Flecainide toxicity--treatment with intravenous fat emulsion and extra corporeal life support.

ventricular arrhythmias include phase two re-entry as well as triggered automaticity following intracellular calcium accumulation in epicardial cells (5). Cardiac arrhythmias seen with hypothermia usually resolve spontaneously with rewarming (6). It has been noted that hypothermic myocardium is less responsive to antiarrhythmic drugs and defi brillation at temperatures below 28 ° C/82.4 ° F (6), as noted in our patient. When cardiac instability with loss of circulation is noted, the best available care includes extra-corporeal membrane oxygenation (ECMO) or CPB (7). Th e neurologically intact survival rate in cardiac arrest patients treated with these modalities is approximately 50% (8). In patients with return of spontaneous circulation, the rates of multi-organ failure are high and pulmonary edema is encountered frequently (8). Th is is probably why ECMO has slightly better outcomes than traditional CPB as it is capable of providing pulmonary support (7). Remarkably, the patient walked home, neurologically intact aft er a prolonged hospital stay complicated by acute respiratory distress syndrome, prolonged delirium, clostridium diffi cile colitis and acute tubular necrosis due to rhabdomyolysis. In summary, it is important to anticipate life-threatening arrhythmias when managing a severely hypothermic patient and recognize that usual resuscitative measures may fail. Early activation of surgical/trauma protocols to institute appropriate re-warming including CPB/ECMO is vital. Declaration of interest: Th e authors report no confl icts of interest. Th e authors alone are responsible for the content and writing of the paper.