- Email: [email protected]
Second-degree atrioventricular block in an adolescent with an acute alcohol intoxication
Journal Pre-proof Second-degree atrioventricular block in an adolescent with an acute alcohol intoxication
Anita W. Lekx, Sjane Lingius, Dennis G. Barten PII:
S0735-6757(19)30556-X
DOI:
https://doi.org/10.1016/j.ajem.2019.158419
Reference:
YAJEM 158419
To appear in:
American Journal of Emergency Medicine
Received date:
26 June 2019
Revised date:
24 August 2019
Accepted date:
28 August 2019
Please cite this article as: A.W. Lekx, S. Lingius and D.G. Barten, Second-degree atrioventricular block in an adolescent with an acute alcohol intoxication, American Journal of Emergency Medicine(2019), https://doi.org/10.1016/j.ajem.2019.158419
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier.
Journal Pre-proof
Second-degree atrioventricular block in an adolescent with an acute alcohol intoxication
Anita W. Lekx1, MD; Sjane Lingius1, MD; Dennis G. Barten1, MD 1
Department of Emergency Medicine, VieCuri Medical Center, Venlo, the Netherlands.
of
Keywords: alcohol, intoxication, atrioventricular block, cardiac conduction disturbance
ro
Corresponding author:
Department of Emergency Medicine
re
VieCuri Medical Center
-p
A.W. Lekx, MD
lP
P.O. Box 1926 5900 BX Venlo
na
The Netherlands
Jo ur
Telephone number: +31 77 320 5810 e-mail: [email protected]
Conflict of Interest Statement: The authors have no conflicts of interest relevant to this article to disclose.
Journal Pre-proof
Second-degree atrioventricular block in an adolescent with an acute alcohol intoxication
1. Introduction
Binge drinking adolescents often present to the emergency department (ED) with an
of
alcohol intoxication. Clinical signs of alcohol intoxications are impaired
ro
consciousness and vomiting, occasionally complicated by pulmonary aspiration. Alcohol is also involved in many traumatic injuries and is known to contribute to the
-p
leading causes of death among adolescents [1,2]. Emergency physicians are often
re
not aware of the fact that excessive alcohol intake can also lead to atrioventricular
lP
(AV) conduction disturbances. Here we present a case of a second-degree AV block
Jo ur
2. Case report
na
in an adolescent with acute alcohol intoxication.
A 15 year old male adolescent was brought to the emergency department by ambulance. When he came home after a night out he vomited and according to his father there was an obvious aroma of alcohol. When he subsequently showed an episode of apnea, his parents called for an ambulance. On arrival at the ED, his Glasgow Coma Scale (GCS) was 1-4-1. In the recovery position his airway was clear. He had a pulse rate of 110 bpm and a blood pressure of 106/54 mmHg. His temperature was 35.6 ºC. He was closely monitored and received intravenous fluids (NaCL 0.9%). His blood alcohol level was 2665 mg/l.
Journal Pre-proof
The monitor showed an irregular heartbeat that intermittently dropped to 60 bpm. The ECG showed a second-degree AV block type 1 (Wenkebach) [fig 1].
During his stay at the ED his GCS improved and he was admitted to the short stay unit with overnight monitoring. The next morning he had recovered to a full level of consciousness and his ECG had normalized [fig 2]. He expressed remorse and was
of
discharged. With his and his parents’ permission a referral was made to an alcohol
ro
prevention clinic where they will be informed about the consequences of alcohol
re
-p
(ab)use, especially at his age.
lP
3. Discussion
na
Patients with an alcohol intoxication often present with decreased consciousness, bradycardia and hypotension [2,3,4], but tachycardia is also observed [4]. Supportive
Jo ur
care is usually sufficient. However, there is an increased risk of arrhythmias and sudden cardiac death [3,13].
Chronic alcohol consumption can result in alcoholic cardiomyopathy. Atrial fibrillation is the most commonly associated arrhythmia [5,6]. Cardiac conduction disturbances is rather rare in incidental excessive alcohol intake and the etiology is not well known.
The speed of cardiac impulse propagation is determined by a complex interaction between various components of the conduction system. This process is precisely
Journal Pre-proof regulated and is able to rapidly adapt to the ever changing physiological demands [3].
