Antidysrhythmic Toxicity Workup

  • Author: Joshua B Gaither, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Nov 21, 2011
 

Laboratory Studies

Disopyramide - Class IA

Specific laboratory studies to determine disopyramide levels are highly technical and rarely useful for management of toxicity in the ED. Tests include quantitation and identification of disopyramide by chromatography and serum blood levels.

Procainamide - Class IA

Specific laboratory studies to determine levels are highly technical and not useful for management of toxicity in the ED; these include modified enzyme-mediated immunoassay and blood level tests. Procainamide levels are 12-16 mg/mL for mild toxicity and greater than 16 mg/mL for serious toxicity.

Total procainamide and N -acetyl procainamide (NAPA) therapeutic levels are 5-30 mg/mL; junctional tachycardia and conduction defects occur when levels are 42 mg/mL; severe hypotension and lethargy occur at levels greater than 60 mg/mL.

Quinidine - Class IA

Therapeutic levels are 2-6 mg/mL, with toxic levels greater than 8 mg/mL. Levels above 14 mg/mL have been found to cause cardiac toxicity in most patients.

An increase of 50% in the QT interval or QRS complex indicates significant toxicity. Check electrolyte levels.

Lidocaine - Class IB

Tests for lidocaine levels and its metabolite, monoethylglycylxylidide (MEGX), are available.

Effective plasma concentrations are 1.5-5 mg/mL. CNS toxicity is seen with 7 mg/mL. Fatal concentration is greater than 15 mg/mL for an adult and at least 3.8 mg/mL for a child.

Mexiletine and tocainide - Class IB, lidocaine analogs

Blood level tests are available and are cited most frequently in postmortem. Blood level tests are not useful in acute management.

Encainide - Class IC

Blood and urine level tests are available but are not useful in acute management.

Flecainide - Class IC

Blood level tests are available. Most serum ranges are derived from postmortem blood samples. A fluorescence polarization immunoassay also is available.

Propafenone - Class IC

Blood level tests are performed by liquid chromatography.

Ajmaline, cibenzoline, detajmium - Class IC

Cibenzoline blood level tests are performed using liquid chromatography.

Amiodarone - Class III

Obtain appropriate cultures to rule out an infectious etiology if the patient presents with ARDS and/or pulmonary fibrosis. Obtain thyroid function tests, including triiodothyronine (T3) and free T3, because thyroxine (T4), free T4, and thyroid-stimulating hormone (TSH) may remain elevated despite drug withdrawal.

Liver function tests are recommended, even though severe hepatic failure is rare. Torsade de pointes is a common proarrhythmia in older patients and patients with hypertrophic cardiomyopathies, although generally rare with amiodarone.

Bretylium - Class III

Serum concentration measurements are available but do not play a role in acute management of poisoning.

N-acetyl procainamide - Class III

Blood level tests are available but not useful for acute management.

Sotalol, ibutilide, and dofetilide - Class III

Testing for these agents still is under investigation.

Adenosine

No tests are available.

Next

Imaging Studies

  • A chest x-ray (CXR) may be obtained for patients with cardiopulmonary signs and symptoms.
Previous
Next

Other Tests

  • Electrocardiogram (ECG): Measurements of the QT interval and QRS prolongation, together with hypotension, are sensitive for serious poisoning.
Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Joshua B Gaither, MD  Fellow in Emergency Medicine Services, Prehospital and Disaster Care, Denver Health-University of Colorado

Joshua B Gaither, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Carin M Van Gelder, MD  Assistant Professor, Department of Emergency Medicine, Yale University; EMS Medical Director, NHSHP and EMS Physician, SHARP Team; Attending Physician, Emergency Medicine, Yale-New Haven Medical Center

Carin M Van Gelder, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Massachusetts Medical Society, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT  Associate Clinical Professor, Department of Surgery/Emergency Medicine and Toxicology, University of Texas School of Medicine at San Antonio; Medical and Managing Director, South Texas Poison Center

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Clinical Toxicologists, American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, Society for Academic Emergency Medicine, and Texas Medical Association

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Michael J Burns, MD  Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Eileen C Quintana, MD, and Richard Sinert, DO, to the development and writing of this article.

References

  1. Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol (Phila). Dec 2010;48(10):979-1178. [Medline].

  2. Tzivoni D, Banai S, Schuger C, Benhorin J, Keren A, Gottlieb S, et al. Treatment of torsade de pointes with magnesium sulfate. Circulation. Feb 1988;77(2):392-7. [Medline].

