SplintER Series: One Big Bounce
Figure 1. AP and Lateral x-rays of the right knee. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 16139
Beta-Blockers for Inhalant-Induced Ventricular Dysrhythmias
Background
There are a few unique scenarios when beta-blockers may be indicated for patients in cardiac arrest. Use of esmolol for refractory ventricular fibrillation was summarized in a 2016 PharmERToxGuy post with an accompanying infographic. Another potential use for beta-blockers is in the rare case of a patient with inhalant-induced ventricular dysrhythmias. The term ‘sudden sniffing death’ refers to acute cardiotoxicity associated with inhaling hydrocarbons. Check out this ACMT Toxicology Visual Pearl for more information about the background and diagnosis of inhalant abuse.
It is thought that inhalants causes myocardial sensitization via changes in various cardiac channels (e.g., sodium channels, potassium channels, calcium channels, or gap junctions) leading to prolonged repolarization and conduction [1, 2]. Additionally, chronic inhalant use can lead to structural heart damage. When the above alterations are combined with a sudden increase in catecholamines (e.g., exercise, caught sniffing), a dysrhythmia can develop which is often fatal [2-4].
Evidence
There are no case reports to support the use beta-blockers to treat inhalant-induced dysrhythmias. However, the case reports below include patients that ingested various hydrocarbons who developed ventricular dysrhythmias and improved following the initiation of beta-blockers. As the adverse cardiac effects should be similar between inhaled and ingested hydrocarbons, we can potentially extrapolate this data to patients with inhalant-induced dysrhythmias.
| Demographics | Agent(s) Ingested | Cardiac Effects | Interventions | Resolution of dysrhythmia following BB? |
|---|---|---|---|---|
| 39 yo M [5] | Trichloroethylene | pVT/VF arrest | Defibrillation, Propranolol bolus and infusion |
Y |
| 70 yo F [6] | Trichloroethylene | Bigeminy, Junctional rhythm | Esmolol bolus and infusion |
Y |
| 23 yo F [7] | Chloral hydrate | VF arrest | Esmolol bolus and infusion |
Y |
| 27 yo M [8] | Chloral hydrate, Loxapine, Fluoxetine | Stable VT | Propranolol bolus and infusion |
Y |
| 3 yo M [9] | Chloral hydrate | Sinus tachycardia, Bigeminy, Trigeminy, NSVT | Esmolol bolus and infusion |
Y |
| 44 yo M [10] | Chloral hydrate | Stable VT | Propranolol bolus, Labetalol infusion |
Y |
BB=beta-blocker; pVT=polymorphic ventricular tachycardia; VT=ventricular tachycardia; VF=ventricular fibrillation; NSVT=non-sustained ventricular tachycardia
Bottom Line
- Patients presenting to the ED with cardiopulmonary manifestations of inhalant use should have routine electrolytes and an ECG to assess cardiac status
- A quiet environment is important to decrease stimulation and minimize catecholamine surges
- For both stable and non-perfusing dysrhythmias, propranolol or esmolol are reasonable choices to counteract the catecholamine effects, in addition to standard care [5-10]
- Consider avoiding epinephrine and other catecholamines unless necessary, as they may worsen the dysrhythmia
Want to learn more about EM Pharmacology?
Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.
References
- Nelson LS. Toxicologic myocardial sensitization. J Toxicol Clin Toxicol. 2002;40(7):867–79. doi: 10.1081/clt-120016958. PMID: 12507056.
- Tormoehlen LM, Tekulve KJ, Nañagas KA. Hydrocarbon toxicity: A review. Clin Toxicol (Phila). 2014 Jun;52(5):479–89. doi: 10.3109/15563650.2014.923904. PMID: 24911841.
- Bass M. Sudden sniffing death. JAMA. 1970 Jun 22;212(12):2075–9. PMID: 5467774.
- Baydala L. Inhalant abuse. Paediatr Child Health. 2010 Sep;15(7):443–54. doi: 10.1093/pch/15.7.443. PMID: 21886449.
- Gindre G, Le Gall S, Condat P, Bazin JE. [Late ventricular fibrillation after trichloroethylene poisoning]. Ann Fr Anesth Reanim. 1997;16(2):202–3. doi: 10.1016/s0750-7658(97)87204-8. PMID: 9686084.
