Bupropion Overdose Followed by Cardiac Arrest and, Later, ST Elevation. Is it STEMI?

A young woman presented with status seizures and apparent overdose of bupropion.  There was a question of cocaine use too (with later suspicion of possible ingestion or body stuffing).She had status seizures for which she was intubated and medically treated (successfully) with propofol and benzos.An ECG was recorded:Sinus tach, with a slightly widened QRS (113 ms) and slightly long QTThere is a slightly abnormally large R-wave in aVR.So there might be some sodium channel blockade here, which is expected with cocaine.Bicarbonate was given.This was recorded 8 hours later:QRS = 148 ms and large R-wave in aVR (very dangerous)This is typical of Na channel blockade.  Bupropion and Cocaine are both powerful Na channel blockers.Computerized QTc = 486 msBazett correction = 546 msFridericia correction = 528 msMy measurement = 550 msBazett = 618 msFridericia = 598 ms(Very long QT)Shortly thereafter, the patient had a witnessed PEA arrest that resolved with epinephrine and bicarbonate.The arrest was not due to an arrhythmia (not Torsades de Pointes).Here is the post arrest ECG:There is RBBB with QRS duration is 137 ms and there is a very large R-wave in aVR.There are 2 bumps on the T-wave; one could be a U-wave.Since a long QU is also dangerous, let ' s assume it is all T-wave.Computerized QT = 420 ms, with QTc = 490 ms. I measure 480 ms.  Fridericia correction = 615 ms.  Very long. The exact etiology of the PEA arrest was uncertain but a because the Na...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs