ASSESSMENT & COMPLICATIONS
Arrhythmias may occur with a variety of drugs or toxins (Table 38–1). They may also occur as a result of hypoxia, metabolic acidosis, or electrolyte imbalance (eg, hyperkalemia, hypokalemia, hypomagnesemia, or hypocalcemia), or following exposure to chlorinated solvents or chloral hydrate overdose. Atypical ventricular tachycardia (torsades de pointes) is often associated with drugs that prolong the QT interval.
Table 38–1.Common toxins or drugs causing arrhythmias.1 |Favorite Table|Download (.pdf) Table 38–1. Common toxins or drugs causing arrhythmias.1
|Arrhythmia ||Common Causes |
|Sinus bradycardia ||Beta-blockers, calcium channel blockers, clonidine, digitalis glycosides, organophosphates |
|Atrioventricular block ||Beta-blockers, calcium channel blockers, class Ia antiarrhythmics (including quinidine), carbamazepine, clonidine, digitalis glycosides, lithium |
|Sinus tachycardia ||Beta-agonists (eg, albuterol), amphetamines, anticholinergics, antihistamines, caffeine, cocaine, pseudoephedrine, tricyclic and other antidepressants |
|Wide QRS complex ||Class Ia and class Ic antiarrhythmics, phenothiazines (eg, thioridazine), potassium (hyperkalemia), propranolol, tricyclic antidepressants, bupropion, lamotrigine, diphenhydramine (severe overdose) |
|QT interval prolongation and torsades de pointes ||Arsenic, class Ia and class III antiarrhythmics, citalopram, droperidol, lithium, methadone, pentamidine, sertraline, sotalol, and many other drugs2 |
|Ventricular premature beats and ventricular tachycardia ||Amphetamines, cocaine, ephedrine, caffeine, chlorinated or fluorinated hydrocarbons, digoxin, aconite (found in some Chinese herbal preparations), fluoride, theophylline. QT prolongation can lead to atypical ventricular tachycardia (torsades de pointes). |
Hypoxia or electrolyte imbalance should be sought and treated. If ventricular arrhythmias persist, administer lidocaine or amiodarone at usual antiarrhythmic doses. Note: Wide QRS complex tachycardia in the setting of tricyclic antidepressant overdose (or diphenhydramine or class Ia antiarrhythmic drugs) should be treated with sodium bicarbonate, 50–100 mEq intravenously by bolus infusion. Caution: In such cases, avoid class Ia antiarrhythmic agents (eg, procainamide, disopyramide) and amiodarone, which may aggravate arrhythmias caused by tricyclic antidepressants. Torsades de pointes associated with prolonged QT interval may respond to intravenous magnesium (2 g intravenously over 2 minutes) or overdrive pacing. Treat digitalis-induced arrhythmias with digoxin-specific antibodies.
For tachyarrhythmias induced by chlorinated solvents, chloral hydrate, Freons, or sympathomimetic agents, use propranolol or esmolol (see doses given above in Hypertension section).
et al. Ventricular dysrhythmias associated with poisoning and drug overdose: a 10-year review of statewide poison control center data from California. Am J Cardiovasc Drugs. 2015 Feb;15(1):43–50.
et al. A literature review of the use of sodium bicarbonate for the treatment of QRS widening. J Med Toxicol. 2016 Mar;12(1):121–9.
et al. Start me up! Recurrent ventricular tachydysrhythmias following intentional concentrated caffeine ingestion. Clin Toxicol (Phila). 2015;53(8):830–3.
et al. The cardiac complications of methamphetamines. Heart Lung Circ. 2016 Apr;25(4):325–32.