Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults

St‐Onge, Maude; Anseeuw, Kurt; Cantrell, F. Lee; Gilchrist, Ian C.; Hantson, Philippe; Bailey, Benoît; Lavergne, Valéry; Gosselin, Sophie; Kerns, William; Laliberté, Martin; Lavonas, Eric J.; Juurlink, David N.; Muscedere, John; Yang, Chen Chang; Sinuff, Tasnim; Rieder, Michael J.; Mégarbane, Bruno

doi:10.1097/ccm.0000000000002087

Cited by 125 publications

(194 citation statements)

References 96 publications

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“…Glucagon failed to improve the haemodynamics of several patients as reported by three case series 35–37. An experts consensus report looking into the treatment of calcium channel blocker toxicity does not recommend the routine use of glucagon due to reported variable effects 38. In addition, glucagon reliably results in inhibition of gastric contractions, nausea and vomiting, which could further complicate the course of a patient with altered mental status who has yet to be intubated 39…”

Section: Discussionmentioning

confidence: 99%

Pharmacological and mechanical management of calcium channel blocker toxicity

Fadhlillah¹,

Patil

2018

BMJ Case Reports

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Cardiovascular instability associated with calcium channel blocker toxicity comprises a small percentage of overdose presentations, yet they are associated with a high mortality rate. We detail the management of a 64-year-old man who took an intentional overdose of 840 mg nimodipine. We include the treatment he received and highlight the scarcity of evidence behind the use of gastric decontamination, calcium, glucagon, intravenous lipid emulsion, high-dose insulin therapy, sodium bicarbonate, vasopressors and methylene blue in calcium channel blocker toxicity. Additionally, the article explores the use of electrical pacing and venoarterial extracorporeal membrane oxygenation (VA-ECMO). Following successful weaning of VA-ECMO, the patient was successfully extubated but remained neurologically impaired due to hypoxic-ischaemic brain injury, critical care polyneuropathy and renal failure requiring dialysis. He has cerebral performance category 3; he has mild cognitive impairment but able to perform some activities of daily living independently and communicate his thoughts and needs. He requires no respiratory or cardiovascular support.

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Section: Discussionmentioning

confidence: 99%

Pharmacological and mechanical management of calcium channel blocker toxicity

Fadhlillah¹,

Patil

2018

BMJ Case Reports

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“…Expert consensus recommendations for the management of CCB poisonings were published and stepwise management was recommended. However, unfortunately, there are no strongly recommended first‐line treatments for refractory patients and the level of evidence was very low 2. Therefore, a multimodal therapeutic approach is often used according to the situation 3, 4, 5…”

Section: Discussionmentioning

confidence: 99%

Efficacy of isoproterenol for treating amlodipine overdose resulting in bradycardia

Ebihara

Morita

Kawada

et al. 2017

Acute Medicine & Surgery

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CaseAmlodipine predominantly affects vascular smooth muscle cells. Amlodipine overdose usually presents with vasodilatory shock, accompanied by reflex tachycardia rather than bradycardia.An 81‐year‐old woman presented with impaired consciousness 8 h after ingesting 50 5‐mg amlodipine tablets with suicidal intent. On admission, her blood pressure was 50/40 mmHg and her heart rate was 45 b.p.m. Serum amlodipine level was extremely high (474.4 ng/mL), causing refractory bradycardia. She remained hypotensive despite fluid resuscitation, and therefore was administered dopamine and norepinephrine. She was also administered glucagon and calcium gluconate, and underwent high‐dose insulin euglycemic therapy.OutcomeAlthough her blood pressure improved, bradycardia progressively worsened and isoproterenol infusion was initiated, which resulted in an improvement in her heart rate. The patient discharged on day 14 without any complications.ConclusionIsoproterenol is effective for treating bradycardia after amlodipine overdose.

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“…Gastric lavage or activated charcoal may be considered if patients present less than 1 hour post-ingestion. IV calcium is also recommended in early management for improvement in contractility and blood pressure because it is readily available and carries little risk [15][16][17][18]. Vasopressor and HDI therapy should be considered early to maintain mean arterial pressures with frequent glucose and electrolyte monitoring.…”

Section: Discussionmentioning

confidence: 99%

A Case of Amlodipine Overdose: Role of High Dose Insulin Therapy

Tran¹,

Tang²,

Webber³

et al. 2017

EMIJ

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Introduction: High dose insulin (HDI) therapy, defined as > 0.5 units/kg/hour, has been postulated to improve hemodynamics in both calcium channel blocker (CCB) and beta-blocker overdose. Proposed benefits of HDI include coronary and systemic vasodilation due to enhancement of nitric oxide synthase activity leading to improved contractility and decreased systemic vascular resistance, respectively. HDI also directly improves cardiac contractility by increasing glucose uptake and improving calcium handling within cardiac cells. We present a case of a patient with amlodipine overdose and her response to HDI therapy.Case presentation: A 52 year old female presented with amlodipine overdose after suicide attempt leading to shock. She received continuous intravenous infusion of regular insulin at a rate of 2 units/kg/hour and epinephrine titrated up to 80 mcg/hour to maintain mean arterial pressure above 65. After several hours, there was concern for worsening hypokalemia so insulin was suspended. Patient subsequently became more hypotensive, requiring further uptitration of epinephrine. When continuous insulin was later restarted, there was an observed immediate improvement in blood pressure. Patient was eventually weaned off of vasopressors, followed by insulin, by day 3. She was downgraded from the ICU on day 5. Conclusion:In patients with CCB overdose, initial management should include fluid resuscitation, calcium supplementation, and early consideration of vasopressors and HDI therapy. Although there are currently no controlled human studies to evaluate the benefits of HDI therapy, this case revealed worsening hypotension upon cessation of therapy followed by rapid improvement in blood pressure when restarting insulin. Based on this observation, HDI therapy may have a prominent role in management of CCB overdose.

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Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults

Abstract: Supplemental Digital Content is available in the text.

Cited by 125 publications

References 96 publications

Pharmacological and mechanical management of calcium channel blocker toxicity

Pharmacological and mechanical management of calcium channel blocker toxicity

Efficacy of isoproterenol for treating amlodipine overdose resulting in bradycardia

A Case of Amlodipine Overdose: Role of High Dose Insulin Therapy

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