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Bicarbonate therapy for unstable propafenone-induced wide complex tachycardia

Published online by Cambridge University Press:  21 May 2015

Jeff Brubacher
Jeff Brubacher*
Affiliation:
Vancouver General Hospital, Vancouver, BC, and Division of Emergency Medicine, Department of Surgery, University of British Columbia, Vancouver, BC, and British Columbia Drug and Poison Information, Vancouver, BC
*
[email protected]

Abstract

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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.

Keywords

propafenonesodium channel blockersanti-arrhythmia agentsadverse effectsatrial fibrillation
Type
Pharmacotherapy • Pharmacothérapie
Information
Canadian Journal of Emergency Medicine , Volume 6 , Issue 5 , September 2004 , pp. 349 - 356
Copyright
Copyright © Canadian Association of Emergency Physicians 2004

References

1.Benjamin, EJ, Wolf, PA, D’Agostino, RB, Silbershatz, H, Kannel, WB, Levy, D.Impact of atrial fibrillation on the risk of death: the framingham heart study. Circulation 1998;98(10):946–52.CrossRefGoogle ScholarPubMed
2.Falk, RH.Atrial fibrillation. N Engl J Med 2001;344(14):1067–78.CrossRefGoogle ScholarPubMed
3.Schreck, DM, Rivera, AR, Tricarico, VJ.Emergency management of atrial fibrillation and flutter: intravenous diltiazem versus intravenous digoxin. Ann Emerg Med 1997;29(1):135–40.Google Scholar
4.Segal, JB, McNamara, RL, Miller, MR, Kim, N, Goodman, SN, Powe, NR, et al. The evidence regarding the drugs used for ventricular rate control. J Fam Pract 2000;49(1):47–59.Google Scholar
5.Crozier, I, Melton, I, Pearson, S.Management of atrial fibrillation in the emergency department. Intern Med J 2003;33(4):182–5.Google Scholar
6.Stoddard, MF.Risk of thromboembolism in new onset or transient atrial fibrillation. Progr Cardiovasc Dis 1996;39(1):69–80.Google Scholar
7.Stoddard, MF, Dawkins, PR, Prince, CR, Ammash, NM.Left atrial appendage thrombus is not uncommon in patients with acute atrial fibrillation and a recent embolic event: a trans-esophageal echocardiographic study. J Am Coll Cardiol 1995;25 (2):452–9.CrossRefGoogle ScholarPubMed
8.Stoddard, MF, Singh, P, Dawn, B, Longaker, RA.Left atrial thrombus predicts transient ischemic attack in patients with atrial fibrillation. Am Heart J 2003;145(4):676–82.Google Scholar
9.Van Gelder, IC, Hagens, VE, Bosker, HA, Kingma, JH, Kamp, O, Kingma, T, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 2002;347(23):1834–40.Google Scholar
10.Wyse, DG, Waldo, AL, DiMarco, JP, Domanski, MJ, Rosenberg, Y, Schron, EB, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl JMed 2002;347 (23):1825–33.Google Scholar
11.Falk, RH.Managment of atrial fibrillation — radical reform or modest modification? N Engl J Med 2002;347(23):1883–4.Google Scholar
12.Hughes, C, Sunderji, R, Gin, K.Oral propafenone for rapid conversion of recent onset atrial fibrillation — A review. Can J Cardiol 1997;13(9):839–42.Google ScholarPubMed
13.Khan, IA.Single oral loading dose of propafenone for pharmacological cardioversion of recent-onset atrial fibrillation. J Am Coll Cardiol 2001;37(2):542–7.Google Scholar
14.Kowey, PR, Marinchak, RA, Rials, SJ, Bharucha, DB.Classification and pharmacology of antiarrhythmic drugs. Am Heart J 2000;140(1):12–20.Google Scholar
15.Kolecki, PF, Curry, SC.Poisoning by sodium channel blocking agents. Crit Care Clin 1997;13(4):829–48.CrossRefGoogle ScholarPubMed
16.Koppel, C, Oberdisse, U, Heinemeyer, G.Clinical course and outcome in class IC antiarrhythmic overdose. J Toxicol Clin Toxicol 1990;28(4):433–44.Google Scholar
17.Henry, JA, Cassidy, SL.Membrane stabilising activity: a major cause of fatal poisoning. Lancet 1986;1:1414–7.CrossRefGoogle Scholar
18.McHugh, TP, Perina, DG.Propafenone ingestion. Ann Emerg Med 1987;16(4):437–40.CrossRefGoogle ScholarPubMed
