Reactions Weekly | 2021
Atropine/dobutamine/epinephrine
Abstract
Lack of efficacy: 2 case reports In a case series, two men aged 19-year-old and 26-year-old were described, out of whom a 19-year-old man exhibited a lack of efficacy of atropine and epinephrine while being treated for cardiac arrest and cardiogenic shock related to Tako-Tsubo cardiomyopathy and a 26-year-old man exhibited a lack of efficacy of dobutamine while being treated for cardiogenic shock related to Tako-Tsubo cardiomyopathy [routes not stated]. Case 1: The 19-year-old man, who had a history of asthma, alcohol consumption and active smoking including cannabis, presented with cardiac arrest on asystole. He was immediately resuscitated. He received an epinephrine bolus of 1mg every 3 min (40mg total). Following the initial resuscitation, his condition was changed to a shockable rhythm. External electric shocks were applied, and amiodarone was administered. The spontaneous circulatory activity was recovered. He started receiving continuous epinephrine up to 5 mg/h to maintain arterial pressure. Acute intoxication by opioids was suspected. Thus, he also received naloxone. During transport to a hospital, he developed bradycardia and asystoles. He was admitted, and he required external cardiac massage, vascular filling, atropine 0.5mg and epinephrine. Due to recurrent cardiac arrest and refractory cardiogenic shock, he was placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO). The post-ECMO examinations revealed hyperlactataemia, hepatic cytolysis, acute hepatic failure and troponinaemia. Based on further investigation, he was diagnosed with reverse Tako-Tsubo cardiomyopathy. Amphetamine derivatives were found in urine and blood samples. A speed tablet was found by his family in his bedroom. He received symptomatic treatment with norepinephrine and continuous sedation with midazolam and sufentanil. His symptoms were improved. The ECMO was withdrawn at 96h. Later, he had complete myocardial recovery. Case 2: The 26-year-old man, who had a history of recreational use of cannabis and unspecified amphetamines, presented to an emergency room with cardiogenic shock following the drug use. An electrocardiogram showed ST elevation of the V1 to V4 segments, and a transthoracic echocardiogram revealed hypokinesis of medial and basal regions of the left ventricle with a subaortic velocity-time integral measured at 6cm and a normal right ventricle function. He also developed acute lung oedema. He was admitted, and tracheal intubation was initiated. Dobutamine infusion was initiated at a rate of 15μg.kg-1.min-1. However, he had persistent signs of cardiogenic shock. Therefore, a VA-ECMO was placed. The urine test was positive for amphetamines. Later, he was diagnosed with reverse Tako-Tsubo cardiomyopathy. Thus, the dobutamine was replaced with levosimendan. Consequently, his symptoms began to recover, and the ECMO flow rate was decreased. After completion of the levosimendan treatment, the ECMO was discontinued.