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An Unexpected Etiology of Ventricular Dysrhythmia

Author
Megan Acho, MD
Fellow, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Ian Barbash, MD, MS
Assistant Professor, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh


Case

A 41-year-old man with a history of alcohol and cocaine abuse presented to the emergency department after experiencing an out-of-hospital cardiac arrest while at a party. Cardiopulmonary resuscitation was administered by bystanders and return of spontaneous circulation was achieved. He was intubated in the field. On arrival to the emergency room, he was bradycardic with a heart rate of 36, PR interval of 214 milliseconds, QRS of 148 milliseconds, and a corrected QT interval of 600 milliseconds. Vital signs were also noteworthy for hypotension to the 90s/30s mmHg. Urine toxicology was negative for cocaine and tricyclic antidepressants. He was admitted to the Medical Intensive Care Unit.

The patient was started on dopamine, norepinephrine, and isoproterenol infusions. Electrocardiography demonstrated a PR interval of 68 milliseconds, QRS of 186 milliseconds and a corrected QT interval of 641 milliseconds with the following rhythm:

Electrocardiography
His rhythm subsequently degenerated into ventricular tachycardia.

Question

  1. An excessive dose of which of the following is the most likely etiology of this patient's abnormal electrocardiographic findings?

    A. Cocaine
    B. Loperamide
    C. Metoprolol
    D. Midazolam
    E. Nortriptyline

  2. In addition to initiating Advanced Cardiac Life Support (ACLS) protocol, which of the following is the best treatment at this time?

    A. Administer intravenous flecainide
    B. Initiate transvenous pacing
    C. Administer intravenous sodium bicarbonate
    D. Administer intravenous beta blockade

Answer