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• W4387254196 abstract "SESSION TITLE: Cardiovascular Disease Case Report Posters 7 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Flecainide is a Class IC anti-arrhythmic drug with a narrow therapeutic index. Toxicity is rare but mortality is high if not recognized earlier. Flecainide blocks the sodium channels, slows upstroke of cardiac action potential, and reduces excitability with greatest effect on His-Purkinje and ventricular myocardium thereby decreasing contractility and ejection fraction. CASE PRESENTATION: A 61-year-old- female with past medical history of atrial fibrillation status post ablation on Flecainide 100 mg twice daily, not on anticoagulation secondary to history of subarachnoid hemorrhage and frequent falls presents to Emergency Department (ED) with generalized weakness for 2 days. The patient's heart rate was 32 and blood pressure was 86/42 mmHg.She had an episode of witnessed seizure in ED and was found to have hyponatremia with sodium of 120 mEq. The seizure attack was aborted after 60 seconds post 4 mg of intravenous (IV) lorazepam and hypertonic saline was initiated. Metabolic panel was also notable for acute kidney injury (AKI) with creatinine of 2.33. Electrocardiogram (EKG) demonstrated junctional bradycardia with heart rate 35/min. She received 2mg of IV Atropine. Transcutaneous pacing was attempted, however unsuccessful due to poor capture. Blood pressure and heart rate improved after initiating peripheral norepinephrine. In the setting of new AKI, she received IV sodium bicarbonate bolus and was started on infusion due to concern of flecainide toxicity. Isoproterenol was added after consulting Cardiology. Post intervention EKG showed right bundle branch block (RBBB), QTc interval of 697 ms and QRS duration of 174 ms. Sodium bicarbonate infusion was discontinued on the second day and Norepinephrine and Isoproterenol was weaned off on third day after returning to normal sinus rhythm and heart rate. Flecainide levels were elevated to 1.5 (Normal therapeutic index is 0.2 to 1) and resulted after 5 days. DISCUSSION: Flecainide toxicity is primarily dependent on recognizing the EKG pattern and clinical findings as serum drug levels takes days to weeks. QRS duration < 200 ms is associated with RBBB, likely has P waves and experience rapid recovery. QRS duration > 200 ms likely has EKG changes of Left bundle branch block, absent P waves with need of mechanical ventilation and increased mortality. Sodium bicarbonate is the first line of treatment as it reverses sodium blockade and narrows QRS and manages cardiovascular instability. Lipid emulsion has been used in some case reports as an adjunct as flecainide is lipid soluble. Extracorporeal membrane oxygenation (ECMO) is considered for resuscitation if pharmacological intervention fails. ECMO maintains cardiac output and perfusion while helping with medication metabolism and clearance. CONCLUSIONS: Flecainide Toxicity should be considered in patients presenting with tachyarrhythmia or bradyarrhythmia, especially in the setting of AKI. Renal parameters should be monitored periodically. If toxicity is suspected, we recommend treating it with sodium bicarbonate infusion along with vasopressors if required. REFERENCE #1: Ghataoura R, Patil S. Flecainide toxicity: a presentation to the emergency department with literature review. BMJ Case Rep. 2020;13(2):e232691. REFERENCE #2: Khatiwada P, Clark L, Khunger A, Rijal BB, Ritter J. A case report of flecainide toxicity with review of literature. Cureus. 2022;14(2):e22261. REFERENCE #3: Valentino MA, Panakos A, Ragupathi L, Williams J, Pavri BB. Flecainide toxicity: a case report and systematic review of its electrocardiographic patterns and management. Cardiovasc Toxicol. 2017;17(3):260-266. DISCLOSURES: No relevant relationships by Omar Al Wahadneh No relevant relationships by Talha Bin Farooq No relevant relationships by Jeel Gala No relevant relationships by Amogh Nadkarni No relevant relationships by Danish Thameem" @default.
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• W4387254196 date "2023-10-01" @default.
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• W4387254196 title "FLECAINIDE TOXICITY IN SETTING OF ACUTE KIDNEY INJURY" @default.
• W4387254196 doi "https://doi.org/10.1016/j.chest.2023.07.388" @default.
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