- Mortiz F, de La Chapelle A, Bauer F, Leroy JP, Goullé JP, Bonmarchand G. Esmolol in the treatment of severe arrhythmia after acute trichloroethylene poisoning. Intensive Care Med. 2000 Feb;26(2):256. doi: 10.1007/s001340050062. PMID: 10784325.
- Shakeer SK, Kalapati B, Al Abri SA, Al Busaidi M. Chloral hydrate overdose survived after cardiac arrest with excellent response to intravenous β-blocker. Oman Med J. 2019 May;34(3):244–8. doi: 10.5001/omj.2019.46. PMID: 31110633.
- Zahedi A, Grant MH, Wong DT. Successful treatment of chloral hydrate cardiac toxicity with propranolol. Am J Emerg Med. 1999 Sep;17(5):490–1. doi: 10.1016/s0735-6757(99)90256-5. PMID: 10496517.
- Nordt SP, Rangan C, Hardmaslani M, Clark RF, Wendler C, Valente M. Pediatric chloral hydrate poisonings and death following outpatient procedural sedation. J Med Toxicol. 2014 Jun;10(2):219–22. doi: 10.1007/s13181-013-0358-z. PMID: 24532346.
- Wong O, Lam T, Fung H. Two cases of chloral hydrate overdose. Hong Kong Journal of Emergency Medicine. 2009 Jul;16(3):161–7. doi: 10.1177/102490790901600307.
SplintER Series: To Immobilize or Not to Immobilize: That is the Question
A patient presents to the Emergency Department after sustaining a twisting knee injury while skiing. She felt a pop and was unable to bear weight afterward secondary to pain and a feeling of instability. Shortly after the injury, she noted increased swelling and pain. On examination, she has a moderate effusion and a positive Lachman test. An x-ray was obtained and is shown above (Image 1. Case courtesy of Mikael Häggström, M.D. – Author info – Reusing images, CC0, via Wikimedia Commons).
SplintER Series: Attack by Bat
30-year-old male presents to the ED with pain over the right shoulder after being assaulted by a bat. The right arm is held in adduction and has a limited range of motion due to pain. An x-ray of the right shoulder was obtained and is shown above (Figure 1. Case courtesy of Dr. Ian Bickle, Radiopaedia.org, rID: 74640).
SplintER Series: The Tooth of the Cervical Spine
80-year-old male patient brought in by ambulance for a witnessed fall. A cervical collar was placed by EMS because of midline neck pain. The patient is neurologically intact. A CT of the cervical spine was obtained and is shown above (Case courtesy of Dr. Talal F M Abdullah, Radiopaedia.org, rID: 58030).
Diagnosis on Sight: Neck Bruising Leads to a Surprise Diagnosis
A 76-year-old female with a history of HTN, TIA, CAD, left CEA, and CKD presented to the emergency department for evaluation of neck bruising and swelling. The patient stated that the night before, she was eating popcorn and choked on a kernel. She states that she coughed to clear her throat and shortly after she developed swelling and bruising to the left side of her neck, which has progressively gotten worse. The patient has a remote history of left carotid endarterectomy and was concerned that her symptoms could be related to the prior surgery. On examination, she had ecchymosis and a hematoma/mass to the left side of her neck without palpable thrill or bruit. A well-healed CEA scar was noted. A CTA of the neck was obtained to determine the source of the ecchymosis/hematoma. What is the diagnosis?
A large neck mass with venous bleeding causing cervical hematoma and ecchymosis.
Explanation:
Image 2. This axial CT angiogram image shows the large left-sided mass with vessels and hemorrhage, which appears to originate from the inferior parotid.
Spontaneous cervical hematoma is an uncommon condition, which can be life-threatening [1]. This first case of spontaneous neck hematoma was described by Capps who observed this condition in a patient with a parathyroid adenoma [2]. Symptoms of neck hematoma include the classic triad named for Capps, which consists of:
- tracheal and esophageal compression
- neck edema and ecchymosis
- tracheal displacement
The condition can be caused by a variety of etiologies including bleeding from masses, underlying coagulopathies, rupture of aneurysms, and infections [1]. CT angiography is typically the test of choice to evaluate the source and extent of bleeding [3]. Large hematomas can lead to airway compromise and require airway and surgical/IR intervention. Smaller, stable hematomas may be observed and can be self-limited. The underlying etiology of the hematoma should be sought and treated.
