Flecainide is an anti-arrhythmic drug with a narrow therapeutic index. Flecainide toxicity is rare, but the mortality is high. This case demonstrates the use of intravenous fat emulsion therapy in conjunction with intravenous sodium bicarbonate treatment for flecainide toxicity. A 50-year-old male with atrial fibrillation and taking flecainide 75 mg twice daily presented to Emergency Department after ingesting 1125 mg of flecainide, in a suicide attempt. An electrocardiogram (ECG) on arrival showed bradycardia, wide QRS complex, prolonged QTc interval. Treatment for flecainide poisoning with intravenous sodium bicarbonate was initiated. On day two, the patient had a cardiac arrest secondary to ventricular tachycardia. After successful defibrillation, the patient had persistent bradycardia and hypotension. Administration of a 20% lipid emulsion bolus, followed by continuous infusion for three hours, resulted in conversion to normal sinus rhythm. This case illustrates the successful treatment of flecainide toxicity with intravenous fat emulsion therapy. To our knowledge, this is the second case that used fat emulsion without concomitant extracorporeal life support. Due to its low prevalence and the fact the lipid emulsion is often used in conjunction with other treatments, there are no randomized clinical trials on the isolated efficacy of lipid infusion. The best treatment is unknown. Given its high mortality, early detection and treatment are paramount.
Keywords: anti-arrhythmic drugs; cardiovascular toxicity; drug overdose; flecainide; intravenous fat emulsion.
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