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Cardiac Arrest and Seizure Following Cannabis Overdose and Alcohol Withdrawal

Annals of Case Reports and Images. 2018;1(1):5
DOI: 10.24983/scitemed.acri.2018.00082
Article Type: Case Report


Cannabis remains one of the most universally abused recreational drugs. Cannabis abuse can have several cardiovascular adverse effects and an overdose can lead to cardiac arrest. Binge alcohol drinking and subsequent withdrawal in the background of cannabis overdose can lead to convulsion and QT prolongation leading to malignant arrhythmia. We report two cases of ventricular fibrillation complicated with seizure precipitated by cannabis overdose and alcohol withdrawal. Such serious clinical presentation complicated with cardiac arrest does not necessarily lead to a fatal outcome if timely medical attention and care are provided. Timely aggressive resuscitative measures combined with intensive care can lead to a successful outcome. Later on, psychiatric counseling and occupational and behavioral therapies can help them to live longer.


  • Alcohol withdrawal; cannabis overdose; cardiac arrest; seizure


Cannabis remains one of the most universally abused recreational drugs worldwide and its popularity has increased considerably due to the recent legalization and medicinal use [1-5]. Sometimes, cannabis overuse can lead to malignant arrhythmia leading to cardiac arrest [5,6]. Alcohol withdrawal following binge drinking combined with cannabis abuse can lead to malignant arrhythmia, seizure, and at times culminating in cardiac arrest [2,5,6]. We report two cases of ventricular fibrillation (VF) complicated with seizure caused by cannabis overdose and alcohol withdrawal following binge drinking.

Case Report

Case 1
A 22-year-old female was found collapsed at home where she received cardiopulmonary resuscitation (CPR) on the spot. In the ambulance, she had witnessed seizure and her breathing became erratic. She was defibrillated for having VF. On arrival to our emergency department, her Glasgow Coma Scale (GCS) was 3/15 and she was intubated. Her vital parameters were stable, but she was acidotic (Table 1). Her urine was found to be positive for cannabis (quantitative estimation was not available). Her computerized tomography (CT) scan of brain and lumbar puncture report were found to be normal. She was transferred to our intensive care unit (ICU) for subsequent care.

When inquired, her relatives told that she smoked several cannabis cigarettes (amounts unknown) and had several units of wine (1 unit of wine in Ireland amounts to ten gram of alcohol) previous night in a party. She was a diagnosed case of asthma and epilepsy for last three years, for which she was currently not in any treatment. She was clinically seizure-free for the last two years. She was a regular cannabis abuser.

In the ICU, she was kept sedated and received phenytoin and levetiracetam for seizure control. She was found to have prolonged rate-corrected QT interval on her electrocardiogram (ECG), for which she received intravenous magnesium sulphate. Subsequently, she was weaned from the ventilator and was extubated after four days. Later, she was discharged to the ward from where she went home.

Case 2
A 24-year-old female was brought to our emergency department after she was found collapsed at home. She smoked several cannabis cigarettes and had several units of wine previous night (again the exact amount was not known). She received CPR and was shocked once for having VF. She was found to be unconscious (GCS of 3/15) and thus was intubated. She had a history of deep venous thrombosis in 2012 and was a regular street drugs abuser (clear history not revealed to us). Her urine was found to be positive for benzodiazepine and cannabis (again the quantitative test was not available). Her CT scan of the brain was found to be normal. She was later transferred to our ICU for subsequent management. She developed recurrent episodes of seizure even after treatment with intravenous phenytoin and midazolam. Her seizure could be controlled with intravenous infusion of phenytoin and regular levetiracetam. She was also found to have prolonged rate-corrected QT interval, for which she received intravenous magnesium as she had a malignant arrhythmia. Finally, she was extubated and discharged to home after 8 days.

Both these patients were kept under psychiatry follow-up and evaluation. To the best of our knowledge, neither of them had any similar event.


Majority of effects of cannabis, including serious cardiac side effects, are mediated by active ingredient delta-9-Tetrahydrocannabinol, a strong myocardial stimulant, through cannabis receptors [1-3]. Cannabis has been reported to cause several types of arrhythmias due to direct effect as well as sympathetic stimulation [1]. It is also known to be a proconvulsant or an anticonvulsant agent [3].

Binge drinking has also been reported to be proarrhythmogenic [1,4]. Alcohol withdrawal can also lead to prolonging rate-corrected QT interval precipitating in malignant arrhythmias [4,5]. Adding to this, the alcohol withdrawal can precipitate seizure typically manifesting after 6-48 hours [3,6].

