Cardiac Dysrhythmia And Seizure As Result Of Use Of Cannabis Combined With Alcohol

Cannabis remains one of the most universally used recreational drugs worldwide. Consumption of cannabis can have several cardiovascular adverse effects and in toxic overdose can lead to even lethal cardiac arrest. Binge alcohol drinking and subsequent withdrawal can lead to convulsion and QT prolongation, which again can predispose to malignant arrhythmia.

We report here two cases of ventricular fibrillation complicated with seizure precipitated by cannabis overdose and alcohol withdrawal following binge drinking.

Such presentation even with cardiac arrest does not necessarily lead to fatal outcome. Supportive measures with associated intensive care and aggressive resuscitation can bring out successful outcome in such cases complicated with serious cardiac events.

Introduction

Cannabis remains one of the most universally abused recreational drugs worldwide and its popularity has increased considerably for legalization and medical use. Sometimes excessive cannabis smoking can lead to fatal cardiac arrest caused by malignant arrhythmia. Alcohol withdrawal following binge drinking commonly associated with cannabis abuse can lead to seizure and malignant arrhythmia. We report here two cases of ventricular fibrillation and seizure induced by cannabis overdose and alcohol withdrawal.

Case Report

Case 1: 22-year-old female patient was found collapsed at home where she received on site resuscitation. In ambulance she was witnessed to have seizure and her breathing became erratic. She was defibrillated for ventricular fibrillation (VF). On arrival her Glasgow Coma Scale (GCS) was 3/15 and thus was intubated. She was vitally stable but was acidotic. Her urine toxicology test was positive for cannabis (quantitative estimation was not done). Her computerized tomographic (CT) scan of brain was found to be normal. She was transferred to intensive care unit (ICU) for further care. Lumber puncture report was normal. Her relatives told that she smoked cigarettes containing cannabis and had several units of alcohol last night. She was a diagnosed case of asthma and seizure in past for which she was currently not on any treatment. She was a regular cannabis abuser.

In the ICU she was kept sedated and received phenytoin and levetiracetam for seizure control. She was found to have prolonged QTc on electrocardiogram (ECG) for which she received magnesium. Subsequently she was weaned from the ventilator and was extubated after four days. Later was discharged to ward.

Case 2: 24-years-old female was brought to our emergency after she was found collapsed at home. She smoked several cannabis cigarettes and had several units of alcohol previous night. She received CPR and was shocked once for VF, which reverted her back to sinus rhythm. She was found to be unconscious (GCS of 3/15), thus she was intubated. She had history of deep venous thrombosis in 2012 and was a regular drug abuser. Her urine was positive for benzodiazepine and cannabis (again no quantitative test was done). Her CT scan of brain was found to be normal. She was later transferred to ICU for further management. She developed recurrent episodes of seizure even after treatment with phenytoin and midazolam, which only responded to round the clock phenytoin and levetiracetam. She was also found to have prolonged QTc, which was treated with IV magnesium. Finally she was successfully extubated, and discharged from hospital after 8 days.

Discussion

Majority of effects of cannabis is due to the active ingredient D9-tetrahydrocannabinol (THC). Effects of THC, mainly cardiac stimulating side effects, are primarily mediated through cannabis receptors. Cannabis has been reported to cause several types of arrhythmias due to direct effect as well as sympathetic stimulation. It is also known to be proconvulsant or anticonvulsant agent.

Binge drinking has also been linked to proarrhythmogenic effect causing several arrhythmias. Alcohol withdrawal can lead to prolong QTc precipating to malignant arrhythmias. Alcohol withdrawal can lead to seizure typically manifesting after 6-48 hours.

Cannabis in combination with alcohol creates more pronounced synergetic effect on heart leading to fatal life threatening VF and seizure. Both patients consumed high amount of cannabis and alcohol and were chronic abuser. VF and seizure could have been caused by cannabis overdose or alcohol withdrawal after binge drinking. It was not possible for us to pinpoint the exact cause, as both factors are well known to cause such complication.

Conclusion

Recreational use of cannabis when combined with alcohol withdrawal following binge drinking can lead to serious cardiac dysrhythmia and seizure.