pointes and fatalities. hERG blockade as IKr was measured using the whole-cell patch clamp technique in HEK 293 cells. This yielded the following IC50 values: ibogaine manufactured by semisynthesis via voacangine (4.09 ± 0.69 µM) or by extraction from T. iboga (3.53 ± 0.16 µM); ibogaine's principal metabolite noribogaine (2.86 ± 0.68 µM); and voacangine (2.25 ± 0.34 µM). In contrast, the IC50 of 18-methoxycoronaridine, a product of rational synthesis and current focus of drug development was >50 µM. hERG blockade was voltage dependent for all of the compounds, consistent with low-affinity blockade. hERG channel binding affinities (K i) for the entire set of compounds, including 18-MC, ranged from 0.71 to 3.89 µM, suggesting that 18-MC binds to the hERG channel with affinity similar to the other compounds, but the interaction produces substantially less hERG blockade. In view of the extended half-life of noribogaine, these results may relate to observations of persistent QT prolongation and cardiac arrhythmia at delayed intervals of days following ibogaine ingestion. The apparent structure-activity relationships regarding positions of substitutions on the ibogamine skeleton suggest that the iboga alkaloids might provide an informative paradigm for investigation of the structural biology of the hERG channel.
Collapse
|
17
|
Yu JH, Chen DY, Chen HY, Lee KH. Intravenous lipid-emulsion therapy in a patient with cardiac arrest after overdose of diphenhydramine. J Formos Med Assoc 2016; 115:1017-1018. [PMID: 27421174 DOI: 10.1016/j.jfma.2016.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 06/08/2016] [Accepted: 06/15/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
- Jiun-Hao Yu
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou Branch and Chang Gung University College of Medicine, Taiwan.
| | - Dong-Yi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Linkou Branch and Chang Gung University College of Medicine, Taiwan
| | - Hsien-Yi Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou Branch and Chang Gung University College of Medicine, Taiwan
| | - Kuo-Hua Lee
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| |
Collapse
|
18
|
|
19
|
Novel Therapies for Myocardial Irritability following Extreme Hydroxychloroquine Toxicity. Case Rep Emerg Med 2015; 2015:692948. [PMID: 26351590 PMCID: PMC4553308 DOI: 10.1155/2015/692948] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 08/03/2015] [Indexed: 11/17/2022] Open
Abstract
Introduction. Hydroxychloroquine (HCQ) overdose is rare and potentially deadly when consumed in large doses. Management of severe HCQ toxicity is limited and infrequently reported. This report presents the case of a massive ingestion of HCQ. Case Report. A 23-year-old female presents following an intentional ingestion of approximately 40 g of HCQ. Within six hours after ingestion, she developed severe hemodynamic instability resulting from myocardial irritability with frequent ventricular ectopic activity leading to runs of polymorphic ventricular tachycardia (PMVT) and ventricular fibrillation (VF) requiring multiple defibrillations. Additional treatments included intravenous diazepam, epinephrine, norepinephrine, sodium bicarbonate, and magnesium sulfate. Despite the ongoing hemodynamic instability, the patient was also treated with Intralipid (ILE) and received hemodialysis. Improvements in her hemodynamics were observed after 18 hours. She survived her massive overdose of HCQ. Conclusion. HCQ poisoning is rare but serious because of its rapid progression to life-threatening symptoms. Hemodynamic support, gastric decontamination, electrolyte monitoring and replacement, and management of arrhythmias are the mainstays of treatment. The combined role of dialysis and ILE in the setting of massive HCQ overdose may improve outcomes.
Collapse
|
20
|
Evans B, Cox A, Nicol E, Patil Mead M, Behr E. Drug-associated arrhythmia in the military patient. J ROY ARMY MED CORPS 2015; 161:253-8. [DOI: 10.1136/jramc-2015-000492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2015] [Indexed: 02/02/2023]
|
21
|
Sarquella-Brugada G, Campuzano O, Arbelo E, Brugada J, Brugada R. Brugada syndrome: clinical and genetic findings. Genet Med 2015; 18:3-12. [PMID: 25905440 DOI: 10.1038/gim.2015.35] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 02/10/2015] [Indexed: 11/09/2022] Open
Abstract
Brugada syndrome is a rare, inherited cardiac disease leading to ventricular fibrillation and sudden cardiac death in structurally normal hearts. Clinical diagnosis requires a Brugada type I electrocardiographic pattern in combination with other clinical features. The most effective approach to unmasking this diagnostic pattern is the use of ajmaline and flecainide tests, and the most effective intervention to reducing the risk of death is the implantation of a cardioverter defibrillator. To date, 18 genes have been associated with the disease, with the voltage-gated sodium channel α type V gene (SCN5A) being the most common one to date. However, only 30-35% of diagnosed cases are attributable to pathogenic variants in known genes, emphasizing the need for further genetic studies. Despite recent advances in clinical diagnoses and genetic testing, risk stratification and clinical management of patients with Brugada syndrome remain challenging.Genet Med 18 1, 3-12.
