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Challenges in Clinical Electrocardiography

Arrhythmia During Anaphylaxis—An Intrinsic or Extrinsic Cause?

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JAMA Internal Medicine

Published Online: August 21, 2023

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Vickram Vignesh Rangaswamy, MD, DM¹;

Aparna Velmurugan, MBBS²;

S. Balaji, MRCP¹

Author Affiliations

¹Consultant Cardiologist, Department of Cardiology, Sri Ramakrishna Hospital, Coimbatore, India
²Registrar, Department of Cardiology, Sri Ramakrishna Hospital, Coimbatore, India

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A patient in their 50s presented to the emergency department within 30 minutes of ingestion of prawns at a restaurant with complaints of an itchy skin, rash, and generalized weakness. The patient’s pulse rate was 79 bpm, blood pressure was 50/30 mm Hg, and respiratory rate was 20 per minute. Findings on systemic examination were normal. The patient was initially treated with injections of hydrocortisone, chlorpheniramine, and a rapid infusion of 1000 mL of normal saline boluses. However, they continued to remain hypotensive (blood pressure, 70/50 mm Hg). The patient was then given adrenaline, 1 mg (1:10 000 dilution), intravenously. Immediately after the intravenous adrenaline injection, wide complex tachycardia was observed on the cardiac monitor. A 12-lead electrocardiogram (ECG) showed a wide complex tachycardia (WCT) at a rate of 105 beats per minute (bpm) (Figure, A). After 3 minutes, the WCT slowed and gradually returned to sinus rhythm. The subsequent ECG showed a 1-mm ST elevation in leads I, and aVL, and ST depression and T-wave inversion in leads II, III, aVF, and V₃ to V₆ (Figure, B).¹

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A patient in their 50s presented to the emergency department within 30 minutes of ingestion of prawns at a restaurant with complaints of an itchy skin, rash, and generalized weakness. The patient’s pulse rate was 79 bpm, blood pressure was 50/30 mm Hg, and respiratory rate was 20 per minute. Findings on systemic examination were normal. The patient was initially treated with injections of hydrocortisone, chlorpheniramine, and a rapid infusion of 1000 mL of normal saline boluses. However, they continued to remain hypotensive (blood pressure, 70/50 mm Hg). The patient was then given adrenaline, 1 mg (1:10 000 dilution), intravenously. Immediately after the intravenous adrenaline injection, wide complex tachycardia was observed on the cardiac monitor. A 12-lead electrocardiogram (ECG) showed a wide complex tachycardia (WCT) at a rate of 105 beats per minute (bpm) (Figure, A). After 3 minutes, the WCT slowed and gradually returned to sinus rhythm. The subsequent ECG showed a 1-mm ST elevation in leads I, and aVL, and ST depression and T-wave inversion in leads II, III, aVF, and V₃ to V₆ (Figure, B).¹

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Article Information

Corresponding Author: Vickram Vignesh Rangaswamy, MD, DM, Sri Ramakrishna Hospital, Coimbatore 641044, India (vickramvignesh@gmail.com).

Published Online: August 21, 2023. doi:10.1001/jamainternmed.2023.2259

Conflict of Interest Disclosures: None reported.

References

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Tisdale JE , Patel RV , Webb CR , Borzak S , Zarowitz BJ . Proarrhythmic effects of intravenous vasopressors. Ann Pharmacother. 1995;29(3):269-281. doi:10.1177/106002809502900309 PubMed Google Scholar Crossref

Campbell RL , Bellolio MF , Knutson BD , et al. Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine. J Allergy Clin Immunol Pract. 2015;3(1):76-80. doi:10.1016/j.jaip.2014.06.007 PubMed Google Scholar Crossref

Li X , Ma Q , Yin J , et al. A clinical practice guideline for the emergency management of anaphylaxis. Front Pharmacol. 2020;13:28.Google Scholar

Pumphrey R . Anaphylaxis: can we tell who is at risk of a fatal reaction? Curr Opin Allergy Clin Immunol. 2004;4(4):285-290. doi:10.1097/01.all.0000136762.89313.0b PubMed Google Scholar Crossref

Wolff AA , Levi R . Histamine and cardiac arrhythmias. Circ Res. 1986;58(1):1-16. doi:10.1161/01.RES.58.1.1 PubMed Google Scholar Crossref

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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