Calcium channel blocker toxicity: Difference between revisions

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==Work-Up==
==Work-Up==
*ECG
#ECG
**PR prolongation
##PR prolongation
**Bradydysrhythmia
##Bradydysrhythmia
*Glucose
#Glucose
*Chemistry
#Chemistry


==DDx==
==DDx==
*Beta blockers
#Beta blockers
**More likely to cause CNS changes
##More likely to cause CNS changes
**Hypoglycemia is more common
##Hypoglycemia is more common
*Digoxin
#Digoxin
**Nausea/vomiting is more common
##Nausea/vomiting is more common
*Clonidine
#Clonidine
**Miosis, somnolence
##Miosis, somnolence
*Cholinergic agents
#Cholinergic agents
**SLUDGE
##SLUDGE


==Treatment==
==Treatment==
*Monotherapy only successful for trivial overdoses
Monotherapy only successful for trivial overdoses


Phase 1
===Phase 1===
*Charcoal 1g/kg (max 50g)
#Charcoal 1g/kg (max 50g)
**Consider if present within 1-2hr with delayed-release preparation
##Consider if present within 1-2hr with delayed-release preparation
*Fluids
#Fluids
*Atropine
#Atropine
**Adult: 0.5-1mg IV q2-3min to max of 3g
##Adult: 0.5-1mg IV q2-3min to max of 3g
**Ped: 0.02mg/kg (minimum is 0.1mg)
##Ped: 0.02mg/kg (minimum is 0.1mg)
*Calcium
#Calcium
**Calcium gluconate 30-60mL of 10% soln
##Calcium gluconate 30-60mL of 10% soln
**Calcium chloride 10-20mL of 10% soln (requires central line)
##Calcium chloride 10-20mL of 10% soln (requires central line)


Phase 2
===Phase 2===
*Glucagon
#Glucagon
**5mg IV bolus q10min x 2
##5mg IV bolus q10min x 2
*Vasopressors
#Vasopressors
**Norepinephrine is agent of choice
##Norepinephrine is agent of choice
*High-dose insulin and glucose
#High-dose insulin and glucose
**Takes 30-60min for effect
##Takes 30-60min for effect
**Glucose:
##Glucose:
***Adult: 50mL of D50W
###Adult: 50mL of D50W
***Ped: 2.5mL/kg of D10
###Ped: 2.5mL/kg of D10
**Insulin bolus 1 Unit/kg followed by 0.5units/kg/hr
##Insulin bolus 1 Unit/kg followed by 0.5units/kg/hr
***Titrate infusion until hypotension is corrected or max 2u/kg/hr
###Titrate infusion until hypotension is corrected or max 2u/kg/hr
**Potassium
##Potassium
***If <3 administer 20mEq IV
###If <3 administer 20mEq IV


==Disposition==
==Disposition==
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==Source==
==Source==
Rosen's
Rosen's


[[Category:Cards]]
[[Category:Tox]]
[[Category:Tox]]

Revision as of 21:22, 11 June 2011

Background

  • Hemodialysis is ineffective
  • Precipitous deterioration is common (esp w/ verapamil)
  • Nifedipine can kill a child with a single pill
  • 2 Classes:
    • 1. Dihydropyridines (nifedipine, amlodipine, nicardipine)
      • Systemic vasodilation, mild effect on heart
      • Toxicity = Hypotension, reflex tachycardia
        • Note: with higher doses peripheral selectivity is lost
          • I.e. may see decreased inotrophy, bradycardia
    • 2. Non-dihydropyridines (Verapamil, diltiazem)
      • Stronger effect on heart, weak vasodilators
      • Toxicity = Bradycardia, decreased inotropy

Diagnosis

  • Cardiovascular
    • Hypotension (any CCB overdose)
    • Bradycardia (usually only seen with verapamil/dilt)
    • AV/sinus block
    • CHF
  • Pulmonary
    • Respiratory depression
    • Pulmonary edema
  • GI
    • Nausea/vomiting
  • Neurologic
    • Lethargy, confusion, coma
  • Metabolic
    • Hyperglycemia

Work-Up

  1. ECG
    1. PR prolongation
    2. Bradydysrhythmia
  2. Glucose
  3. Chemistry

DDx

  1. Beta blockers
    1. More likely to cause CNS changes
    2. Hypoglycemia is more common
  2. Digoxin
    1. Nausea/vomiting is more common
  3. Clonidine
    1. Miosis, somnolence
  4. Cholinergic agents
    1. SLUDGE

Treatment

Monotherapy only successful for trivial overdoses

Phase 1

  1. Charcoal 1g/kg (max 50g)
    1. Consider if present within 1-2hr with delayed-release preparation
  2. Fluids
  3. Atropine
    1. Adult: 0.5-1mg IV q2-3min to max of 3g
    2. Ped: 0.02mg/kg (minimum is 0.1mg)
  4. Calcium
    1. Calcium gluconate 30-60mL of 10% soln
    2. Calcium chloride 10-20mL of 10% soln (requires central line)

Phase 2

  1. Glucagon
    1. 5mg IV bolus q10min x 2
  2. Vasopressors
    1. Norepinephrine is agent of choice
  3. High-dose insulin and glucose
    1. Takes 30-60min for effect
    2. Glucose:
      1. Adult: 50mL of D50W
      2. Ped: 2.5mL/kg of D10
    3. Insulin bolus 1 Unit/kg followed by 0.5units/kg/hr
      1. Titrate infusion until hypotension is corrected or max 2u/kg/hr
    4. Potassium
      1. If <3 administer 20mEq IV

Disposition

  • Admit all symptomatic pts
  • Admit all sustained-release ingestions
  • D/C if asymptomatic x 6-8hrs

See Also

Source

Rosen's

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