Calcium channel blocker toxicity: Difference between revisions
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*Hemodialysis is ineffective
*Hemodialysis is ineffective
*Precipitous deterioration is common (esp with verapamil)
*Precipitous deterioration is common (esp with verapamil)
*[[Nifedipine]]can kill a child with a single pill
*[[Nifedipine]] can kill a child with a single pill


===2 Classes===
===2 Classes===
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**I.e. may see decreased inotrophy, bradycardia
**I.e. may see decreased inotrophy, bradycardia


====Non-dihydropyridines (verapamil, diltiazem)====
====Non-dihydropyridines====
*[[Verapamil]], [[Diltiazem]]
*Stronger effect on heart, weak vasodilators
*Stronger effect on heart, weak vasodilators
*Toxicity = Bradycardia, decreased inotropy
*Toxicity = Bradycardia, decreased inotropy
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**[[Hypotension]] (any CCB overdose)
**[[Hypotension]] (any CCB overdose)
**[[Bradycardia]] (usually only seen with [[verapamil]]/[[diltiazem]])
**[[Bradycardia]] (usually only seen with [[verapamil]]/[[diltiazem]])
**AV/sinus block
**[[AV block|AV/sinus block]]
**[[CHF]]
**[[CHF]]
*Pulmonary
*Pulmonary
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**[[Nausea/vomiting]]
**[[Nausea/vomiting]]
*Neurologic
*Neurologic
**Lethargy, confusion, coma
**Lethargy, [[confusion]], [[coma]]
*Metabolic
*Metabolic
**[[Hyperglycemia]] (inhibits insulin release from pancreatic islet cells)
**[[Hyperglycemia]] (inhibits insulin release from pancreatic islet cells)
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*[[ECG]]
*[[ECG]]
**PR prolongation (varying degrees of AV block)
**PR prolongation (varying degrees of AV block)
***AV block occurs more commonly with verapamil
***[[AV block]] occurs more commonly with verapamil
**Bradydysrhythmia
**[[Bradyarrythmia]]
*Glucose
*Glucose
**hyperglycemia, may help distinguish β-blocker toxicity
**hyperglycemia, may help distinguish β-blocker toxicity
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*Consider [[whole bowel irrigation]] if sustained or extended-release, esp if the drug is verapamil or diltiazem
*Consider [[whole bowel irrigation]] if sustained or extended-release, esp if the drug is verapamil or diltiazem


===Fluids===
===[[IV fluids]]===
*Initial 20cc/kg bolus especially if source of hypotension is undifferentiated and also possibly hypovolemic or due to [[Sepsis]]
*Initial 20cc/kg bolus especially if source of hypotension is undifferentiated and also possibly hypovolemic or due to [[Sepsis]]


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===[[Glucagon]]===
===[[Glucagon]]===
*5mg IV bolus q10min x 2
*5mg IV bolus q10min x 2
*will often cause severe nausea/vomiting, give Zofran prior
*will often cause severe [[nausea/vomiting]], give [[Zofran]] prior


===[[Vasopressors]]===
===[[Vasopressors]]===
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*Takes 30-60min for effect  
*Takes 30-60min for effect  
*Glucose:  
*[[Dextrose|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 given with 1amp of D50, then 0.5 – 1 unit/kg/hr continuous infusion
*[[Insulin]] bolus 1 unit/kg given with 1amp of D50, then 0.5 – 1 unit/kg/hr continuous infusion
**Titrate infusion until hypotension is corrected or max 2u/kg/hr  
**Titrate infusion until hypotension is corrected or max 2u/kg/hr  
**Titrate dextrose drip to avoid hypoglycemia
**Titrate dextrose drip to avoid hypoglycemia
**initial glucose checks q15 minutes until blood sugar stability established
**initial glucose checks q15 minutes until blood sugar stability established
*Potassium  
*[[Potassium]]
**If <3 administer 20mEq IV
**If <3 administer 20mEq IV


Revision as of 20:25, 27 January 2019

Background

  • Hemodialysis is ineffective
  • Precipitous deterioration is common (esp with verapamil)
  • Nifedipine can kill a child with a single pill

2 Classes

Dihydropyridines

  • Nifedipine, Amlodipine, Nicardipine
    • Systemic vasodilation, mild effect on heart
  • Toxicity = Hypotension, reflex tachycardia
  • With higher doses of toxicity peripheral selectivity is lost
    • I.e. may see decreased inotrophy, bradycardia

Non-dihydropyridines

  • Verapamil, Diltiazem
  • Stronger effect on heart, weak vasodilators
  • Toxicity = Bradycardia, decreased inotropy

Clinical Features

Differential Diagnosis

Symptomatic bradycardia

Evaluation

  • ECG
  • Glucose
    • hyperglycemia, may help distinguish β-blocker toxicity
  • Chemistry
    • Serum calcium is often normal

Management

The majority of literature on calcium channel blocker overdose management is low-quality evidence and high-dose insulin and extracorporeal life support have the best evidence; other therapies such as include calcium, dopamine, norepinephrine, and lipid emulsion therapy may be beneficial but are poorly studied[1]

  • Monotherapy only successful for trivial overdoses

GI decontamination

  • Charcoal
    • 1g/kg (max 50g) x1
    • Consider if present within 1-2hr with delayed-release preparation
  • Consider whole bowel irrigation if sustained or extended-release, esp if the drug is verapamil or diltiazem

IV fluids

  • Initial 20cc/kg bolus especially if source of hypotension is undifferentiated and also possibly hypovolemic or due to Sepsis

Atropine

  • Adult: 0.5-1mg IV q2-3min to max of 3g
  • Ped: 0.02mg/kg (minimum is 0.1mg)
  • Administer to anyone with symptomatic bradycardia

Calcium

Avoid if digoxin toxicity is possible

  • Calcium gluconate 3g (30-60mL of 10% soln)
  • Calcium chloride 1-3g IV bolus (10-20mL of 10% soln (requires large IV/central line)
    • Preferred over calcium gluconate because it provides triple the amount of calcium on a weight-to-weight basis [2]
    • Give Calcium 1g Q5min to titrate to BP effect
    • If effect in BP is seen can give as a drip at 10-50mg/kg/hr
    • can safely push serum Calcium levels to 15-18 or even low 20s if patient tolerates (double normal)

Glucagon

Vasopressors

  • Norepinephrine is agent of choice
    • Start at 2mcg/min, uptitrate rapidly, goal MAP 65mmHg

High-dose insulin and glucose

  • Mechanism of Action: Insulin has a positive inotropic effect on the heart by improving metabolic support of cardiac tissues during hypotensive shock (cardiac tissues preferentially utilize fatty acid as an energy source during normal condition; under stressed conditions, cardiac tissues rely on glucose metabolism as their primary energy source). Some studies have also demonstrated that high doses of insulin can induce endothelial nitric oxide synthase activity and improve microvascular dysfunction by a vasodila- tory effect in cardiac and pulmonary vasculature
  • Takes 30-60min for effect
  • Glucose:
    • Adult: 50mL of D50W
    • Ped: 2.5mL/kg of D10
  • Insulin bolus 1 unit/kg given with 1amp of D50, then 0.5 – 1 unit/kg/hr continuous infusion
    • Titrate infusion until hypotension is corrected or max 2u/kg/hr
    • Titrate dextrose drip to avoid hypoglycemia
    • initial glucose checks q15 minutes until blood sugar stability established
  • Potassium
    • If <3 administer 20mEq IV

Intravenous lipid emulsion

  • 1.5mL/kg bolus of 20% lipid followed by 0.25mL/kg/minute

Disposition

  • Admit all symptomatic patients
  • Admit all sustained-release ingestions
  • Discharge if asymptomatic x 6-8hrs

See Also

Video

{{#widget:YouTube|id=twKMOXaH2dE}}

References

  1. ↑ St-Onge M, et al. Treatment for calcium channel blocker poisoning: a systematic review. Clin Toxicol 2014 PDF
  2. ↑ Tintinalli's 7th Ed.
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