5: ECPR for Isobutyl nitrate inhalation (poppers) poisoning

Introduction: Inhaled alkyl nitrite analogues, commonly known as “poppers,” are short-acting vasodilators that can cause euphoria, dizziness, and related effects. Nitrites rarely result in acute life-threatening complications such as ventricular dysrhythmias. We report a case of electrical storm following accidental inhalation of isobutyl nitrite. Case Presentation: A 40-year-old male had accidental occupational exposure to isobutyl nitrite, after which he became unconscious and was brought to our hospital. On arrival, he was found to be in ventricular fibrillation, and cardiopulmonary resuscitation was initiated as per Advanced Cardiac Life Support protocol. He required three defibrillations, with return of spontaneous circulation achieved after 30 minutes. Post-resuscitation, an SaO2–SpO2 gap of 15% was noted, suggesting a high probability of methemoglobinemia. The patient was immediately treated with methylene blue (2 mg/kg) and transferred to the intensive care unit. Due to hypotension, vasopressors and inotropes were initiated. Two-dimensional echocardiography revealed severe left ventricular systolic dysfunction with an ejection fraction of approximately 30%. Management and Outcome: In the ICU, the patient developed multiple episodes of ventricular tachycardia requiring cardioversion, without sustained return of spontaneous circulation. Extracorporeal cardiopulmonary resuscitation was initiated using a 25 Fr multistage venous cannula in the left femoral vein and a 19 Fr return cannula in the right common femoral artery. Spontaneous circulation was achieved within eight minutes. Over the next 24 hours, the patient experienced eight additional episodes of ventricular tachycardia, all managed with cardioversion, and was started on a lignocaine infusion for 48 hours. The patient gradually regained sensorium, and co-oximetry showed no evidence of methemoglobinemia. Left ventricular function improved to 40%. ECMO was weaned and discontinued on day three. The patient was extubated on day four and discharged on day nine with no recurrence of arrhythmias on telemetry. Conclusion: This case highlights a rare but life-threatening complication of isobutyl nitrite exposure presenting as refractory ventricular arrhythmias. Prompt recognition and timely initiation of extracorporeal support were crucial for survival.