Esmolol in the treatment of severe arrhythmia after acute trichloroethylene poisoning

Abstract

Sir: Trichloroethylene (TCE) is an organic solvent widely used as a metal degreaser and dry cleaning agent. Arrhythmia and severe depression of the central nervous system are life threatening in acute TCE intoxication when TCE blood concentration is > 1.5 mg/l [1, 2, 3].Beta-adrenoreceptor blocking agents are considered to be the treatment of choice in arrhythmia induced by trichloroethylene. We report the immediate efficacy of esmolol treatment for life-threatening TCE-induced arrhythmia.A 70-year-old female (80 kg) ingested a supposed quantity of 1 l 90 % TCE solution in an attempted suicide. She was found by the emergency unit, several hours following ingestion, at home in coma (Glasgow coma scale of 7). She had vomited and seconddegree chemical burns covered her cheek, shoulders, neck and back. Findings on admission included blood pressure 120/ 70 mmHg, several extrasystolic beats, and normal QRS complex were noticed on the EKG monitoring. She was intubated, mechanically ventilated and admitted to the intensive care unit. Further treatment included hyperventilation [1], gastric lavage and activated charcoal.On the second day, the patient developed bigeminy followed by junctional rhythm. A 20 mg esmolol bolus was administered over 5 min, which resulted in sinus rhythm without recurrence of ESV. The bolus was alternated with a 2 mg/min esmolol infusion.Blood concentration of TCE and trichloroethanol were respectively 67 mg/l and 36 mg/l on admission. No other drugs were found in serum. Liver and renal functions, serum electrolytes, coagulation tests were within the normal range.She was extubated on the 3rd day and discharged on the 9th day to a psychiatric ward.Although life threatening, treatment of arrhythmia induced by TCE has rarely been reported in the literature [3]. As no beta-adrenoreceptor blockers offer distinct advantages over the others in the treatment of cardiac arrhythmias, their pharmacokinetic and/or pharmacodynamic properties will influence the choice of the agent [4]. Esmolol was chosen for its rapid onset of action and its short elimination half-life of 9 min. Moreover, esmolol is rapidly metabolised by an erythrocyte cytosol esterase, independent of renal and hepatic function [5]. Treatment with beta-adrenoreceptor blocking agents should take into consideration that ventricular arrhythmia have been reported as late as on the 5th day [3]. Use of propranolol has also been reported with some efficacy (bolus of 5 mg and subsequently 0.5 mg/h) [3]. The effect may be prolonged by renal or hepatic insufficiency (half-life of 3±4 h) and complicate the management of gastric haemorrhage or dehydration induced by caustic diarrhoea which are frequent complications of acute TCE intoxication.The authors suggest that esmolol should be considered in the treatment of TCE-induced arrhythmia. References1. Perbellini L, Olivato D, Zedde A, Miglioranzi R (1991) Acute trichloroethylene poisoning by ingestion: clinical and pharmacokinetic aspect. Intensive Care Med 17: 234±235 2. Brüning T, Vamvakas S, Makropoulo...

Acute Inhalant-Induced Atrial Fibrillation With Severe Hypocalcemia: A Case Report and Review of the Pathophysiology

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