Severe carbamazepine-induced cardiotoxicity with multisystem involvement: early recognition and advanced therapeutic approach

Carbamazepine (CBZ) toxicity is a medical emergency due to severe neurological and cardiovascular risks. Management is challenging due to CBZ's prolonged elimination, enterohepatic recirculation, and active metabolites. We report a severe CBZ intoxication in a 23-year-old male who ingested 24 g in a suicide attempt. He presented in profound coma (Glasgow Coma Scale 3) with respiratory failure, requiring orotracheal intubation and mechanical ventilation. ECG showed sinus tachycardia and slightly widened QRS complexes. Echocardiography revealed myocardial depression with a left ventricular ejection fraction of 40%. His CBZ plasma level was critically high (44 mcg/mL). Treatment included multiple-dose activated charcoal, intravenous lipid emulsion, and continuous venovenous hemodiafiltration, leading to rapid CBZ clearance, cardiotoxicity reversal, and neurological recovery. He was extubated on day three and discharged in stable condition. This case highlights severe CBZ-induced cardiotoxicity and emphasizes early recognition and advanced therapies for improved outcomes.