Known clinical effects of alcohol on the cardiovascular system are a reduced heart rate variability with a higher average rate, decreased blood pressure variability, lower stroke volume and vasodilatation [4].
of
With regards to cardiac conduction disturbances in excessive alcohol intake, some
ro
explanations for the disturbance have been proposed.
-p
Alcohol causes an imbalance and dysregulation of the autonomic nerve system:
re
whilst the sympathetic activity is enhanced, the parasympathetic activity is reduced. Also, vagal innervation of the sinus node can be inhibited. As a consequence,
lP
cardiac conduction does not respond accurately to the physiological demands (e.g.
na
enhanced oxygen demand or low environmental temperature) [7]. Additionally, stimuli that lead to an increased vagal tone, such as vomiting and
Jo ur
removing an i.v. line, might influence cardiac conduction [5,8]. Hypothermia, which is also related to AV conduction delay in non-alcoholic subjects, is another important contributor [11]. Finally, acute ethanol exposure of cardiac cells isolated from animal models caused a significant reduction or increase in current densities of some ion currents. The decreased calcium current, and probably the sodium current as well, may therefore be associated with AV block after acute alcohol intake [11]. In the literature, AV conduction disturbance due to alcohol intoxications is mainly described in case reports. A systematic review of case reports observed that most cases concern relatively young patients (14-29 years old), which could partly be explained by their exclusion
Journal Pre-proof criteria of chronic alcoholism, a substantial history of alcohol intake or cardiomyopathy. P-wave and QTc prolongation are the most common ECG changes, followed by T-wave abnormalities and QRS complex widening. [9]. Cases with first, second and third degree AV blocks are reported as well [5, 8].
A prospective, randomized study which assessed hospitalized patients found no significant difference in PR-interval length between patients with alcohol intoxication
of
and controls. However, patients with alcohol intoxication had a longer PR interval on
ro
day one compared to the next day. This difference was significantly smaller in the control group [10]. There is no obvious dose-response relationship between alcohol
re
-p
level or serum osmolality and ECG changes [3,4,10].
Supportive care is usually sufficient. However, among all reported cases, two patients
lP
developed a cardiorespiratory arrest and needed resuscitation. One patient
na
developed a third degree block on removal of an i.v. line which restored after administration of a precordial thump [8]. Another patient went from first degree AV
Jo ur
block into a Mobitz tye 1 followed by cardiorespiratory arrest and successful resuscitation [11]. This underlines the need for close monitoring. Prognosis is good and recovery simply depends on elimination of alcohol from the blood.
Complete recovery of the AV block was described in all reported cases, except for one in which the block was assumed to be pre-existing [12].
Journal Pre-proof 4. Conclusion
AV conduction disturbance is a symptom that is associated with acute alcohol intoxication. The etiology is probably multifactorial but not yet well understood. Because of the risk of arrhythmias and sudden cardiac death, monitoring is advised
Jo ur
na
lP
re
-p
ro
of
to ensure patient safety until the conduction disturbances are resolved.
Journal Pre-proof References [data] [1] Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X. Contribution of Excessive Alcohol Consumption to Deaths and Years of Potential Life Lost in the United States. Preventing Chronic Disease, v11; 2014 [2] World Health Organization, Fact sheets Alcohol https://www.who.int/news-room/fact-sheets/detail/alcohol [3] Kléber A.G., Rudy Y., Basic mechanisms of cardiac impulse propagation and associated arrhythmias. Physiol. Rev. 2004;84:431-88
of
[4] Buckman J. F., Eddie D., Vaschillo E.G., Garcia A., Bates M.E. Immediate and Complex Cardiovascular Adaptation to an Acute Alcohol Dose. Alcoholism: Clinical and Experimental Research. 2015;39:2334-44.
