Refractory ventricular tachyarrhythmia following a suicidal massive caffeine overdose: a case report and review of emergency management

Caffeine is one of the most widely consumed psychoactive substances worldwide and is readily accessible in tablet formulations and caffeinated beverages. Although moderate caffeine intake is generally considered safe, massive acute ingestion can result in severe toxicity involving the central nervous and cardiovascular systems. Life-threatening manifestations include seizures, profound electrolyte disturbances, metabolic derangements, and malignant ventricular arrhythmias. Because caffeine has favorable dialyzable properties, including low molecular weight, low protein binding, and a relatively small volume of distribution, extracorporeal toxin removal may play a critical therapeutic role in severe intoxication refractory to conventional supportive and antiarrhythmic management. We report the case of a previously healthy 16-year-old Iranian adolescent girl who intentionally ingested 10.8 g of caffeine in a suicide attempt. Approximately two hours after ingestion, she presented with markedly reduced consciousness, agitation, generalized tremor, intermittent tonic/myoclonic seizure-like activity, sinus tachycardia (180–190 beats/min), hypokalemia (serum potassium 2.7 mEq/L), primary metabolic acidosis, significant rhabdomyolysis, and electrocardiographic abnormalities including mild QRS widening and QTc prolongation (~ 500 ms). Urine toxicology screening was positive for caffeine, supporting the diagnosis in conjunction with the clear ingestion history and subsequent patient confirmation. Despite early airway protection, gastrointestinal decontamination, electrolyte and acid–base correction, dual antiarrhythmic therapy with amiodarone and lidocaine, and repeated synchronized electrical cardioversion, she developed recurrent refractory sustained ventricular tachycardia, transient progression to asystole requiring cardiopulmonary resuscitation, and persistent severe metabolic instability. Emergency intermittent hemodialysis was initiated approximately 3–4 h after emergency department arrival, resulting in rapid correction of metabolic acidosis, complete cessation of malignant ventricular arrhythmias, and sustained restoration of stable sinus rhythm. The patient subsequently demonstrated progressive neurological recovery without persistent cardiac or neurological sequelae. This case highlights the potentially catastrophic cardiovascular consequences of massive caffeine intoxication and emphasizes the importance of early recognition, aggressive supportive care, rapid correction of metabolic abnormalities, and timely escalation to extracorporeal toxin removal in refractory cases. In patients with persistent malignant ventricular arrhythmias despite optimized pharmacologic and electrical management, intermittent hemodialysis may represent a life-saving therapeutic intervention capable of rapidly reversing toxicity and improving clinical outcomes.