Collapse
Affiliation(s)
| | - Oscar Campuzano
- Cardiovascular Genetics Centre, University of Girona-IDIBGI, Girona, Spain.,Department of Medical Sciences, School of Medicine, University of Girona, Spain
| | - Elena Arbelo
- Arrhythmia Unit, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Josep Brugada
- Pediatric Arrhythmia Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Arrhythmia Unit, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Ramon Brugada
- Cardiovascular Genetics Centre, University of Girona-IDIBGI, Girona, Spain.,Department of Medical Sciences, School of Medicine, University of Girona, Spain.,Cardiology Service, Hospital Josep Trueta, Girona, Spain
| |
Collapse
|
22
|
|
23
|
Koenig X, Hilber K. The anti-addiction drug ibogaine and the heart: a delicate relation. Molecules 2015; 20:2208-28. [PMID: 25642835 PMCID: PMC4382526 DOI: 10.3390/molecules20022208] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 11/11/2014] [Accepted: 11/26/2014] [Indexed: 12/13/2022] Open
Abstract
The plant indole alkaloid ibogaine has shown promising anti-addictive properties in animal studies. Ibogaine is also anti-addictive in humans as the drug alleviates drug craving and impedes relapse of drug use. Although not licensed as therapeutic drug and despite safety concerns, ibogaine is currently used as an anti-addiction medication in alternative medicine in dozens of clinics worldwide. In recent years, alarming reports of life-threatening complications and sudden death cases, temporally associated with the administration of ibogaine, have been accumulating. These adverse reactions were hypothesised to be associated with ibogaine’s propensity to induce cardiac arrhythmias. The aim of this review is to recapitulate the current knowledge about ibogaine’s effects on the heart and the cardiovascular system, and to assess the cardiac risks associated with the use of this drug in anti- addiction therapy. The actions of 18-methoxycoronaridine (18-MC), a less toxic ibogaine congener with anti-addictive properties, are also considered.
Collapse
Affiliation(s)
- Xaver Koenig
- Department of Neurophysiology and Neuropharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Schwarzspanierstrasse 17, Vienna 1090, Austria.
| | - Karlheinz Hilber
- Department of Neurophysiology and Neuropharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Schwarzspanierstrasse 17, Vienna 1090, Austria.
| |
Collapse
|
24
|
Shenoy S, Lankala S, Adigopula S. Management of calcium channel blocker overdoses. J Hosp Med 2014; 9:663-8. [PMID: 25066023 DOI: 10.1002/jhm.2241] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 07/01/2014] [Accepted: 07/08/2014] [Indexed: 11/09/2022]
Abstract
Calcium channel blockers (CCBs) are some of the most commonly used medications in clinical practice to treat hypertension, angina, cardiac arrhythmias, and some cases of heart failure. Recent data show that CCBs are the most common of the cardiovascular medications noted in intentional or unintentional overdoses.(1) Novel treatment approaches in the form of glucagon, high-dose insulin therapy, and intravenous lipid emulsion therapies have been tried and have been successful. However, the evidence for these are limited to case reports and case series. We take this opportunity to review the various treatment options in the management of CCB overdoses with a special focus on high-dose insulin therapy as the emerging choice for initial therapy in severe overdoses.