-p
ro
[5] Van Stigt A.H., Overduin R.J., Staats L.C., Loen V., van der Heyden M.A.G. A Heart too Drunk to Drive; AV Block following Acute Alcohol Intoxication. Chinese Journal of Physiology. 2016;59:1-8
re
[6] Djoussé L, Levy D, Benjamin E.J., Blease S.J., Russ A., Larson M.G., Massaro J.M., D’Agostino R.B., Wolf P.A., Ellison R.C. Long-term alcohol consumption and the risk of atrial fibrillation in the Framingham Study. Am. J. Cardiol. 2004;93:710-3
na
lP
[7] Reed S.F., Porges S.W., Newlin D.B., Effects of alcohol on vagal regulation of cardiovascular function: contributions of the polyvagal theory to the psychophysiology of alcohol. Exp. Clin. Psychopharmacol 1999;7:484-92
Jo ur
[8] Van Cleef A.N.H., Schuurman M.J., Busari J.O. Third-degree atrioventricular block in an adolescent following acute alcohol intoxication. BMJ Case Reports. 2011; doi: 10.1136/bcr.07.2011.4547 [9] Raheja H., Namana V., Chopra K., Sinha A., Gupta, S.S. Electrocardiogram Changes with acute alcohol intoxication: A systematic review. The open cardiovascular Medicine Journal. 2018;12:1-6 [10] Aesebø W., Aesebø W, Erikssen J, Jonsbu J., Stavem K. ECG changes in patients with acute ethanol intoxication. Scandinavian Cardiovascular Journal. 2009;41:79-84 [11] Eilam O., Heyman S.N. Wenkebach-type atrioventricular block in severe alcohol intoxication. Ann. Emerg. Med. 1991;20:1170 [12] Brvar, M. and Bunc M. High-degree atrioventricular block in acute ethanol poisoning: A case report. Cases J. 2009;2:8559 [13] Lorsheyd A., de Lange D.W., Hijmering M.L., Cramer M.J., van de Wiel A. PR and QTc interval prolongation on the electrocardiogram after binge drinking in healthy individuals. Neth J Med. 2005; 63: 59-63
Journal Pre-proof Abstract Binge drinking adolescents often present to the emergency department with an alcohol intoxication. Known clinical signs of alcohol intoxications are impaired consciousness and vomiting, occasionally complicated by pulmonary aspiration. Emergency physicians are often not aware of the fact that excessive alcohol intake can also lead to atrioventricular (AV) conduction disturbances. We present a case of a second-degree AV block in an adolescent with an acute alcohol intoxication. The
of
etiology of this condition is not well understood; possible explanations are reviewed
Jo ur
na
lP
re
-p
ro
in this manuscript.
Figure 1
Figure 2
Anita W. Lekx, Sjane Lingius, Dennis G. Barten PII:
S0735-6757(19)30556-X
DOI:
https://doi.org/10.1016/j.ajem.2019.158419
Reference:
YAJEM 158419
To appear in:
American Journal of Emergency Medicine
Received date:
26 June 2019
Revised date:
24 August 2019
Accepted date:
28 August 2019
Please cite this article as: A.W. Lekx, S. Lingius and D.G. Barten, Second-degree atrioventricular block in an adolescent with an acute alcohol intoxication, American Journal of Emergency Medicine(2019), https://doi.org/10.1016/j.ajem.2019.158419
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Published by Elsevier.
Journal Pre-proof
Second-degree atrioventricular block in an adolescent with an acute alcohol intoxication
Anita W. Lekx1, MD; Sjane Lingius1, MD; Dennis G. Barten1, MD 1
Department of Emergency Medicine, VieCuri Medical Center, Venlo, the Netherlands.
of
Keywords: alcohol, intoxication, atrioventricular block, cardiac conduction disturbance
ro
Corresponding author:
Department of Emergency Medicine
re
VieCuri Medical Center
-p
A.W. Lekx, MD
lP
P.O. Box 1926 5900 BX Venlo
na
The Netherlands
Jo ur
Telephone number: +31 77 320 5810 e-mail: [email protected]
Conflict of Interest Statement: The authors have no conflicts of interest relevant to this article to disclose.
Journal Pre-proof
Second-degree atrioventricular block in an adolescent with an acute alcohol intoxication
1. Introduction
Binge drinking adolescents often present to the emergency department (ED) with an
of
alcohol intoxication. Clinical signs of alcohol intoxications are impaired
ro
consciousness and vomiting, occasionally complicated by pulmonary aspiration. Alcohol is also involved in many traumatic injuries and is known to contribute to the
-p
leading causes of death among adolescents [1,2]. Emergency physicians are often
re
not aware of the fact that excessive alcohol intake can also lead to atrioventricular
lP
(AV) conduction disturbances. Here we present a case of a second-degree AV block
Jo ur
2. Case report
na
in an adolescent with acute alcohol intoxication.