Cannabis in combination with alcohol produces pronounced synergetic myocardial effect culminating in life-threatening VF complicated with seizure, which can lead to cardiac arrest [1,3]. Both the patients consumed a high amount of cannabis and alcohol (although the exact figure was not known) and were chronic abusers of both. Also, to admit that, this VF combined with seizure might have been caused by cannabis overdose or alcohol withdrawal. It was not possible for us to pinpoint the exact etiology, as both factors were well known to cause such adverse effects.

These two case reports showed that the combined massive ingestion of alcohol and cannabis and the induced cardiac arrhythmia could lead to a serious cardiac event propagating to cardiac arrest. Cannabis is known to induce myocardial ischemia and malignant arrhythmia in toxic overdose, but when combined with massive alcohol ingestion and subsequent withdrawal, this can lead to cerebral excitation propagating to seizure, as both alcohol withdrawal and delta-9-Tetrahydrocannabinol can lead to seizure. Cardiac arrest in such a situation is always dangerous and has serious consequences and even can lead to fatality as known for and cardiac arrest. Timely targeted resuscitative effort can result in a successful outcome in the otherwise young healthy individuals and we should always make a positive resuscitative effort in such cases instead of losing hope. Afterward psychiatric counseling, occupational and behavioral therapies, along with lifestyle modifications can help these people to live longer.


Cannabis abuse can also lead to serious cardiac dysrhythmia complicated with seizure and ultimately cardiac arrest. If timely and proper resuscitative efforts are instituted, these patients can have a successful outcome.


  1. Charbonney E, Sztajzel JM, Poletti PA, Rutschmann O. Paroxysmal atrial fibrillation after recreational marijuana smoking: another “holiday heart”? Swiss Med Wkly 2005;135(27-28):412-414. PMID: 16220412; DOI: 2005/27/smw-11014
  2. Mittleman MA, Lewis RA, Maclure M, Sherwood JB, Muller JE. Triggering myocardial infarction by marijuana. Circulation 2001;103(23):2805-2809. PMID: 11401936
  3. Gordon E, Devinsky O. Alcohol and marijuana: effects on epilepsy and use by patients with epilepsy. Epilepsia 2001;42(10):1266-1272. PMID: 11737161
  4. George A, Figueredo VM. Alcohol and arrhythmias: a comprehensive review. J Cardiovasc Med (Hagerstown) 2010;11(4):221-228. PMID: 19923999; DOI: 10.2459/JCM.0b013e328334b42d
  5. Rodrigo C, Epa DS, Sriram G, Jayasinghe S. Acute coronary ischemia during alcohol withdrawal: a case report. J Med Case Rep 2011;5:369. PMID: 21838872; PMCID: PMC3170349; DOI: 10.1186/1752-1947-5-369
  6. McMicken D, Liss JL. Alcohol-related seizures. Emerg Med Clin North Am 2011;29(1):117-124. PMID: 21109108; DOI: 10.1016/j.emc.2010.08.010

Editorial Information

Publication History

Received date: July 24, 2018
Accepted date: August 15, 2018
Published date: September 22, 2018



Conflict of Interest


Informed Consent

The patients’ consents were obtained.


© 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY).

Department of Anaesthesia and Intensive Care, Our Lady of Lourdes Hospital, Drogheda, Ireland
Department of Anaesthesia and Intensive Care, University Hospital Limerick, Dooradoyle, Limerick, Ireland
Department of Anaesthesia and Intensive Care, Tallaght Hospital, Dublin, Ireland
Department of Anaesthesia and Intensive Care, Our Lady of Lourdes Hospital, Drogheda, Ireland
University of Management and Administration, WisZia, Zamosc, Poland
Department of Anaesthesia and Intensive Care, University Hospital Limerick, Dooradoyle, Limerick, Ireland

Address: Department of Anaesthesia and Intensive Care, University Hospital Limerick, St Nessan's Rd, Dooradoyle, Co. Limerick, V94 F858, Ireland
Table 1. Laboratory parameters of patients.