Collapse
Affiliation(s)
- Sundeep Shenoy
- Division of Inpatient Medicine, University of Arizona, Tucson, Arizona
| | | | | |
Collapse
|
25
|
Paksu S, Duran L, Altuntas M, Zengin H, Salis O, Ozsevik SN, Albayrak H, Murat N, Guzel A, Paksu MS. Amitriptyline overdose in emergency department of university hospital: evaluation of 250 patients. Hum Exp Toxicol 2014; 33:980-90. [PMID: 24505046 DOI: 10.1177/0960327113520019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the patients with acute amitriptyline poisoning and investigate predictive factors for the development of life-threatening complications. METHODS Demographics, clinical, laboratory, and electrocardiographic (ECG) findings of 250 patients were evaluated retrospectively. Predictive parameters for the development of serious complications were studied. RESULTS Median age of patients was 14.6 years, of which, 70% of patients were female and 66% were in pediatric age group. The most common pathological clinical finding and laboratory abnormality were alteration of consciousness and hyponatremia. The rate of convulsive seizure, arrhythmia, and respiratory depression were 17 (6.8%), 16 (6.4%), and 11 (4.4%), respectively. These complications were more seen in pediatric patients than adults (15.8% and 1.2%). The incidence of hyponatremia was more in pediatric patients and severe poisoning groups (38.8 and 53.4%, respectively). The levels of amitriptyline and nortriptyline were significantly higher in the group with complications than the group without complications (p < 0.05). All adult patients were discharged with good prognosis. In pediatric age group, one patient was discharged with severe neurological sequelae and one patient died. QRS duration >100 ms, long corrected QT duration interval, and low Glasgow Coma Score (GCS) at admission were identified as independent risk factors for the development of life-threatening complications (odds ratio: 69.4, 1.9, and 1383, respectively; p < 0.05). CONCLUSION Amitriptyline poisoning may be associated with life-threatening complications, especially in pediatric age group and in patients with hyponatremia. Low GCS, presence of hyponatremia, high serum drug levels, and pathological ECG findings on admission may be helpful in predicting the development of complications and poor prognosis.
Collapse
Affiliation(s)
- S Paksu
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - L Duran
- Department of Emergency Medicine, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - M Altuntas
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - H Zengin
- Department of Biochemistry, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - O Salis
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - S N Ozsevik
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - H Albayrak
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Atakum, Samsun, Turkey
| | - N Murat
- Department of Industrial Engineering, Faculty of Engineering, Ondokuz Mayis University, Samsun, Turkey
| | - A Guzel
- Department of Pediatric Emergency, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - M S Paksu
- Pediatric Intensive Care Unit, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| |
Collapse
|
26
|
Littmann L, Bustin DJ, Haley MW. A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity. Med Princ Pract 2014; 23:1-6. [PMID: 23949188 PMCID: PMC5586830 DOI: 10.1159/000354195] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 07/02/2013] [Indexed: 12/03/2022] Open
Abstract
Cardiac arrest victims who present with pulseless electrical activity (PEA) usually have a grave prognosis. Several conditions, however, have cause-specific treatments which, if applied immediately, can lead to quick and sustained recovery. Current teaching focuses on recollection of numerous conditions that start with the letters H or T as potential causes of PEA. This teaching method is too complex, difficult to recall during resuscitation, and does not provide guidance to the most effective initial interventions. This review proposes a structured algorithm that is based on the differentiation of the PEA rhythm into narrow- or wide-complex subcategories, which simplifies the working differential and initial treatment approach. This, in conjunction with bedside ultrasound, can quickly point towards the most likely cause of PEA and thus guide resuscitation.
Collapse
Affiliation(s)
- Laszlo Littmann
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, N.C., USA
- *Laszlo Littmann, MD, PhD, Department of Internal Medicine, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232 (USA), E-Mail
| | - Devin J. Bustin
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, N.C., USA
| | - Michael W. Haley
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, N.C., USA
- Department of Pulmonary and Critical Care Consultants, Carolinas Medical Center, Charlotte, N.C., USA
| |
Collapse
|
27
|
Abstract
The critical care physician is often called to care for poisoned patients. This article reviews the general approach to the poisoned patient, specifically focusing on the utility of the toxidrome. A toxidrome is a constellation of findings, either from the physical examination or from ancillary testing, which may result from any poison. There are numerous toxidromes defined in the medical literature. This article focuses on the more common toxidromes described in clinical toxicology. Although these toxidromes can aid the clinician in narrowing the differential diagnosis, care must be exercised to realize the exceptions and limitations associated with each.
Collapse
Affiliation(s)
- Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, Blue Ridge Poison Center, University of Virginia Health System, University of Virginia School of Medicine, PO Box 800774, Charlottesville, VA 22908-0774, USA.
| | | |
Collapse
|
28
|
Alper K, Reith MEA, Sershen H. Ibogaine and the inhibition of acetylcholinesterase. JOURNAL OF ETHNOPHARMACOLOGY 2012; 139:879-882. [PMID: 22200647 DOI: 10.1016/j.jep.2011.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 11/29/2011] [Accepted: 12/02/2011] [Indexed: 05/31/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Ibogaine is a psychoactive monoterpine indole alkaloid extracted from the root bark of Tabernanthe iboga Baill. that is used globally in medical and nonmedical settings to treat drug and alcohol addiction, and is of interest as an ethnopharmacological prototype for experimental investigation and pharmaceutical development. The question of whether ibogaine inhibits acetylcholinesterase (AChE) is of pharmacological and toxicological significance. MATERIALS AND METHODS AChE activity was evaluated utilizing reaction with Ellman's reagent with physostigmine as a control. RESULTS Ibogaine inhibited AChE with an IC(50) of 520±40 μM. CONCLUSIONS Ibogaine's inhibition of AChE is physiologically negligible, and does not appear to account for observations of functional effects in animals and humans that might otherwise suggest the possible involvement of pathways linked to muscarinic acetylcholine transmission.