Case Conclusion:
The hematoma and ecchymosis resolved over time without intervention. The patient underwent ultrasound-guided lymph node biopsy by interventional radiology. Pathology revealed an aggressive double expressor diffuse large B-Cell lymphoma. A pet scan revealed lymphatic involvement on both sides of the diaphragm. The patient was counseled on treatment options including chemotherapy and after discussion palliative radiation was pursued. Ultimately, the patient transitioned to hospice care.
Want more visual stimulation? Check out the Diagnose on Sight archives!
References:
- Cohen O, Yehuda M, Adi M, Lahav Y, Halperin D. Spontaneous neck hematoma in a patient with fibromuscular dysplasia: a case report and a review of the literature. Case Rep Otolaryngol. 2013;2013:352830. PMID: 24191215.
- Zammit M, Siau R, Panarese A. Importance of serum calcium in spontaneous neck haematoma. BMJ Case Rep. 2020 Sep 6;13(9):e237267. PMID: 32895253.
- Haynes J, Arnold KR, Aguirre-Oskins C, Chandra S. Evaluation of neck masses in adults. Am Fam Physician. 2015 May 15;91(10):698-706. PMID: 25978199.
Trick of the Trade: Upsize the IV with the tourniquet infusion technique
There you are, middle of the night and EMS just brought you one of the sickest of the sick: a septic-looking, chronically ill-appearing, frail, and malnourished patient with low blood pressures. They need vascular access for fluids, antibiotics, and possibly even vasopressors. The patient arrives with only a 22-gauge peripheral IV in the hand. You ask for two large bore IVs. But unfortunately, your best nurses and techs can’t find a vein, and their initial attempts are unsuccessful. Do you move right towards ultrasound-guided placement, intraosseous needle, or a central line? What if the patient only needs a fluid bolus, antibiotics, and admission to the floor?
Trick of the Trade: Tourniquet infusion technique
The tourniquet-infusion technique provides a method to increase the chance of a successfully placed larger bore peripheral IV in the volume-depleted patient.
Technique
- Apply a tourniquet to the extremity, proximal to the existing smaller-gauge IV access site.
- Rapidly infuse 50-100 mL of IV fluids, causing distension of the venous system between the IV and the tourniquet. This distension creates a larger target for venous cannulation in volume-depleted patients.
Tourniquet Infusion Technique: After applying a tourniquet and instillation of an IV bolus of fluids through a small distal 22-gauge IV, large veins are more visible for a second larger-bore IV
Discussion
This technique has been described in the literature for decades [1-3], and has been anecdotally successful in clinical practice. Its methodology capitalizes on pre-existing or easily-placed distal small gauge access (i.e., a 22g IV in the hand) as a stepping stone to larger venous cannulation.
Quinn and Sheikh investigated the employment of this technique for 22 adult patients with an acute abdomen who had been referred from the ED in hypovolemic shock. A peripheral IV had not been obtained in any of these patients using standard cannulation methods. By employing this tourniquet-infusion technique to upsize the IVs, they were able to successfully obtain adequate access for resuscitation in 15 of the 22 patients (68%). They noted no complications secondary to this technique. The authors noted that of the other 7 patients in this small study, 2 died and 5 required ultrasound-guided IJ venous line placement. In total, 15 patients were potentially spared unnecessary central venous catheterization. This technique is a simple, quick, and effective way of establishing a more appropriate line for resuscitation of sicker patients [1].
Pearls
- For large-bore antecubital IV placement, consider placing a tourniquet in close proximity and just proximal to the elbow joint.
- Consider the patient’s cardiac and pulmonary history to ensure that an additional fluid bolus is clinically appropriate.
References
- Stein JI. A new technique for obtaining large-bore peripheral intravenous access. Anesthesiology. 2005 Sep;103(3):670. doi: 10.1097/00000542-200509000-00041. PMID: 16130004.
- Quinn LM, Sheikh A. Establishing intravenous access in an emergency situation. Emerg Med J. 2014 Jul;31(7):593. doi: 10.1136/emermed-2012-202106. Epub 2013 Jun 15. PMID: 23771897.
- Williams DJ, Bayliss R, Hinchliffe R. Surgical technique. Intravenous access: obtaining large-bore access in the shocked patient. Ann R Coll Surg Engl. 1997 Nov;79(6):466. PMID: 9422881; PMCID: PMC2502954.