Propafenone-induced cardiac arrest: full recovery with insulin, is it possible?

A case of lethal suicidal intoxication with propafenone and diazepam

Diazepam poisoning is a common emergency situation, but propafenone poisoning is relatively rare. We reported a case of propafenone poisoning combined with diazepam. An 18-year-old female patient was admitted to our hospital with an overdose of oral propafenone and diazepam. The patient was treated with medication that proved to be useful, but the sinus rhythm could not be recovered, and cardiac arrest occurred. A bipolar temporary pacemaker and extracorporeal membrane oxygenation (ECMO) were installed. However, even with multiple electrode positions, effective capture could not be achieved. The patient eventually died. We should be alert to the possibility of co-poisoning.

Propafenone Poisoning of a Female Adolescent After a Suicide Attempt

Propafenone is an antiarrhythmic agent for the management of ventricular and supraventricular tachycardia and atrial fibrillation. Propafenone poisoning is rare but may be life-threatening due to drug-induced arrhythmias. Electrocardiographic changes in PR, QRS, and QT intervals have been recorded. We present a case of a 15-year-old female adolescent who developed arrhythmias and convulsions due to propafenone intoxication, in an attempt to commit suicide. The outcome of the case was a full recovery from the arrhythmias and the seizures. The aim of this article is to highlight the possibility of a lethal intoxication by a common antiarrhythmic drug. Our case aims to present our therapeutic strategy that relies mainly on close monitoring of patients and cardiac output support.

Propafenone and propranolol dual toxicity

Propranolol is a highly lipid-soluble beta-receptor antagonist and propafenone is a potent class 1c anti-arrhythmic agent with strong Na-channel blockade effect. We describe a novel case of dual overdose of propafenone and propranolol resulting in hypotension, generalized seizures, and reduced level of consciousness that was successfully treated. A 52-year-old female ingested 500 mg of propranolol and 1.5 g of propafenone. The patient was brought to the emergency department (ED) and exhibited signs of systemic toxicity and reduced level of consciousness. The patient was treated as a case of combined β-blocker and propafenone toxicity using high dose insulin, NaHCO3, glucagon, atropine, and dopamine. She started improving and becoming more alert, with subsequent ECGs revealing normal sinus rhythm. The patient was discharged 4 days later. We believe that early administration of NaHCO3 should be administered in patients exhibiting signs of Na-channel blockade.

Pediatric extracorporeal cardiopulmonary resuscitation settled in an emergency department for a propafenone intentional intoxication

The use of drugs in suicide attempts is becoming more and more frequent among adolescents. Intentional intoxication with propafenone is very rare and mainly reported in adults associated with other drugs. The therapeutic approach is symptomatic, since there is no specific antidote for propafenone. We present a pediatric case of intentional ingestion of 1.8 g of propafenone that caused refractory cardiogenic shock. The patient was successfully rescued with extracorporeal cardiopulmonary resuscitation in the emergency department of a secondary level peripheral hospital.

Full recovery after prolonged resuscitation from cardiac arrest due to propafenone intoxication: A case report

RATIONALE

The prognosis of cardiac arrest (CA) induced by propafenone intoxication was thought to be very poor. The maximal duration of cardiopulmonary resuscitation (CPR) for propafenone induced CA is unknown.

PATIENT CONCERNS

We describe a case that was successfully resuscitated after prolonged CPR (totaling 340 minutes during one hospital visit) for propafenone intoxication without subsequent neurological sequela.

DIAGNOSES

A previously healthy 36-year-old female who developed multiple and prolonged CAs after consuming 98 tablets of 50mg propafenone. The CPR duration of this case, to the best of our knowledge, is the longest of all existing propafenone-induced CPR events to still have full recovery. We also analyse the contributing factors to this successful CPR.

INTERVENTIONS

Sodium bicarbonate, inotropic drugs and pacemaker application did not prevent the occurrence of CA. A full recovery was eventually achieved after prolonged CPR with a mechanical CPR device, blood purification and other aggressive supportive treatments.

OUTCOMES

Full recovery without neurological sequela.

LESSONS

Prolonged CPR including the application of mechanical CPR devices should be considered in propafenone-related CA, especially in young patients without significant comorbidities and delayed resuscitation.

Successful treatment of propafenone-induced cardiac arrest by calcium gluconate

Propafenone is prescribed for the control of cardiac ventricular arrhythmias. Poisoning from propafenone intoxication is rare, but the survival rate of patients is low. We present a case of a 37-year-old man who developed cardiac arrest due to propafenone intoxication. Cardiopulmonary resuscitation, plasmapheresis, and other medical treatments had no effect on cardiac arrest. After repeated administrations of calcium gluconate, the patient achieved a full recovery. To the best of our knowledge, this is the first case report in which a full recovery from cardiac arrest was achieved by administration of calcium gluconate. We recommend that for patients poisoned by propafenone, close monitoring for decreased blood calcium is important.

Successful Treatment of Propafenone Intoxication With Intravenous Lipid Emulsion

Severe cardiac effects, including cardiac arrest, are a rare complication of high-dose propafenone intake. Among patients who experience cardiac arrest, the survival rate is low. This report presents the case of a young female patient who developed cardiac arrest linked to propafenone intake. While spontaneous circulation was restored with cardiopulmonary resuscitation, vital signs did not recover despite supportive treatment. However, after the administration of intravenous lipid emulsion (ILE), vital signs and cardiac functions resolved and the patient survived. This case is the second to describe the successful use of ILE for propafenone intoxication. However, as all of the findings of this patient were clearly linked to propafenone, we believe the benefits of ILE were more clearly defined in this case than in the other.

Comparison of the therapeutic effect between sodium bicarbonate and insulin on acute propafenone toxicity

PURPOSE

Unlike other sodium-channel-blocking antiarrhythmic agents, propafenone has β-blocking effects and calcium-channel-blocking effects. Yi et al recently studied insulin's treatment effect on acute propafenone toxicity in rats. However, because the degree of effectiveness of insulin compared to the previously known antidote sodium bicarbonate (NaHCO3) was not studied, the 2 treatment methods were compared for propafenone intoxication in rats.

METHODS

Rats received intravenous propafenone (36 mg/[kg h]) for 12 minutes. After the induction of toxicity, rats (n = 10 per group) received normal saline solution (NSS), NaHCO3, or insulin with glucose as treatment. Animals in the NSS, NaHCO3, and Insulin groups received an intravenous infusion of 36 mg/(kg h) propafenone until death occurred. For each animal, the mean arterial pressure (MAP, heart rate, PR interval, QRS duration, total hemoglobin, sodium, potassium, potential of hydrogen, bicarbonate, glucose, lactate, and central venous oxygen saturation (Scvo2) were measured and compared among the groups.

RESULTS

Survival of the Insulin group was greater than that of the NSS group by log-rank test (P = .021). Sodium bicarbonate prevented the decline of MAP for 55 minutes. In comparison, insulin prevented the decline of MAP and heart rate, and the elongation of the PR interval and QRS duration for 55 minutes (P < .05). Propafenone toxicity led to decreased Ca(2+), potential of hydrogen, and Scvo2 and increased lactate levels. Insulin prevented the decrease of Ca(2+) and Scvo2, whereas NaHCO3 prevented the increase in lactate.

CONCLUSION

Insulin treatment was more effective than NaHCO3 on acute propafenone toxicity in rat. Therefore, when propafenone-induced cardiotoxicity occurs, which is unresponsive to current treatment methods, glucose-insulin infusion may be considered.