CASE REPORT
A 38 year-old female with a past medical history of huffing-associated cardiac arrest, was standing at the bus stop when she was witnessed to experience tonic-clonic seizure activity followed by collapse. Emergency Medical Services arrived on the scene shortly thereafter and she was found to be in ventricular fibrillation.  Epinephrine 3mg and Amiodarone 450mg were administered as bolus therapy and she was defibrillated thee time for persistent ventricular tachycardia.  The patient had return of spontaneous circulation, but in the emergency department (ED) developed torsade de pointes (Figure, Panel A ), which degenerated into ventricular fibrillation requiring defibrillation. According to acquaintance reports, the patient was huffing volatile chemicals just prior to her arrest.
In the ED, her physical examination was unrevealing. Her laboratory analysis was notable for a critically low serum potassium concentration of 2.6 mEq/L (normal range 3.5-4.5), high sensitivity troponin-I of 2,406 ng/L (reference range < 34 ng/L), and elevated serum lactate at 6.3 mmol/L (reference range 0.3-2.0 mmol/L); consistent with acidosis from resuscitated sudden cardiac death and resultant systemic hypoperfusion. The patient was intubated and transferred to the intensive care unit and during transit, torsade de pointes recurred (Figure, Panel B ), resolving spontaneously. She was admitted with a primary diagnosis of cardiac arrest secondary to tetrafluoroethane inhalation. Electrocardiography (ECG) revealed a rate-corrected QT interval (QTc) of 502 ms. Emergent transthoracic echocardiography revealed normal left ventricular systolic function with an ejection fraction of 60% by Simpson’s biplane method without segmental wall motion abnormalities. Therefore, coronary angiography was deferred despite elevated biomarkers. Urine toxicology was positive for amphetamines (1,000 ng/ml cutoff for detection), but negative for cocaine. Serum toxicology was negative for ethanol (<10 ng/ml). Toxicology for volatile petrochemicals was not available in our laboratory. Unfortunately, the patient had severe anoxic brain injury with marked autonomic dysfunction and supportive care was ultimately withdrawn.