Collapse
Affiliation(s)
- Kenneth Alper
- Department of Psychiatry, New York University School of Medicine, New York, NY 10016, USA.
| | | | | |
Collapse
|
29
|
Emamhadi M, Mostafazadeh B, Hassanijirdehi M. Tricyclic antidepressant poisoning treated by magnesium sulfate: a randomized, clinical trial. Drug Chem Toxicol 2012; 35:300-3. [DOI: 10.3109/01480545.2011.614249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
30
|
Alper KR, Stajić M, Gill JR. Fatalities temporally associated with the ingestion of ibogaine. J Forensic Sci 2012; 57:398-412. [PMID: 22268458 DOI: 10.1111/j.1556-4029.2011.02008.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Ibogaine is a naturally occurring psychoactive plant alkaloid that is used globally in medical and nonmedical settings for opioid detoxification and other substance use indications. All available autopsy, toxicological, and investigative reports were systematically reviewed for the consecutive series of all known fatalities outside of West Central Africa temporally related to the use of ibogaine from 1990 through 2008. Nineteen individuals (15 men, four women between 24 and 54 years old) are known to have died within 1.5-76 h of taking ibogaine. The clinical and postmortem evidence did not suggest a characteristic syndrome of neurotoxicity. Advanced preexisting medical comorbidities, which were mainly cardiovascular, and/or one or more commonly abused substances explained or contributed to the death in 12 of the 14 cases for which adequate postmortem data were available. Other apparent risk factors include seizures associated with withdrawal from alcohol and benzodiazepines and the uninformed use of ethnopharmacological forms of ibogaine.
Collapse
Affiliation(s)
- Kenneth R Alper
- Department of Psychiatry, New York University School of Medicine, New York, NY 10016, USA.
| | | | | |
Collapse
|
31
|
Mégarbane B. Présentation clinique des principales intoxications et approche par les toxidromes. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-011-0433-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
32
|
Amitriptylinbedingter Herz-Kreislauf-Stillstand. Anaesthesist 2011; 60:541-5. [DOI: 10.1007/s00101-011-1848-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 12/03/2010] [Accepted: 12/30/2010] [Indexed: 10/18/2022]
|
33
|
van Noord C, Eijgelsheim M, Stricker BHC. Drug- and non-drug-associated QT interval prolongation. Br J Clin Pharmacol 2011; 70:16-23. [PMID: 20642543 DOI: 10.1111/j.1365-2125.2010.03660.x] [Citation(s) in RCA: 182] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Sudden cardiac death is among the most common causes of cardiovascular death in developed countries. The majority of sudden cardiac deaths are caused by acute ventricular arrhythmia following repolarization disturbances. An important risk factor for repolarization disturbances is use of QT prolonging drugs, probably partly explained by gene-drug interactions. In this review, we will summarize QT interval physiology, known risk factors for QT prolongation, including drugs and the contribution of pharmacogenetics. The long QT syndrome can be congenital or acquired. The congenital long QT syndrome is caused by mutations in ion channel subunits or regulatory protein coding genes and is a rare monogenic disorder with a mendelian pattern of inheritance. Apart from that, several common genetic variants that are associated with QT interval duration have been identified. Acquired QT prolongation is more prevalent than the congenital form. Several risk factors have been identified with use of QT prolonging drugs as the most frequent cause. Most drugs that prolong the QT interval act by blocking hERG-encoded potassium channels, although some drugs mainly modify sodium channels. Both pharmacodynamic as well as pharmacokinetic mechanisms may be responsible for QT prolongation. Pharmacokinetic interactions often involve drugs that are metabolized by cytochrome P450 enzymes. Pharmacodynamic gene-drug interactions are due to genetic variants that potentiate the QT prolonging effect of drugs. QT prolongation, often due to use of QT prolonging drugs, is a major public health issue. Recently, common genetic variants associated with QT prolongation have been identified. Few pharmacogenetic studies have been performed to establish the genetic background of acquired QT prolongation but additional studies in this newly developing field are warranted.