19.Molia, AC, Tholon, JP, Lamiable, DL, Trenque, TC.Unintentional pediatric overdose of propafenone. Ann Pharmacotherapy 2003; 37(7–8):1147–8.Google Scholar
20.Sadeg, N, Richecoeur, J, Dumontet, M.[Propafenone poisoning]. Therapie 2003;58(4):381–3; discussion 387.CrossRefGoogle ScholarPubMed
21.Maxeiner, H, Klug, E.Lethal suicidal intoxication with propafenone, after a history of self-inflicted injuries. Forensic Sci Int 1997;89(1–2):27–32.Google Scholar
22.Eray, O, Fowler, J.Severe propafenone poisoning responded to temporary internal pacemaker. Vet Hum Toxicol 2000;42 (5):289.Google Scholar
23.Fonck, K, Haenebalcke, C, Hemeryck, A, Belpaire, F, Jordaens, L, Calle, P, et al. ECG changes and plasma concentrations of propafenone and its metabolites in a case of severe poisoning. J Toxicol Clin Toxicol 1998;36(3):247–51.CrossRefGoogle Scholar
24.Kerns, W 2nd, English, B, Ford, M.Propafenone overdose. Ann Emerg Med 1994;24(1):98–103.Google Scholar
25.Rambourg-Schepens, MO, Grossenbacher, F, Buffet, M, Lamiable, D.Recurrent convulsions and cardiac conduction disturbances after propafenone overdose. Vet Hum Toxicol 1999;41 (3):153–4.Google Scholar
26.Friocourt, P, Martin, C, Lozac’h, L.[Self-poisoning with propafenone. Apropos of a case]. [French]. Annales de Cardiologie et d Angeiologie 1988;37:(3)133–6.Google Scholar
27.Olm, M, Jimenez, MJ, Munne, P.[Efficacy of intravenous methoxamine in propafenone poisoning]. Presse Med 1989;18 (22):1124.Google Scholar
28.Palette, C, Maroun, N, Gaulier, JM, Priolet, B, Lachatre, G, Bedos, JP, et al. [Fatal poisoning with propafenone: a case report documented with blood concentration levels]. Therapie 2003;58(4): 384–6; discussion 387.CrossRefGoogle ScholarPubMed
29.Cocozzella, D, Curciarello, J, Corallini, O, Olivera, A, Alburquerque, MM, Fraquelli, E, et al. Propafenone hepatotoxicity: report of two new cases. Dig Dis Sci 2003;48(2):354–7.CrossRefGoogle ScholarPubMed
30.Gandolfi, A, Rota, E, Zanghieri, G, Tolomelli, S, Bagnulo, A, Mengoli, M.[Acute cholestatic hepatitis caused by propafenone. Report of a case and review of the literature]. Recenti Prog Med 2001;92(3):197–9.Google ScholarPubMed
31.Grieco, A, Forgione, A, Giorgi, A, Miele, L, Gasbarrini, G.Propafenone-related cholestatic hepatitis in an elderly patient. Ital Heart J 2002;3(7):431–4.Google Scholar
32.Mondardini, A, Pasquino, P, Bernardi, P, Aluffi, E, Tartaglino, B, Mazzucco, G, et al. Propafenone-induced liver injury: report of a case and review of the literature. Gastroenterology 1993;104(5): 1524–6.CrossRefGoogle ScholarPubMed
33.Schuppel, R, Probst, M.Acute cholestatic hepatitis and the sudden rise of the pacing threshold 5 weeks after vvi-pacemaker implantation. J Intern Med 1994;236(3):353–6.CrossRefGoogle ScholarPubMed
34.Spinler, SA, Elder, CA, Kindwall, KE.Propafenone-induced liver injury. Ann Pharmacotherapy 1992;26(7–8):926–8.Google Scholar
35.Hill, MR, Gotz, VP, Harman, E, McLeod, I, Hendeles, L.Evaluation of the asthmogenicity of propafenone, a new antiarrhythmic drug. Comparison of spirometry with methacholine challenge. Chest 1986;90(5):698–702.CrossRefGoogle ScholarPubMed
36.Olm, M, Munne, P, Jimenez, MJ.Severe reactive airways disease induced by propafenone. Chest 1989;95(6):1366–7.Google Scholar
37.Miwa, LJ, Jolson, HM.Propafenone associated agranulocytosis. Pacing Clin Electrophysiol 1992;15(4 Pt 1):387–90.Google Scholar
38.Zeng, ZQ, Zhu, L.[Hemolytic reaction resulting from propafenone administration.] Zhonghua Nei Ke Za Zhi 1991;30 (4):217–8.Google Scholar
39.O’Rourke, DJ, Palac, RT, Holzberger, PT, Gerling, BR, Greenberg, ML.Propafenone-induced drug fever in the absence of agranulocytosis. Clin Cardiol 1997;20(7):662–4.Google Scholar
40.Odeh, M, Seligmann, H, Oliven, A.Propafenone-induced ataxia: report of three cases. Am J Med Sci 2000;320(2):151–3.Google Scholar
