Propranolol
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Heart arrest treated with enoximone: 2 case reports Two patients developed heart arrest, one during treatment with propranolol [therapeutic indication not stated], and the other following an intentional overdose of propranolol. A 38-year-old woman, who had a history of severe systemic sclerosis with pulmonary fibrosis and heart failure, presented with sudden-onset palpitations, dizziness, and dyspnoea. Her ECG on admission showed supraventricular tachycardia (170 beats/min); her BP was 100/60mm Hg. She received IV adenosine, and a subsequent IV amiodarone bolus and infusion. After 15 minutes, she had not improved so she received IV propranolol 1.5mg. Immediately after, her rhythm altered from supraventricular tachycardia to sinus bradycardia (35 beats/min). She became apnoeic and unresponsive; her carotid pulse was absent. Her amiodarone infusion was stopped, and she started receiving CPR. After 15 minutes of advanced life support and epinephrine [adrenaline], her heart arrest persisted; she remained in sinus bradycardia. She was given IV enoximone 100mg and, 3 minutes later, her spontaneous circulation recovered. Her BP was 150/110mm Hg. An ECG showed she had a normal sinus rhythm (130 beats/min). She was transferred, unconscious, to the ICU and she received mechanical ventilation. Over the next hour, her haemodynamic parameters normalised and stabilised. She regained consciousness and was subsequently discharged with no neurological sequelae. A 50-year-old man ingested propranolol 1600mg, with hydrochloric acid and oxazepam. He was brought to the ED 40 minutes later, with hypotension (BP 90/60mm Hg), and a HR of 45 beats/min [time to reaction onset not stated]. He received fluids, oxygen, flumazenil, and a dopamine infusion. During transfer to another hospital, his condition deteriorated and, on arrival, he had a heart arrest. An ECG showed no carotid pulse and bradycardia (40 beats/min). He was intubated and began receiving CPR. He received epinephrine, then atropine; subsequent epinephrine doses were given every 3 minutes. Blood gas analysis showed metabolic acidosis (pH 6.91), and he received sodium bicarbonate. He received fluids for possible hypovolaemia. After 30 minutes of advanced life support, he remained in heart arrest, confirmed on ECG. He received IV enoximone 100mg followed by an infusion of 5 µg/kg/min. After a further 5 minutes of advanced life support, the monitor showed some narrow QRS complexes, and his carotid pulse was palpable. Immediately after, he regained a normal sinus rhythm (80 beats/min). His BP was 80/60mm Hg. He was transferred to the ICU, in shock, with a BP of 80/40mm Hg and a cardiac index of 2.3 L/min/m2; he received prolonged infusions of enoximone, dopamine, and norepinephrine [noradrenaline]. Enoximone 5 µg/kg/min was continued for the following 96 hours; his dopamine and norepinephrine were stopped on day 6. His cardiac situation was subsequently stable, and he was later discharged with no neurological problems. Author comment: "In case 1, cardiac arrest was probably
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