  3. ATMAI. Effect of prophylactic amiodarone on mortality after acute myocardial infarction and in congestive heart failure: meta-analysis of individual data from 6500 patients in randomised trials. Amiodarone Trials Meta-Analysis Investigators. Lancet. Nov 15 1997;350(9089):1417-24. [Medline].

  4. Bacaner M, Brietenbucher J, LaBree J. Prevention of ventricular fibrillation, acute myocardial infarction (myocardial necrosis), heart failure, and mortality by bretylium: is ischemic heart disease primarily adrenergic cardiovascular disease?. Am J Ther. Sep-Oct 2004;11(5):366-411. [Medline].

  5. Batcher EL, Tang XC, Singh BN, Singh SN, Reda DJ, Hershman JM. Thyroid function abnormalities during amiodarone therapy for persistent atrial fibrillation. Am J Med. Oct 2007;120(10):880-5. [Medline].

  6. Connolly SJ, Schnell DJ, Page RL, et al. Dose-response relations of azimilide in the management of symptomatic, recurrent, atrial fibrillation. Am J Cardiol. Nov 1 2001;88(9):974-9. [Medline].

  7. Ellenhorn MJ, ed. Antidysrhythmic agents toxicity. In: Ellenhorn's Medical Toxicology - Diagnosis and Treatment of Human Poisoning. 2nd ed. Lippincott Williams & Wilkins; 1997:498-551.

  8. Goldfrank L. Antidysrhythmic agent toxicity. In: Goldfrank's Toxicology Emergencies. McGraw-Hill;1994:715-25.

  9. Hoffman BF. Arrhythmias and antiarrhythmic drugs. Mt Sinai J Med. Mar 1997;64(2):136-41. [Medline].

  10. Hohnloser SH. Proarrhythmia with class III antiarrhythmic drugs: types, risks, and management. Am J Cardiol. Oct 23 1997;80(8A):82G-89G. [Medline].

  11. Joshi S, Raiszadeh F, Pierce W, Steinberg JS. Antiarrhythmic induced electrical storm in Brugada syndrome: a case report. Ann Noninvasive Electrocardiol. Jul 2007;12(3):274-8. [Medline].

  12. Juurlink DN, Mamdani M, Kopp A, et al. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA. Apr 2 2003;289(13):1652-8. [Medline].

  13. Kowey PR, Marinchak RA, Rials SJ, Bharucha D. Pharmacologic and pharmacokinetic profile of class III antiarrhythmic drugs. Am J Cardiol. Oct 23 1997;80(8A):16G-23G. [Medline].

  14. MacNeil DJ. The side effect profile of class III antiarrhythmic drugs: focus on d,l- sotalol. Am J Cardiol. Oct 23 1997;80(8A):90G-98G. [Medline].

  15. Naccarelli GV, Wolbrette DL, Khan M, et al. Old and new antiarrhythmic drugs for converting and maintaining sinus rhythm in atrial fibrillation: comparative efficacy and results of trials. Am J Cardiol. Mar 20 2003;91(6A):15D-26D. [Medline].

  16. Ravishankar R, Samuels LE, Kaufman MS, et al. Amiodarone-associated hemoptysis. Am J Med Sci. Dec 1998;316(6):390-2. [Medline].

  17. Wyman MG, Wyman RM, Cannom DS, Criley JM. Prevention of primary ventricular fibrillation in acute myocardial infarction with prophylactic lidocaine. Am J Cardiol. Sep 1 2004;94(5):545-51. [Medline].

  18. Saksena S, Slee A, Waldo AL, Freemantle N, Reynolds M, Rosenberg Y, et al. Cardiovascular Outcomes in the AFFIRM Trial (Atrial Fibrillation Follow-Up Investigation of Rhythm Management) An Assessment of Individual Antiarrhythmic Drug Therapies Compared With Rate Control With Propensity Score-Matched Analyses. J Am Coll Cardiol. Nov 1 2011;58(19):1975-85. [Medline].

  19. Nattel S. Dronedarone in Atrial Fibrillation - Jekyll and Hyde?. N Engl J Med. Nov 14 2011;[Medline].

  20. Kozlowski D, Budrejko S, Lip GY, Mikhailidis DP, Rysz J, Raczak G, et al. Dronedarone: An overview. Ann Med. Jul 11 2011;[Medline].

  21. Jackevicius CA, Tom A, Essebag V, Eisenberg MJ, Rahme E, Tu JV, et al. Population-level incidence and risk factors for pulmonary toxicity associated with amiodarone. Am J Cardiol. Sep 1 2011;108(5):705-10. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.