A 15 year old male adolescent was brought to the emergency department by ambulance. When he came home after a night out he vomited and according to his father there was an obvious aroma of alcohol. When he subsequently showed an episode of apnea, his parents called for an ambulance. On arrival at the ED, his Glasgow Coma Scale (GCS) was 1-4-1. In the recovery position his airway was clear. He had a pulse rate of 110 bpm and a blood pressure of 106/54 mmHg. His temperature was 35.6 ºC. He was closely monitored and received intravenous fluids (NaCL 0.9%). His blood alcohol level was 2665 mg/l.
Journal Pre-proof
The monitor showed an irregular heartbeat that intermittently dropped to 60 bpm. The ECG showed a second-degree AV block type 1 (Wenkebach) [fig 1].
During his stay at the ED his GCS improved and he was admitted to the short stay unit with overnight monitoring. The next morning he had recovered to a full level of consciousness and his ECG had normalized [fig 2]. He expressed remorse and was
of
discharged. With his and his parents’ permission a referral was made to an alcohol
ro
prevention clinic where they will be informed about the consequences of alcohol
re
-p
(ab)use, especially at his age.
lP
3. Discussion
na
Patients with an alcohol intoxication often present with decreased consciousness, bradycardia and hypotension [2,3,4], but tachycardia is also observed [4]. Supportive
Jo ur
care is usually sufficient. However, there is an increased risk of arrhythmias and sudden cardiac death [3,13].
Chronic alcohol consumption can result in alcoholic cardiomyopathy. Atrial fibrillation is the most commonly associated arrhythmia [5,6]. Cardiac conduction disturbances is rather rare in incidental excessive alcohol intake and the etiology is not well known.
The speed of cardiac impulse propagation is determined by a complex interaction between various components of the conduction system. This process is precisely
Journal Pre-proof regulated and is able to rapidly adapt to the ever changing physiological demands [3].
Known clinical effects of alcohol on the cardiovascular system are a reduced heart rate variability with a higher average rate, decreased blood pressure variability, lower stroke volume and vasodilatation [4].
of
With regards to cardiac conduction disturbances in excessive alcohol intake, some
ro
explanations for the disturbance have been proposed.
-p
Alcohol causes an imbalance and dysregulation of the autonomic nerve system:
re
whilst the sympathetic activity is enhanced, the parasympathetic activity is reduced. Also, vagal innervation of the sinus node can be inhibited. As a consequence,
lP
cardiac conduction does not respond accurately to the physiological demands (e.g.
na
enhanced oxygen demand or low environmental temperature) [7]. Additionally, stimuli that lead to an increased vagal tone, such as vomiting and
Jo ur
removing an i.v. line, might influence cardiac conduction [5,8]. Hypothermia, which is also related to AV conduction delay in non-alcoholic subjects, is another important contributor [11]. Finally, acute ethanol exposure of cardiac cells isolated from animal models caused a significant reduction or increase in current densities of some ion currents. The decreased calcium current, and probably the sodium current as well, may therefore be associated with AV block after acute alcohol intake [11]. In the literature, AV conduction disturbance due to alcohol intoxications is mainly described in case reports. A systematic review of case reports observed that most cases concern relatively young patients (14-29 years old), which could partly be explained by their exclusion
Journal Pre-proof criteria of chronic alcoholism, a substantial history of alcohol intake or cardiomyopathy. P-wave and QTc prolongation are the most common ECG changes, followed by T-wave abnormalities and QRS complex widening. [9]. Cases with first, second and third degree AV blocks are reported as well [5, 8].
A prospective, randomized study which assessed hospitalized patients found no significant difference in PR-interval length between patients with alcohol intoxication
of
and controls. However, patients with alcohol intoxication had a longer PR interval on
ro
day one compared to the next day. This difference was significantly smaller in the control group [10]. There is no obvious dose-response relationship between alcohol
re
-p
level or serum osmolality and ECG changes [3,4,10].
