Flecainide toxicity—treatment with intravenous fat emulsion and extra corporeal life support

Abstract

Sivalingam et al. ventricular arrhythmias include phase two re-entry as well as triggered automaticity following intracellular calcium accumulation in epicardial cells (5). Cardiac arrhythmias seen with hypothermia usually resolve spontaneously with rewarming (6). It has been noted that hypothermic myocardium is less responsive to antiarrhythmic drugs and defi brillation at temperatures below 28 ° C/82.4 ° F (6), as noted in our patient. When cardiac instability with loss of circulation is noted, the best available care includes extra-corporeal membrane oxygenation (ECMO) or CPB (7). Th e neurologically intact survival rate in cardiac arrest patients treated with these modalities is approximately 50% (8). In patients with return of spontaneous circulation, the rates of multi-organ failure are high and pulmonary edema is encountered frequently (8). Th is is probably why ECMO has slightly better outcomes than traditional CPB as it is capable of providing pulmonary support (7).Remarkably, the patient walked home, neurologically intact aft er a prolonged hospital stay complicated by acute respiratory distress syndrome, prolonged delirium, clostridium diffi cile colitis and acute tubular necrosis due to rhabdomyolysis.In summary, it is important to anticipate life-threatening arrhythmias when managing a severely hypothermic patient and recognize that usual resuscitative measures may fail. Early activation of surgical/trauma protocols to institute appropriate re-warming including CPB/ECMO is vital.

Flecainide toxicity: a presentation to the emergency department with literature review

“…A novel method for stabilising patients is through the initiation of invasive haemodynamic support, although this is restricted to cases where conventional treatment options have been exhausted and cardiovascular compromise remains. ECMO is a temporising measure to allow for cardiac recovery and drug elimination 17. A case report documented the use of ECMO for 26 hours in a patient with a deliberate flecainide overdose, to maintain cardiac output and vital organ perfusion while allowing time for drug metabolism and clearance.…”

Wolff‐Parkinson‐White, Brugada phenocopy, and flecainide toxicity: All in one patient

“…Sodium bicarbonate (NaHCO₃) is commonly used to reverse drug‐induced sodium channel blockade caused by different agents including flecainide . While there are no definitive guidelines for management of severe flecainide intoxication, intravenous fat emulsion (IFE) and extracorporeal membrane oxygenation (ECMO) have been successfully used …”

Three Cases of Cardiac Arrest with Massive Flecainide Intoxication Treated with Extracorporeal Assistance

“…The exact action of IFE is unclear, but the lipophilic properties of IFE seem to neutralize the flecainide's toxicity [10]. Some cases have been described with different approaches resulting in good outcomes, but these need more investigation to validate their efficacy in this setting [11][12][13][14][15]. In addition, due to its micellar action, blood dose tracking is distorted and the American College of Medical Toxicology recommends IFE when there is hemodynamic instability, but not in cardiac arrest patients [16].…”

“…In 2013, Sivalingam et al described VA-ECMO placement in refractory cardiac shock after an OHCA preceded by CPR for 10 min. VA-ECMO was stopped after 24 h with a CPC score of 1 [14]. Finally, in 2015, Reynolds et al described the placement of VA-ECMO after 50 min of CPR.…”