# Sodium bicarbonate to the ROSCue: a case report on how sodium bicarbonate successfully resuscitated a patient in cardiac arrest from suspected quetiapine and trazodone overdose

## TL;DR

Sodium bicarbonate successfully revived a patient in cardiac arrest caused by quetiapine and trazodone overdose, suggesting its potential use in drug-induced sodium channel block.

## Contribution

This case report highlights the novel use of sodium bicarbonate in resuscitating cardiac arrest from non-tricyclic antidepressant drug overdose.

## Key findings

- Sodium bicarbonate administration narrowed the patient's QRS complex and restored spontaneous circulation.
- Both trazodone and quetiapine can cause sodium channel blockade, which sodium bicarbonate can counteract.
- The case suggests broader use of sodium bicarbonate in drug-induced sodium channel toxicity may be life-saving.

## Abstract

Per ACLS algorithms (Class III, LOE B), sodium bicarbonate (SB) use is indicated for cardiac arrest with underlying hyperkalaemia, tricyclic antidepressant (TCA) overdose, or pre-existing severe metabolic acidosis, with routine use of SB being discouraged due to concerns raised in animal studies. However, SB is a potent antidote for sodium channel blockade (SCB) in drug toxicities beyond TCA toxicity and should be considered more broadly.

We present a 50-year-old man who suffered an out-of-hospital cardiac arrest with a wide-complex bradycardia (QRS 184 ms) due to suspected quetiapine (atypical antipsychotic) and trazodone (serotonin modulator) overdose. After SB administration, the QRS narrowed to 142 ms and ROSC was immediately achieved.

Trazodone, a popular sleep medication, rarely leads to cardiac arrhythmias, and secondary cardiac arrest is exceptionally rare. Nonetheless, both trazodone and quetiapine can cause SCB in toxic doses. Intravenous SB can rapidly overcome medication-induced SCB and narrow a prolonged QRS and/or QTc interval. Although the role of SB in cardiac arrest remains limited, SB in SCB toxicity in TCA overdose and in other drug toxicities can be life-saving. SB should be considered in patients with wide QRS and suspected drug overdose.