Collapse
Affiliation(s)
- Charlotte van Noord
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | |
Collapse
|
34
|
Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL. Part 14: Pediatric Advanced Life Support. Circulation 2010; 122:S876-908. [DOI: 10.1161/circulationaha.110.971101] [Citation(s) in RCA: 473] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
35
|
Brubacher J. Bicarbonate therapy for unstable propafenone-induced wide complex tachycardia. CAN J EMERG MED 2010; 6:349-56. [PMID: 17381993 DOI: 10.1017/s1481803500009635] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A previously healthy 73-year-old woman presented to hospital with acute atrial fibrillation. After intravenous procainamide failed to restore sinus rhythm, she was treated with 300 mg of oral propafenone and discharged with a prescription for propafenone and propranolol. Six hours later she took 150 mg of propafenone as prescribed. Within 1 hour she became dyspneic and collapsed. On arrival in hospital she was unconscious, with a wide complex tachycardia and no obtainable blood pressure. After defibrillation and lidocaine, she converted to a wide complex sinus rhythm, but remained profoundly hypotensive despite intravenous epinephrine and dopamine. Hypertonic sodium bicarbonate (HCO3) was administered and, shortly thereafter, her blood pressure increased, her QRS duration normalized and her clinical status improved dramatically. In this case of severe refractory propafenone-related cardiac toxicity, intravenous HCO3 led to a profound clinical improvement. Emergency physicians should be familiar with the syndrome of sodium-channel blocker poisoning and recognize the potentially important role of bicarbonate in its treatment.
Collapse
Affiliation(s)
- Jeff Brubacher
- Vancouver General Hospital, Vancouver, British Columbia, Canada.
| |
Collapse
|
36
|
Cardiovascular Toxicology. Clin Toxicol (Phila) 2010. [DOI: 10.3109/9781420092264-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
37
|
Kit YC, Yin LH, Leung MK, Gay KP, Tak WY. CASH as a mnemonic for indications of sodium bicarbonate for sodium channel blocker intoxication. Am J Emerg Med 2009; 27:1013-5. [DOI: 10.1016/j.ajem.2009.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 07/19/2009] [Indexed: 11/26/2022] Open
|
38
|
Eyer F, Stenzel J, Schuster T, Felgenhauer N, Pfab R, von Bary C, Zilker T. Risk assessment of severe tricyclic antidepressant overdose. Hum Exp Toxicol 2009; 28:511-9. [DOI: 10.1177/0960327109106970] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prognostic factors for severe complications in tricyclic antidepressant (TCA) overdose remain unclear. We therefore evaluated the value of clinical characteristics and electrocardiograph (ECG) parameters to predict serious events (seizures, arrhythmia, death) in severe TCA overdose of 100 patients using logistic regression models for risk assessment. The overall fatality rate was 6%, arrhythmia occurred in 21% and 31% of the patients developed seizures. Using an univariable logistic regression model, the maximal QRS interval (OR 1.22; 95% CI 1.06-1.41; p = .005), the time lag between ingestion and occurrence of first symptoms of overdose (OR 1.13; 95% CI 0.99-1.29; p = .072) and the age (OR 0.73; 95% CI 0.55-0.98; p = .038) were determined as the solely predictive parameters. In the multivariable logistic regression model, the QRS interval could not be established as independent predictor, however, the terminal 40-ms frontal plane QRS vector (T40) reached statistical significance regarding prediction of serious events (odds ration [OR] 1.70; 95% confidence interval [CI] 1.02-2.84; p = .041), along with age and time lag between ingestion and onset of symptoms of overdose with a sensitivity and specificity of 71% and 70%, respectively. Evaluation of both clinical characteristics and ECG-parameters in the early stage of TCA overdose may help to identify those patients who urgently need further aggressive medical observation and management.
