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First Case of Acute Poisoning with Amiodarone and Flecainide in Attempted Suicide Successfully Managed with Lipid Emulsion Thera

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First Case of Acute Poisoning with Amiodarone and Flecainide in Attempted Suicide Successfully Managed with Lipid Emulsion Thera healthcare Case Report First Case of Acute Poisoning with Amiodarone and Flecainide in Attempted Suicide Successfully Managed with Lipid Emulsion Therapy in the Emergency Department: Case Report and Literature Review Cristina Bologa 1,2, Catalina Lionte 1,2,* , Alexandra Popescu 2, Victorita Sorodoc 1,2 and Laurentiu Sorodoc 1,2 1 Internal Medicine and Clinical Toxicology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; cristina.bologa@umfiasi.ro (C.B.); victorita.sorodoc@umfiasi.ro (V.S.); laurentiu.sorodoc@umfiasi.ro (L.S.) 2 2nd Medical Clinic, “Sf. Spiridon” Emergency Clinical County Hospital, 700111 Iasi, Romania; [email protected] * Correspondence: catalina.lionte@umfiasi.ro or [email protected]; Tel.: +40-742082318 Abstract: Acute antiarrhythmics poisoning represents a challenge in the Emergency Department (ED). These patients often develop malignant arrhythmias in need of exceptional therapeutic measures in the ICU. We report a 47-year-old patient admitted to the ED 5 h after the ingestion of a large dose of amiodarone and flecainide in a suicide attempt. During their ED stay, the patient developed signs of cardiotoxicity evidenced by electrocardiogram and ventricular arrhythmias. The toxicological results showed a level of 4.8 mg/L amiodarone and 2.98 mg/L flecainide. He was successfully treated in the Citation: Bologa, C.; Lionte, C.; ED using a large dose of sodium bicarbonate and lipid emulsion therapy. After hospital admission, Popescu, A.; Sorodoc, V.; Sorodoc, L. First Case of Acute Poisoning with he remained stable, with no need for exceptional therapeutic measures such as mechanical circulatory Amiodarone and Flecainide in support, cardiac pacing or ECMO. We emphasize the importance of an early start of pharmacological Attempted Suicide Successfully therapies in the ED, which might improve the outcome in antiarrhythmic acute poisoning. Managed with Lipid Emulsion Therapy in the Emergency Keywords: suicide; poisoning; amiodarone; flecainide; cardiotoxicity; lipid emulsion therapy; Emer- Department: Case Report and gency Department Literature Review. Healthcare 2021, 9, 671. https://doi.org/10.3390/ healthcare9060671 1. Introduction Academic Editor: Pedram Sendi Antiarrhythmic drugs are widely used in clinical practice. Antiarrhythmic drug therapy carries an understood risk for toxic side effects, even with therapeutic doses. Received: 13 May 2021 Flecainide induces ventricular tachycardia (VT), which is often resistant to direct current Accepted: 1 June 2021 Published: 4 June 2021 cardioversion because the intense sodium channel blockade increases the voltage threshold for cellular depolarization [1]. Amiodarone prolongs the QT interval, causes conduction Publisher’s Note: MDPI stays neutral disturbances and VT. Amiodarone is also related to exacerbations of VT and an increased with regard to jurisdictional claims in defibrillation threshold [2,3]. A combination of these two antiarrhythmics in intentional published maps and institutional affil- overdose could lead to dramatic cardiotoxicity. iations. A review of the literature showed no report of a case with a poisoning including an association of amiodarone and flecainide. We found only two case reports of amiodarone intentional overdose: the first case was of a patient who ingested 8000 mg amiodarone in a suicide attempt, where the blood concentration was 1.1 mg/L, managed with supportive measures; the second case was of a patient with mixed overdose of amiodarone, diltiazem Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. and metoprolol, with a serum level of amiodarone of 2.7 mg/L, in need of intensive care This article is an open access article unit (ICU) therapy [4,5]. In flecainide overdose, there is a need for exceptional therapeutic distributed under the terms and interventions both in the Emergency Department (ED) and ICU [6–9]. conditions of the Creative Commons We report the case of a patient who attempted suicide by ingesting a large dose of amio- Attribution (CC BY) license (https:// darone and flecainide, with an electrocardiogram (ECG) depicting signs of cardiotoxicity creativecommons.org/licenses/by/ and ventricular arrhythmias, which was managed successfully in the ED, after hypertonic 4.0/). sodium bicarbonate administration and initiation of lipid emulsion therapy (LET). Healthcare 2021, 9, 671. https://doi.org/10.3390/healthcare9060671 https://www.mdpi.com/journal/healthcare Healthcare 2021, 9, x 2 of 14 We report the case of a patient who attempted suicide by ingesting a large dose of amiodarone and flecainide, with an electrocardiogram (ECG) depicting signs of cardio- Healthcare 2021, 9, 671 2 of 15 toxicity and ventricular arrhythmias, which was managed successfully in the ED, after hypertonic sodium bicarbonate administration and initiation of lipid emulsion therapy (LET). AfterAfter ED ED admission of of a patient with mixed antiarrhythmic drugs poisoning, ECG monitoring,monitoring, recognition ofof signs signs of of cardiotoxicity cardiotoxicity and and early early initiation initiation of hypertonicof hypertonic sodium so- diumbicarbonate bicarbonate and LET and mayLET improvemay improve the outcome the outcome and avoid and avoid exceptional exceptional therapeutic therapeutic mea- measuressures in the in ICU.the ICU. 2.2. Case Case Presentation Presentation AA 47-year-old 47-year-old patient patient was was admitted admitted to to the the ED ED for for fatigue, fatigue, anxiety, anxiety, headache. headache. The Thepa- patient declared the ingestion of 2000 mg amiodarone and 5000 mg flecainide in a suicide tient declared the ingestion of 2000 mg amiodarone and 5000 mg flecainide in a suicide attempt, 5 h prior to ED arrival. Glasgow Coma Scale score was 12, BP 110/80 mmHg, attempt, 5 h prior to ED arrival. Glasgow Coma Scale score was 12, BP 110/80 mmHg, heart rate 71 bpm. heart rate 71 bpm. The patient had an episode of atrial fibrillation converted to sinus rhythm with The patient had an episode of atrial fibrillation converted to sinus rhythm with flecainide two years before, had been subjected to a radiofrequency catheter ablation with flecainide two years before, had been subjected to a radiofrequency catheter ablation with the isolation of the pulmonary veins one year earlier for atrial flutter, with successful the isolation of the pulmonary veins one year earlier for atrial flutter, with successful res- restoration and maintenance of sinus rhythm, and took amiodarone 100 mg daily since. toration and maintenance of sinus rhythm, and took amiodarone 100 mg daily since. He He had a history of depression, but he had quit the specific therapy for several months. had a history of depression, but he had quit the specific therapy for several months. Dur- During transportation, the monitor recorded a sinus rhythm of 86/min, a prolonged PR ing transportation, the monitor recorded a sinus rhythm of 86/min, a prolonged PR inter- interval 240 msec with a normal QRS complex (Figure1). He was first admitted to a vallocal 240 hospital, msec with where a normal he received QRS complex an initial (Figure dose of1). activated He was first charcoal admitted and to normal a local saline hos- pital,solution, where then he referred received to an our initial ED for dose specific of activated therapy. charcoal The ECG and recorded normal upon saline first solution, medical thencontact referred showed to our an irregular ED for specific rhythm, therapy. a first-degree The ECG atrioventricular recorded upon (AV) first block medical with contact a wide showedQRS complex. an irregular rhythm, a first-degree atrioventricular (AV) block with a wide QRS complex. (a) (b) Figure 1. (a) Monitor recordingrecording duringduring transportation transportation to to the the first first hospital hospital shows showsa sinus a sinus rhythm rhythm of 86/min,of 86/min, a prolonged a prolonged PR PRinterval interval of 240of 240 msec msec with with normal normal QRS QRS complex complex of 110of 110 msec.; msec.; (b) 12-lead(b) 12-lead ECG ECG recorded recorded in the in the local local hospital, hospital, 3 h 3 after h after the the ingestion of drugs, shows irregular sinus rhythm of 71/min, with a prolonged PR interval of 280 msec, a wide QRS ingestion of drugs, shows irregular sinus rhythm of 71/min, with a prolonged PR interval of 280 msec, a wide QRS complex complex of 160 msec, and slightly prolonged QTc interval of 479 msec. of 160 msec, and slightly prolonged QTc interval of 479 msec. UponUpon admission toto ourour ED,ED, arterialarterial blood blood gases gases (ABG), (ABG), liver liver and and kidney kidney panel, panel, alkaline alka- linephosphatase phosphatase and and LDH LDH were were normal, normal, WBC WBC 12.000/mmc, 12.000/mmc, blood blood glucose glucose 170 170 mg/dL, mg/dL, and urineurine toxicological toxicological screen screen negative. negative. Cardiac Cardiac ultrasound ultrasound excluded excluded a structural a structural disease. disease. Car- diacCardiac biomarkers biomarkers were were within within normal normal range. range. GivenGiven the the large large dose dose of of antiarrhythmics antiarrhythmics ingested, ingested, we we began began sodium sodium bicarbonate bicarbonate 8.4% 8.4% administration,administration, up to 500 mEq/L (Table (Table 11).). A second ABG showed pHpH 7.537.53 andand aa sodiumsodium concentrationconcentration >150 mEq/L. mEq/L. We We initially initially administered administered 1 g/kg activated activated charcoal, charcoal, followed byby 25 25 g g every every
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