Supportive care is usually sufficient. However, among all reported cases, two patients
lP
developed a cardiorespiratory arrest and needed resuscitation. One patient
na
developed a third degree block on removal of an i.v. line which restored after administration of a precordial thump [8]. Another patient went from first degree AV
Jo ur
block into a Mobitz tye 1 followed by cardiorespiratory arrest and successful resuscitation [11]. This underlines the need for close monitoring. Prognosis is good and recovery simply depends on elimination of alcohol from the blood.
Complete recovery of the AV block was described in all reported cases, except for one in which the block was assumed to be pre-existing [12].
Journal Pre-proof 4. Conclusion
AV conduction disturbance is a symptom that is associated with acute alcohol intoxication. The etiology is probably multifactorial but not yet well understood. Because of the risk of arrhythmias and sudden cardiac death, monitoring is advised
Jo ur
na
lP
re
-p
ro
of
to ensure patient safety until the conduction disturbances are resolved.
Journal Pre-proof References [data] [1] Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X. Contribution of Excessive Alcohol Consumption to Deaths and Years of Potential Life Lost in the United States. Preventing Chronic Disease, v11; 2014 [2] World Health Organization, Fact sheets Alcohol https://www.who.int/news-room/fact-sheets/detail/alcohol [3] Kléber A.G., Rudy Y., Basic mechanisms of cardiac impulse propagation and associated arrhythmias. Physiol. Rev. 2004;84:431-88
of
[4] Buckman J. F., Eddie D., Vaschillo E.G., Garcia A., Bates M.E. Immediate and Complex Cardiovascular Adaptation to an Acute Alcohol Dose. Alcoholism: Clinical and Experimental Research. 2015;39:2334-44.
-p
ro
[5] Van Stigt A.H., Overduin R.J., Staats L.C., Loen V., van der Heyden M.A.G. A Heart too Drunk to Drive; AV Block following Acute Alcohol Intoxication. Chinese Journal of Physiology. 2016;59:1-8
re
[6] Djoussé L, Levy D, Benjamin E.J., Blease S.J., Russ A., Larson M.G., Massaro J.M., D’Agostino R.B., Wolf P.A., Ellison R.C. Long-term alcohol consumption and the risk of atrial fibrillation in the Framingham Study. Am. J. Cardiol. 2004;93:710-3
na
lP
[7] Reed S.F., Porges S.W., Newlin D.B., Effects of alcohol on vagal regulation of cardiovascular function: contributions of the polyvagal theory to the psychophysiology of alcohol. Exp. Clin. Psychopharmacol 1999;7:484-92
Jo ur
[8] Van Cleef A.N.H., Schuurman M.J., Busari J.O. Third-degree atrioventricular block in an adolescent following acute alcohol intoxication. BMJ Case Reports. 2011; doi: 10.1136/bcr.07.2011.4547 [9] Raheja H., Namana V., Chopra K., Sinha A., Gupta, S.S. Electrocardiogram Changes with acute alcohol intoxication: A systematic review. The open cardiovascular Medicine Journal. 2018;12:1-6 [10] Aesebø W., Aesebø W, Erikssen J, Jonsbu J., Stavem K. ECG changes in patients with acute ethanol intoxication. Scandinavian Cardiovascular Journal. 2009;41:79-84 [11] Eilam O., Heyman S.N. Wenkebach-type atrioventricular block in severe alcohol intoxication. Ann. Emerg. Med. 1991;20:1170 [12] Brvar, M. and Bunc M. High-degree atrioventricular block in acute ethanol poisoning: A case report. Cases J. 2009;2:8559 [13] Lorsheyd A., de Lange D.W., Hijmering M.L., Cramer M.J., van de Wiel A. PR and QTc interval prolongation on the electrocardiogram after binge drinking in healthy individuals. Neth J Med. 2005; 63: 59-63
Journal Pre-proof Abstract Binge drinking adolescents often present to the emergency department with an alcohol intoxication. Known clinical signs of alcohol intoxications are impaired consciousness and vomiting, occasionally complicated by pulmonary aspiration. Emergency physicians are often not aware of the fact that excessive alcohol intake can also lead to atrioventricular (AV) conduction disturbances. We present a case of a second-degree AV block in an adolescent with an acute alcohol intoxication. The
of
etiology of this condition is not well understood; possible explanations are reviewed
Jo ur
na
lP
re
-p
ro
in this manuscript.
Figure 1
Figure 2