Background: Exposures to designer drugs have increased significantly over the last decade. 2C-E, a synthetic hallucinogenic phenethylamine, is an emerging designer drug that is available on the Internet. We report the first case, to our knowledge, of a fatal 2C-E exposure that had sustained return of spontaneous circulation (ROSC) after intravenous fat emulsion (IFE) therapy.
Case Report: A 19-year old man developed agitation and violent behavior one hour after inhaling 2C-E at a party. He subsequently collapsed and became unresponsive. His friends attempted CPR for approximately 30 min before driving him to a local hospital. The patient was found to be in cardiac arrest upon arrival with a rectal temperature of 104.7 degrees F. Standard ACLS measures were performed; 1.6 mg naloxone, 4 mg atropine, 5 mg epinephrine, 3 g Ca 2 , and 250 mEq sodium bicarbonate (bicarb) were administered. An IFE bolus of 90 mL of 20% solution was administered 46 minutes after ED arrival and sustained ROSC occurred simultaneously. He was given an additional 150 mEq of bicarb and infusions of dopamine, norepinephrine and IFE at 900 mL/hr were started. External cooling with the Arctic Sun (TM) device was initiated and acetaminophen administered. Initial labs revealed the following: sodium 150 mEq/L, CO2 4 mEq/L, glucose 282 mg/dL, creatinine 2.1 mg/dL, lactate 32.6 mEq/L, troponin 0.01 ng/mL, acetaminophen 5 mcg/ mL, salicylate 2.5 mg/dL, ethanol 0.06 mg/dL, and INR 2.1. The comprehensive urine drug screen was positive only for facility administered medications. He died several hours later due to severe physiologic derangements resulting from his prolonged arrest. The Bureau of Criminal Apprehension confirmed the substance as 2C-E.
Discussion: There are no documented cases of severe injury or death related to the use of 2C-E. The mainstay of treatment, similar to that of other hallucinogenic amphetamines, is hydration, benzodiazepines, and supportive care. IFE was used in this case due to cardiac arrest refractory to standard ACLS measures. Sustained ROSC correlated with the timing of IFE bolus administration. The use of IFE as a treatment is an expanding area of interest in toxicology. The literature is replete with reports of its successful use in the management of lethal overdoses, particularly those due to anesthetics and lipophilic drugs. This is the first reported use of IFE for the treatment of cardiac arrest due to phenethylamines.
Conclusion: Intravenous fat emulsion should be considered in patients with a deteriorating clinical condition or cardiac arrest due to phenethylamines refractory to conventional therapies.