Clinical Practice and Cases in Emergency Medicine

Introduction: Kratom (Mitragyna speciosa) is an unregulated herbal supplement increasingly associated with severe toxicity. Concentrated liquid formulations pose risks, with emerging reports of seizures, hepatotoxicity, and arrhythmias.

Case Report:A previously healthy 24-year-old woman ingested a highly concentrated kratom extract and developed seizure-like activity followed by pulseless monomorphic ventricular tachycardia. She underwent approximately 45 minutes of resuscitation, including multiple defibrillations, dual-sequential shocks, amiodarone, lidocaine, magnesium, calcium, sodium bicarbonate, potassium repletion, epinephrine, and esmolol. Persistent instability prompted consultation with cardiology and cardiothoracic surgery, and she was cannulated for venoarterial extracorporeal membrane oxygenation (ECMO) in the emergency department. Lab studies showed profound hypokalemia, acidosis, and elevated lactate. Urine toxicology confirmed mitragynine. She stabilized on ECMO, was decannulated on hospital day two, extubated on day three, and discharged home neurologically intact on day seven.

Conclusion: Concentrated kratom extracts can precipitate life-threatening ventricular arrhythmias in previously healthy individuals. Emergency physicians should consider kratom in unexplained cardiac arrests and recognize the role of advanced support, including ECMO, in refractory toxicologic arrests.