Peer Review Report: Round 1

Reviewer 1 Comments

  1. This case report is structurally well-written. However, there are still some issues that need to be addressed.
    ResponseThanks for the positive input. We really appreciate this. We have tried our best to respond to your queries. We hope the manuscript will be acceptable now. However, we are ready to answer any further queries.
  2. In Case 1, her relatives told that she smoked cigarettes containing cannabis and had several units of alcohol last night. Please clarify how her family define unit of alcohol. Units of alcohol are used in the United Kingdom as a measure to quantify the actual alcoholic content within a given volume of an alcoholic beverage to provide guidance on total alcohol consumption. One unit of alcohol is defined as 10 milliliters (8 grams) of pure alcohol. Typical quantities or servings of common alcoholic beverages may contain 1-3 units of alcohol. This above-mentioned definition is based on the data provided by Wikipedia databank. If it is hard to clearly determine the amount of alcohol consumed, the sentence should be conservatively revised.
    ResponseAll information about the night party we got from hearsay of the relatives, and we had to believe on that as there was not a hard proof of it. In Ireland the measurement of unit is bit higher compared to UK. In Case 1, the patient drank mostly wine, and 1 unit of wine in Ireland amounts to 10 grams of alcohol compared to 8 grams in UK (Reference). As there was no hard proof of how much units of wine she drank in the night party and she also does not remembered it, we are not able provide the figure. But she was found fully drank and unconscious to be escorted home which amounts to heavy drinking. In our emergency department we can only measure urine or blood positive for alcohol, not the amount. Also, the patient came to us much later when most of the alcohol was metabolized or excreted.
  3. How long had Case 1 been diagnosed as seizure and how long had she stopped treatment for seizure? Did the seizure occur before the current seizure attack?
    ResponseThe patient was diagnosed with seizure three years ago and she was clinically seizure-free for the last two years. The patient was off the treatment since then.
  4. Did the patients have any history of brain injury or head surgery in the past or take any psychotropic drugs that may lead to this fatal event.
    ResponseNo history of head injury in the past, no neurosurgery in past. She is a regular cannabis abuser. Apart from that there was no history of any use of psychotropic drugs or street drugs.
  5. Did the patients have similar attacks prior to this event.
    ResponseIt was not reported to us when we examined the patient.
  6. Did these two patients followed-up on a regular basis after discharge? Were there any complications or consequences later?
    ResponseThe patients are under regular psychiatry follow-ups in our hospital and we have not received any report of seizure.

Reviewer 2 Comments

  1. This is a well-written case report and can be accepted for publication after minor revision.
    ResponseThanks for the input. We are happy to provide all the relevant revisions.
  2. The authors are suggested to further describe the uniqueness of the cases and how the cases contribute to the existing literature. In general, case reports (1) should make a contribution to medical knowledge; (2) must have educational value; (3) or highlight the need for a change in clinical practice or diagnostic/prognostic approaches. In other words, the lessons or experiences that may be learnt from the case reports should be stated in the Discussion section.
    ResponseManuscript is modified as suggested.
  3. I do not understand what it means by a regular drug abuser in Case 2. Please clarify this point. In addition, was Case 1 a drug abuser as well? Did the authors gain the information on the types of drugs the patients abused?
    ResponseThe street drugs we were referring to was substances like heroin, cocaine, etc. The patient didn’t provide details about what she took. But she was known to be an abuser of those street drugs.
  4. In the Abstract, the sentence “Such presentation even with cardiac arrest does not necessarily lead to fatal outcome” is unclear and should be clarified. I believe cardiac arrest itself is a fatal condition.
    ResponseWe meant that even though such condition leads to cardiac arrest, but if resuscitated timely and properly, the patient can survive and have a good outcome. Cardiac arrest is a critical condition, but not always fatal and as per recent literature after ACLS guideline. The neurological outcome and survival after cardiac arrest is greatly improved if following proper practice.
  5. In the Conclusion section, the authors concluded that “recreational” use of cannabis when combined with alcohol withdrawal following binge drinking can lead to serious cardiac dysrhythmia and seizure. I suggested that the word  “recreational” be deleted as it can also lead to serious cardiac dysrhythmia and seizure if cannabis is not used recreationally.
    ResponseManuscript is modified as suggested.
  6. The word “recurrent” of the title “Cardiac arrest and recurrent seizure following cannabis overdose and alcohol withdrawal” may be deleted. It may be unknown whether every patient with the same situation will have recurrent episodes of seizure.
    ResponseAgree, the manuscript is modified as suggested.

Editorial Comments

  1. Please spell the abbreviation of THC as “delta-9-Tetrahydrocannabinol” to avoid any missing or broken character.
    ResponseManuscript is modified as suggested.
  2. In the Discussion section, the abbreviation of QTc should be spelled out completely, namely rate-corrected QT interval.
    ResponseManuscript is modified as suggested.
  3. Please provide a title page that contains the detailed information on the authors, such as degrees and correspondence details.
    ResponseA title page has been added as suggested.

Peer Review Report: Round 2

Reviewer 1 Comments

The article is now accepted for publication. 

Reviewer 2 Comments

I accept the revised manuscript for publication.