Collapse
Affiliation(s)
- Florian Eyer
- Department of Toxicology, 2. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany,
| | - Jochen Stenzel
- Department of Toxicology, 2. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany
| | - Tibor Schuster
- Institute for Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany
| | - Norbert Felgenhauer
- Department of Toxicology, 2. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany
| | - Rudi Pfab
- Department of Toxicology, 2. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany
| | - Christian von Bary
- Deutsches Herzzentrum München, 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Lazarettstrasse 36, D-80636 Munich, Germany
| | - Thomas Zilker
- Department of Toxicology, 2. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, D-81675 Munich, Germany
| |
Collapse
|
39
|
D'Alessandro LCA, Rieder MJ, Gloor J, Freeman D, Buffo-Sequiera I. Life-Threatening Flecainide Intoxication in a Young Child Secondary to Medication Error. Ann Pharmacother 2009; 43:1522-7. [DOI: 10.1345/aph.1l549] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To describe a case of life-threatening flecainide intoxication in a toddler, secondary to accidental reversal of syringes used for oral administration. Case Summary: A 2-year-old male with a history of a persistent junctional reciprocating tachycardia had been receiving flecainide 4.8 mg/kg/day (1 mL 3 times daily) and nadolol 2 mg/kg/day (5 mL once daily) for 10 months. One morning, 3 hours after the drugs were administered, he became bradycardic (heart rate 50 beats/min) and then presented to the emergency department with vital signs absent. After initial cardiopulmonary resuscitation and epinephrine, he was bradycardic; this was followed by wide-complex tachycardia that converted rapidly to narrow-complex tachycardia after bolus administration of intravenous sodium bicarbonate for suspected flecainide intoxication. Following resuscitation, he remained hemodynamically stable and was discharged in normal sinus rhythm without neurologic sequelae. Drug concentrations obtained at the time of presentation showed a serum concentration of flecainide of 0.668 μg/mL. Drug formulations were also analyzed and found to contain the expected concentration of flecainide. Discussion: Literature regarding adverse drug events in the pediatric outpatient population is reviewed, as well as how these risks apply to flecainide, a medication with a low margin of safety. Pediatric experience with flecainide intoxication and sodium bicarbonate administration as an antidote is reviewed. Analysis of the serum drug concentrations demonstrated blood concentrations consistent with syringe reversal, which would have produced a 5-fold flecainide overdose. The Naranjo probability scale indicated a highly probable relationship between flecainide ingestion and the life-threatening event in this case. Conclusions: This case of life-threatening flecainide intoxication in a young child, secondary to accidental reversal of medication syringes, underscores the importance of providing parents with accurate dispensing information and labeling medication bottles and syringes in an unambiguous manner.
Collapse
Affiliation(s)
- Lisa CA D'Alessandro
- Paediatric Resident Year 4, Department of Paediatrics, Children's Hospital, London Health Sciences Centre, University of Western Ontario, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Michael J Rieder
- Departments of Paediatrics, Physiology & Pharmacology and Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario
| | - Jane Gloor
- Departments of Medicine & Paediatrics, Department of Paediatrics, Schulich School of Medicine & Dentistry, University of Western Ontario
| | - David Freeman
- Departments of Medicine and Physiology & Pharmacology, Schulich School of Medicine & Dentistry, University of Western Ontario
| | - Ilan Buffo-Sequiera
- Department of Paediatrics, Schulich School of Medicine & Dentistry, University of Western Ontario
| |
Collapse
|
40
|
Boyle JS, Bechtel LK, Holstege CP. Management of the critically poisoned patient. Scand J Trauma Resusc Emerg Med 2009; 17:29. [PMID: 19563673 PMCID: PMC2720377 DOI: 10.1186/1757-7241-17-29] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2009] [Accepted: 06/29/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinicians are often challenged to manage critically ill poison patients. The clinical effects encountered in poisoned patients are dependent on numerous variables, such as the dose, the length of exposure time, and the pre-existing health of the patient. The goal of this article is to introduce the basic concepts for evaluation of poisoned patients and review the appropriate management of such patients based on the currently available literature. METHODS An unsystematic review of the medical literature was performed and articles pertaining to human poisoning were obtained. The literature selected was based on the preference and clinical expertise of authors. DISCUSSION If a poisoning is recognized early and appropriate testing and supportive care is initiated rapidly, the majority of patient outcomes will be good. Judicious use of antidotes should be practiced and clinicians should clearly understand the indications and contraindications of antidotes prior to administration.
Collapse
Affiliation(s)
- Jennifer S Boyle
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.
| | | | | |
Collapse
|
41
|
|
42
|
Abstract
Emergency physicians are regularly called on to care for critically poisoned patients. This article reviews the general approach and management of the critically poisoned patient. Specific clinical characteristics are identified that may clue the clinician into a specific toxin class as a diagnosis. Appropriate testing in the poisoned patient is reviewed. Complications of poisoning that may bring a rapid demise of the critically ill poisoned patient are highlighted and the management of those complications is discussed.
