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Clinical Practice:
S. Dolenska
Intraoperative cardiac arrest in acquired long QT syndrome
Br. J. Anaesth. 2009; 102: 503-505 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read E-letter] Intraoperative cardiac arrest in acquired long QT syndrome or cocaine overdose leading to ventricula
Kathryn E Morris   (16 June 2009)

Intraoperative cardiac arrest in acquired long QT syndrome or cocaine overdose leading to ventricula 16 June 2009
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Kathryn E Morris,
consultant anaesthetist

Send letter to journal:
Re: Intraoperative cardiac arrest in acquired long QT syndrome or cocaine overdose leading to ventricula

Editor – the maximum total dose of cocaine for application to the nasal mucosa in fit adults is 1.5 mg/kg.

The BNF recommends that in otolaryngology cocaine is applied to the nasal mucosa in concentrations of 4 – 10% and suggests that ‘It should be used only by those skilled in the precautions needed to minimise absorption and the consequent risk of arrhythmias.’(1)

The 35 year old healthy female quoted in this case report by Dolenska (2) probably received between 2.5 and 3 times the recommended dose of cocaine.

VF arrest secondary to iatrogenic cocaine overdose is the diagnosis in this case.

In July 1995, ‘Lesson of the Week’ in the British Medical Journal, reported cases where patients were given similar overdoses and developed ventricular fibrillation within 30 seconds of receiving cocaine in the form of 25% paste (with adrenaline 0.18%) applied to nasal mucosa.(3)

It pointed out the difficulty of applying small quantities of a highly concentrated paste, without exceeding the recommended dose of cocaine.

Instrumentation of the nose immediately following cocaine administration is thought to increase the risk of arrhythmias.(4) In this case, injection of the nasal mucosa may have been contributory.

If cocaine is used, it must be used with caution. Recommended dose limits must not be exceeded.

It seems this lesson has not been learnt.

1. British Medical association-Royal Pharmaceutical Society of Great Britain. British National Formulary. No 56:BMA-RPS,2008: 695 2. Dolenska S. Intraoperative cardiac arrest in acquired long QT syndrome. BJA 102(4):503-5 (2009)

3. Nicholson KEA, Rogers JEG. Lesson of the Week. British Medical Journal 1995; 311:250-251

4. Williamson P, Slack R. BMJ 1995;311:1089 (correspondence)

Conflict of Interest:

None declared