Bicarbonate Therapy for Arrhythmias

Primary Indication: Sodium Channel Blocker-Induced Arrhythmias

• The American Heart Association recommends bicarbonate for ventricular arrhythmias caused by tricyclic antidepressant overdose and other sodium channel blocker toxicity, particularly when QRS prolongation exceeds 120 milliseconds 1, 2
• Bicarbonate works by reversing cardiac conduction delays and ventricular arrhythmias caused by sodium channel blockade, not by correcting acidosis per se, as supported by the American College of Cardiology 2

Secondary Indication: Hyperkalemia-Associated Arrhythmias

• Bicarbonate serves as a temporizing measure for life-threatening arrhythmias caused by severe hyperkalemia by shifting potassium intracellularly, according to the American Heart Association 1

Arrhythmias Where Bicarbonate is NOT Indicated

Ventricular Fibrillation/Cardiac Arrest

• The American Heart Association does not recommend routine bicarbonate administration during cardiac arrest, as it may be harmful, with no improvement in ROSC, hospital admission, or survival to discharge 1, 5

Torsades de Pointes

• The American College of Cardiology recommends magnesium sulfate 1-2 g IV, not bicarbonate, for the treatment of torsades de pointes 1, 2, 5

Critical Monitoring During Bicarbonate Therapy for Arrhythmias

• Monitor serum sodium every 2-4 hours, avoiding levels >150-155 mEq/L, as advised by the American Heart Association 3
• Monitor arterial pH every 2-4 hours, avoiding pH >7.50-7.55, except in TCA toxicity where the target is 7.45-7.55, according to the American College of Cardiology 3

Common Pitfalls to Avoid

• Never mix bicarbonate with calcium-containing solutions or vasoactive amines, as it causes precipitation/inactivation, as warned by the American Heart Association 1, 3