Collapse
|
43
|
In reply. Ann Emerg Med 2008. [DOI: 10.1016/j.annemergmed.2007.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
44
|
The role of fat emulsion therapy in a rodent model of propranolol toxicity: a preliminary study. J Med Toxicol 2008; 2:4-7. [PMID: 18072104 DOI: 10.1007/bf03161005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION In animal models, lipid emulsion therapy has been shown to ameliorate toxicity from a number of lipid soluble agents. This preliminary study addresses the hypothesis that pretreatment with lipid emulsion protects against propranolol toxicity in rodents. METHODS Ten spontaneously ventilating Rattus norvegicus rats were pretreated with either lipid emulsion or 0.9% normal saline before undergoing a constant infusion of propranolol until death. An electrocardiogram (ECG) sampling of heart rate and a QRS duration was performed at two-minute intervals until demise. RESULTS There was no significant difference in lethal doses of propranolol between groups. Comparison of percent change in QRS prolongation and heart rate reduction was performed at 60% of the mean lethal dose in control animals. The percent change in QRS duration was reduced (from -0.9 to 17.3, p=0.016) in the intralipid pretreatment group. Attenuation of propranolol-induced bradycardia observed in the lipid emulsion group approached statistical significance (0% vs. 10.3%, p=0.06). INTERPRETATION The results suggest that lipid emulsion may be effective in ameliorating propranolol toxicity in rats. Previous work gives reason to postulate a pharmacokinetic mechanism for this effect. The results represent encouraging exploratory work, and further work is planned to evaluate the role of lipid emulsion therapy in propranolol toxicity.
Collapse
|
45
|
Devin R, Garrett P, Anstey C. Managing cardiovascular collapse in severe flecainide overdose without recourse to extracorporeal therapy. Emerg Med Australas 2007; 19:155-9. [PMID: 17448102 DOI: 10.1111/j.1742-6723.2006.00909.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Flecainide overdose can rapidly result in profound cardiovascular collapse, and is associated with a relatively high mortality. A case is described where a woman with major toxicity and high serum levels was managed without recourse to invasive modalities such as cardiopulmonary bypass or extracorporeal therapies. Hypertonic sodium bicarbonate is recognized as effective therapy for hypotension and arrhythmias. More recent case reports have concentrated on the use of cardiopulmonary bypass. In this report and other reports describing successful resuscitation, the total dose of sodium bicarbonate is conspicuously higher than in reports describing extracorporeal interventions. Sodium bicarbonate should be given early in the resuscitation, and re-administered as frequently as required, targeting an alkaline pH and improved cardiac output, while accepting hypernatraemia. This case demonstrates the maxim that the correct dose of hypertonic sodium bicarbonate is 'enough'. Cardiopulmonary bypass support can be considered as a salvage therapy.
Collapse
Affiliation(s)
- Ruth Devin
- Intensive Care Unit, Nambour General Hospital, Sunshine Coast, Queensland, Australia
| | | | | |
Collapse
|
46
|
Mongenot F, Gonthier YT, Derderian F, Durand M, Blin D. Traitement d'une intoxication à l'hydroxychloroquine par circulation extracorporelle. ACTA ACUST UNITED AC 2007; 26:164-7. [PMID: 17092685 DOI: 10.1016/j.annfar.2006.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2006] [Accepted: 09/18/2006] [Indexed: 11/16/2022]
Abstract
We report a case of massive overdose of hydroxychloroquine treated with circulatory assistance by peripheral extracorporeal circulation (ECC). We expose the case of a 39-year-old woman who ingested 12 g of hydroxychloroquine with bromazepam, paroxetine, and zolpidem, in a suicide attempt. Patient has developed central nervous system depression, hemodynamic failure, life-threatening ventricular arrhythmias, and serious hypokalemia. Initially the patient has received conventional treatment with gastric lavage and activated charcoal for gastrointestinal decontamination, blood volume expansion and vasopressive drugs, intubation and mechanical ventilation, high dose of diazepam, and potassium replacement. A ventricular fibrillation was treated with external cardiac massage. In spite of this treatment, cardiogenic shock was uncontrolled, and imposed circulatory assistance. After extracorporeal circulation, we observed a spectacular improvement of hemodynamic parameters and electrocardiographic normalization at day one. Extracorporeal circulation could be used as a rescue treatment of cardiotrope and hydroxychloroquine overdoses.