41.Nathan, AW, Bexton, RS, Hellestrand, KJ, Camm, AJ.Fatal ventricular tachycardia in association with propafenone, a new class IC antiarrhythmic agent. Postgrad Med J 1984;60:155–6.Google Scholar
42.Buss, J, Neuss, H, Bilgin, Y, Schlepper, M.Malignant ventricular tachyarrhythmias in association with propafenone treatment. Eur Heart J 1985;6:424–8.Google Scholar
43.Camous, JP, Ichai, C, Meyer, P, Gibelin, P, Baudouy, M, Varenne, A, et al. [Treatment of poisoning caused by new anti-arrhythmia agents (cibenzoline, flecainide and propafenone)]. Presse Med 1987;16(41):2076.Google ScholarPubMed
44.De Jaegere, P, Huyghens, L, Dewilde, P.Sustained ventricular tachycardia occurring during propafenone therapy. Acta Cardiol 1987;42(3):207–12.Google Scholar
45.Millar, RN, Lawrenson, JB, Milne, DA.Normal left ventricular function does not protect against propafenone-induced incessant ventricular tachycardia. S Afr Med J 1993;83(4):256–9.Google Scholar
46.Moroe, K, Annoura, M, Matsuo, K, Yamanouchi, Y, Kumagai, K, Arakawa, K.Proarrhythmic effects of classic drugs. Clin Ther 1993;15(3):559–66.Google Scholar
47.Rosengarten, M, Brooks, R.Torsade de pointes ventricular tachycardia in a hypothyroid patient treated with propafenone. Ca J Cardiol 1987;3(5):234–9.Google Scholar
48.Scanu, P, Grollier, G, Guilleman, D, Iselin, M, Bustany, P, Hurpe, JM, et al. Malignant ventricular tachycardia during propafenone treatment in a child with junctional automatic tachycardia: effectiveness of intravenous molar sodium lactate. Pacing Clin Electrophysiol 1991;14(5 Pt 1):783–6.Google Scholar
49.Bauman, JL, Gallastegui, J, Tanenbaum, SR, Hariman, RJ.Flecainide-induced sustained ventricular tachycardia successfully treated with lidocaine. Chest 1987;92(3):573–5.Google Scholar
50.Lau, W, Newman, D, Dorian, P.Can antiarrhythmic agents be selected based on mechanism of action? Drugs 2000;60(6):1315–28.Google Scholar
51.Siegers, A, Board, PN.Amiodarone used in successful resuscitation after near-fatal flecainide overdose. Resuscitation 2002;53 (1):105–8.Google Scholar
52.Winecoff, AP, Hariman, RJ, Grawe, JJ, Wang, Y, Bauman, JL.Reversal of the electrocardiographic effects of cocaine by lido-caine. Part 1. Comparison with sodium bicarbonate and quini-dine. Pharmacotherapy 1994;14(6):698–703.Google Scholar
53.Bou-Abboud, E, Nattel, S.Relative role of alkalosis and sodium ions in reversal of class I antiarrhythmic drug-induced sodium channel blockade by sodium bicarbonate. Circulation 1996;94 (8):1954–61.Google Scholar
54.Goldman, MJ, Mowry, JB, Kirk, MA.Sodium bicarbonate to correct widened QRS in a case of flecainide overdose. J Emerg Med 1997;15(2):183–6.Google Scholar
55.Kerns, W 2nd, Garvey, L, Owens, J.Cocaine-induced wide complex dysrhythmia. J Emerg Med 1997;15(3):321–9.Google Scholar
56.Keyler, DE, Pentel, PR.Hypertonic sodium bicarbonate partially reverses QRS prolongation due to flecainide in rats. Life Sci 1989;45(17):1575–80.Google Scholar
57.Parker, RB, Perry, GY, Horan, LG, Flowers, NC.Comparative effects of sodium bicarbonate and sodium chloride on reversing cocaine-induced changes in the electrocardiogram. J Cardiovasc Pharmacol 1999;34(6):864–9.Google Scholar
58.Salerno, DM, Murakami, MM, Johnston, RB, Keyler, DE, Pentel, PR.Reversal of flecainide-induced ventricular arrhythmia by hypertonic sodium bicarbonate in dogs. Am J Emerg Med 1995; 13(3):285–93.CrossRefGoogle ScholarPubMed
59.Lovecchio, F, Berlin, R, Brubacher, JR, Sholar, JB.Hypertonic sodium bicarbonate in an acute flecainide overdose. Am J Emerg Med 1998;16(5):534–7.Google Scholar
60.Lanquetot, H, Furet, Y, Kerouredan, V, Poitrineau, O, Hubiche, M, Autret, E.[Fatal poisoning caused by the combination propafenone-amitriptyline;apropos of a case.] Agressologie 1988;29(1):39–42.Google Scholar
61.Roden, DM.Antiarhythmic drugs. In: Goodman and Gilman’s The pharmacologic basis of therapeutics. 9th ed. New York: McGraw-Hill; 1996. 839–74.Google Scholar