Successful treatment of flecainide overdose with sustained mechanical circulatory support

Ms. A is a 33-year-old woman with a history of depression and polysubstance use disorder who presented to our hospital after transfer from another facility’s emergency department after an intentional flecainide overdose. Her spouse heard a “thud” at approximately 5 AM on the day of admission. He found her unconscious after she had ingested 12 tablets of 150-mg flecainide originally prescribed to him. She was taken to another facility, where she was found to be in a wide complex rhythm with a heart rate of 63 (Figure 1) and blood pressure of 69/29. She was given 1 L normal saline, started on 2 μg/kg/min of dobutamine, and electively intubated for airway protection in the setting of altered mental status. Promptly after intubation, she developed pulseless ventricular tachycardia (VT), which necessitated initiation of advanced cardiac life support. During this process, she received 11 ampules of sodium bicarbonate, was started on intravenous (IV) isotonic sodium bicarbonate at 150 cc/h, and given a 500-cc bolus of IV fat emulsion. At this point, return of spontaneous circulation was obtained, and the dobutamine infusion was stopped. On arrival to our hospital, the patient was noted to be in an irregular, wide complex tachycardia; otherwise her physical examination was unremarkable. Result of laboratory studies were notable for Na 160, K 3.0, HCO3 50, Cr 0.78, and iCal 0.77. Her blood gas values were pH 7.71, PaCO2 48, and PaO2 166 on 100% FiO2. During the early part of her course, she received another 11 ampules of bicarbonate, and her bicarbonate gtt was uptitrated to 300 cc/h. With this treatment, her ECG stabilized to a junctional rhythm at 82 bpm with intermittent runs of hemodynamically stable, slow VT.