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A somnolent woman in her fifties with acute circulatory failure.
Tidsskr Nor Laegeforen. 2019 May 28; 139(9)TN

Abstract

BACKGROUND

A woman in her fifties was admitted to hospital with decreased awareness and circulatory failure. She had been treated with left atrial cryoablation a few weeks before admission and had been cardioverted a few days after the procedure because of relapse of atrial fibrillation.

CASE PRESENTATION

On admission, the patient had systolic blood pressure of 80 mm Hg and an ECG with broad QRS-complexes at 380 ms. We suspected intoxication and she was intubated to administer activated charcoal after gastric lavage. She was cardiovascularly unstable and in need of intravenous infusion of noradrenaline and adrenaline. Further investigations at her home suggested that she had poisoned herself with 4-5 g flecainide, 0.3 g oxazepam and 0.5 g meclizine. After administration of 500 mmol sodium bicarbonate and 5 mmol calcium chloride, the QRS complexes narrowed temporarily. On day 2, due to sustained bradycardia and hypotension despite receiving adrenergic medications, a temporary pacemaker was implanted, leading to improved heart rate and blood pressure. She experienced several complications including hypertensive pulmonary oedema, atrial fibrillation, extensively prolonged QT interval because of polypharmacy and Takotsubo cardiomyopathy. She was discharged from the hospital in good health on day 17. At a follow-up visit at the outpatient clinic 12 weeks later, cardiac function had normalised. The QT interval was now normal; however, there were persistent T-wave inversions in leads I, aVL and V4-6.

INTERPRETATION

Flecainide blocks sodium channels in cardiomyocytes. Intoxication with flecainide is rare, with mortality rates of about 10 %. Sodium bicarbonate in larger doses has been reported to stabilise patients with flecainide intoxication due to modification of the binding of flecainide to sodium receptors in cardiomyocytes, and due to alkalisation which makes flecainide detach from sodium receptors. Our patient had a temporary effect with narrowing of QRS complexes after receiving sodium bicarbonate. She also showed a beneficial effect from implantation of a temporary pacemaker, although earlier case reports have described problems with high thresholds and capture failure.

Authors

No affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Case Reports

Language

nor eng

PubMed ID

31140247

Citation

Viland, Jessica, et al. "A Somnolent Woman in Her Fifties With Acute Circulatory Failure." Tidsskrift for Den Norske Laegeforening : Tidsskrift for Praktisk Medicin, Ny Raekke, vol. 139, no. 9, 2019.
Viland J, Langørgen J, Wendelbo Ø. A somnolent woman in her fifties with acute circulatory failure. Tidsskr Nor Laegeforen. 2019;139(9).
Viland, J., Langørgen, J., & Wendelbo, Ø. (2019). A somnolent woman in her fifties with acute circulatory failure. Tidsskrift for Den Norske Laegeforening : Tidsskrift for Praktisk Medicin, Ny Raekke, 139(9). https://doi.org/10.4045/tidsskr.18.0683
Viland J, Langørgen J, Wendelbo Ø. A Somnolent Woman in Her Fifties With Acute Circulatory Failure. Tidsskr Nor Laegeforen. 2019 May 28;139(9) PubMed PMID: 31140247.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - A somnolent woman in her fifties with acute circulatory failure. AU - Viland,Jessica, AU - Langørgen,Jørund, AU - Wendelbo,Øystein, Y1 - 2019/05/27/ PY - 2019/5/30/entrez PY - 2019/5/30/pubmed PY - 2019/12/4/medline JF - Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke JO - Tidsskr. Nor. Laegeforen. VL - 139 IS - 9 N2 - BACKGROUND: A woman in her fifties was admitted to hospital with decreased awareness and circulatory failure. She had been treated with left atrial cryoablation a few weeks before admission and had been cardioverted a few days after the procedure because of relapse of atrial fibrillation. CASE PRESENTATION: On admission, the patient had systolic blood pressure of 80 mm Hg and an ECG with broad QRS-complexes at 380 ms. We suspected intoxication and she was intubated to administer activated charcoal after gastric lavage. She was cardiovascularly unstable and in need of intravenous infusion of noradrenaline and adrenaline. Further investigations at her home suggested that she had poisoned herself with 4-5 g flecainide, 0.3 g oxazepam and 0.5 g meclizine. After administration of 500 mmol sodium bicarbonate and 5 mmol calcium chloride, the QRS complexes narrowed temporarily. On day 2, due to sustained bradycardia and hypotension despite receiving adrenergic medications, a temporary pacemaker was implanted, leading to improved heart rate and blood pressure. She experienced several complications including hypertensive pulmonary oedema, atrial fibrillation, extensively prolonged QT interval because of polypharmacy and Takotsubo cardiomyopathy. She was discharged from the hospital in good health on day 17. At a follow-up visit at the outpatient clinic 12 weeks later, cardiac function had normalised. The QT interval was now normal; however, there were persistent T-wave inversions in leads I, aVL and V4-6. INTERPRETATION: Flecainide blocks sodium channels in cardiomyocytes. Intoxication with flecainide is rare, with mortality rates of about 10 %. Sodium bicarbonate in larger doses has been reported to stabilise patients with flecainide intoxication due to modification of the binding of flecainide to sodium receptors in cardiomyocytes, and due to alkalisation which makes flecainide detach from sodium receptors. Our patient had a temporary effect with narrowing of QRS complexes after receiving sodium bicarbonate. She also showed a beneficial effect from implantation of a temporary pacemaker, although earlier case reports have described problems with high thresholds and capture failure. SN - 0807-7096 UR - https://www.unboundmedicine.com/medline/citation/31140247/A_somnolent_woman_in_her_fifties_with_acute_circulatory_failure L2 - http://tidsskriftet.no/article/18-0683 DB - PRIME DP - Unbound Medicine ER -