Clinical review: Aggressive management and extracorporeal support for drug-induced cardiotoxicity

Failure of various organs may result in the death of acutely poisoned patients. In the 1960s, sedative-induced respiratory failure was the leading cause of death in Western countries. In these cases, endotracheal intubation and mechanical ventilation dramatically improved the prognosis. Similarly, renal replacement therapy with dialysis prevents deaths related to toxicant-induced acute renal failure. Even drug-induced fulminant liver failure is successfully treated in selected cases by liver transplantation. In contrast, the usefulness of temporary mechanical assistance in drug-induced cardiac failure still remains a matter of debate [1,2].However, promising results have been obtained using a combination of percutaneous cardiopulmonary support and cardiac resuscitation [3,4]. Furthermore, a recent report of the first series of acute poisonings treated with extra-corporeal life support (ECLS) [5], together with an increasing number of case reports [6-10], suggests it is necessary to define the place of this aggressive treatment for drug-induced cardiotropic toxicity.Over the past 30 years, improvements in the treatment of drug-induced cardiovascular shock have been due mainly to a better understanding of the different mechanisms of shock. Routine bedside haemodynamic examinations have provided evidence of the different mechanisms of drug-induced cardiovascular shock, which has enabled the selection of drugs to address the different components of shock. Within the same period of time, indications for mechanical ventilation were extended to conscious poisoned patients presenting with severe cardiovascular shock. Consequently, the prognosis of some cardiotropic drug poisonings improved. Indeed, in a prospective study with historical controls, the combination of epinephrine, diazepam and mechanical ventilation significantly improved the outcome of previously fatal chloroquine poisonings [11,12].In addition to supportive treatment, a number of antidotes and specific treat