Collapse
Affiliation(s)
- F Mongenot
- Département d'anesthésie-réanimation cardiovasculaire et thoracique, hôpital Michallon, boulevard de la Chantourne, 38700 La Tronche, Grenoble, France.
| | | | | | | | | |
Collapse
|
47
|
2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric advanced life support. Pediatrics 2006; 117:e1005-28. [PMID: 16651281 DOI: 10.1542/peds.2006-0346] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
48
|
Abstract
Despite that drugs have widely varying indications for therapeutic use, many unrelated drugs share a common cardiac pharmacologic effect if taken in overdose. The purpose of this article is to group together agents that cause similar electrocardiographic effects,review their pharmacologic actions, and discuss the electrocardiographic findings reported in the medical literature.
Collapse
Affiliation(s)
- Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia, P.O. Box 800774, Charlottesville, VA 22908-0774, USA.
| | | | | |
Collapse
|
49
|
Seger DL. A Critical Reconsideration of the Clinical Effects and Treatment Recommendations for Sodium Channel Blocking Drug Cardiotoxicity. ACTA ACUST UNITED AC 2006; 25:283-96. [PMID: 17288499 DOI: 10.2165/00139709-200625040-00008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The cardiac sodium channel is comprised of proteins that span the cardiac cell membrane and form the channel pore. Depolarisation causes the proteins to move and open the sodium channel. Once the channel is open (active conformation), sodium ions move into the cell. The channel then changes from the active conformation to an inactive conformation - the channel remains open, but influx of sodium ions ceases. Recovery occurs as the channel moves from the inactive conformation back to the closed conformation and is then ready to open following the next depolarisation. Sodium channel blocking drugs (NCBDs) occupy receptors in the channel during the active and inactive conformations. The drug dissociates from most of the channel receptors during recovery, but the time it takes the drug to dissociate slows recovery. The slowed recovery prolongs conduction time, the main toxicity of NCBD overdose. Conduction time is further prolonged if heart rate increases as there are more available active and inactive conformations/unit time, which increases channel receptor binding sites for the NCBD. In addition to prolonging conduction time, NCBDs also decrease inotropy. Treatment of NCBD cardiotoxicity has been based on in vitro and animal experiments, and case reports. Assumptions based on this evidence must now be reassessed. For example, canines consistently develop ventricular tachycardia (VT) when tricyclic antidepressants (TCAs) are administered. Much of the literature discussing NCBD cardiotoxicity assumes that TCA poisoning induces VT in humans with the same regularity that occurs in canines. Seemingly, in support of this assumption was the finding that patients with remote myocardial infarction developed VT when therapeutically ingesting a NCBD. However, conduction is prolonged in myocardium that is or has been ischaemic. NCBD prolong conduction more in previously ischaemic myocardium than in normal myocardium, which causes nonuniform conduction and allows the development of re-entrant arrhythmias such as VT. Although some nonuniform conduction may occur in the healthy heart following a NCBD overdose, there is no evidence that nonuniform conduction occurs to the extent that it will cause re-entrant arrhythmias in this setting. Using various animal models and a variety of NCBDs, sodium ions, bicarbonate ions and alkalosis have been compared for the treatment of ventricular arrhythmias, hypotension and mortality. The results of these experiments have been extrapolated to NCBD overdose in humans. Animal models and single treatment approaches may have narrowed our scope. More recent evidence indicates that properties of each individual NCBD may require unique treatment. There is limited evidence that glucagon, which increases initial sodium ion influx into the cardiac cell, should be considered early in the treatment of cardiotoxicity. Another consideration may be treatment of NCBD with faster kinetics. Conduction time is decreased if a NCBD occupying the receptor is replaced by a NCBD that moves off and on the receptor more quickly. There is less evidence for this treatment, as risk may be greater. With greater understanding of the sodium channel and NCBDs, we must reassess our approach to the treatment of patients with healthy hearts who overdose on NCBD.
Collapse
|
50
|
Abstract
The diagnoses and subsequent treatment of poisoned patients manifesting cardiovascular compromise challenges the most experienced emergency physician. Numerous drugs and chemicals cause cardiac and vascular disorders. Despite widely varying indications for therapeutic use, many agents share a common cardiovascular pharmacologic effect if taken in overdose. Standard advanced cardiac life support protocol care of these patients may not apply and may even result in harm if followed. This chapter discusses com-mon cardiovascular toxins and groups them into their common mechanisms of toxicity. Multiple agents exist that result in human cardiovascular toxicity. The management of the toxicity of each agent should follow a rationale approach. The first step in the care of all poisoned patients focuses on good supportive care.
Collapse
Affiliation(s)
- Christopher P Holstege
- Blue Ridge Poison Center, Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia, Charlottesville, 22908-0774, USA.
| | | |
Collapse
|