Calcium channel blocker toxicity: Difference between revisions
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##SLUDGE | ##SLUDGE | ||
==Treatment== | == Treatment == | ||
*Monotherapy only successful for trivial overdoses | |||
*Charcoal 1g/kg (max 50g) x1 | *Monotherapy only successful for trivial overdoses | ||
*Charcoal 1g/kg (max 50g) x1 | |||
**Consider if present w/in 1-2hr w/ delayed-release preparation | **Consider if present w/in 1-2hr w/ delayed-release preparation | ||
#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 | ||
###Requires frequent glucose and K checks | ###Requires frequent glucose and K checks | ||
##Potassium | ##Potassium | ||
###If | ###If <3 administer 20mEq IV | ||
#Calcium | #Calcium | ||
##Calcium gluconate 3g (30-60mL of 10% soln) | ##Calcium gluconate 3g (30-60mL of 10% soln) | ||
##Calcium chloride 1g (10-20mL of 10% soln (requires large IV/central line) | ##Calcium chloride 1g (10-20mL of 10% soln (requires large IV/central line) | ||
#Vasopressors | #Vasopressors | ||
##Norepinephrine is agent of choice | ##Norepinephrine is agent of choice | ||
#Glucagon | #Glucagon | ||
##5mg IV bolus q10min x 2 | ##5mg IV bolus q10min x 2 | ||
#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) | ||
7. Intravenous lipid emulsion (when standard treatment fails | |||
1. 1.5mL/kg of 20% lipid followed by 0.25mL/kg/minute<br> 2. Data show significant benefit in animals and case reports show promise in humans<br> ***** If used, report on http://www.lipidrescue.org to contribute to the database ******<br> | |||
==Disposition== | ==Disposition== | ||
Revision as of 01:47, 20 July 2012
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
- Note: with higher doses peripheral selectivity is lost
- 2. Non-dihydropyridines (verapamil, diltiazem)
- Stronger effect on heart, weak vasodilators
- Toxicity = Bradycardia, decreased inotropy
- 1. Dihydropyridines (nifedipine, amlodipine, nicardipine)
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
- ECG
- PR prolongation
- Bradydysrhythmia
- Glucose
- Chemistry
DDx
- Beta blockers
- More likely to cause CNS changes
- Hypoglycemia is more common
- Digoxin
- Nausea/vomiting is more common
- Clonidine
- Miosis, somnolence
- Cholinergic agents
- SLUDGE
Treatment
- Monotherapy only successful for trivial overdoses
- Charcoal 1g/kg (max 50g) x1
- Consider if present w/in 1-2hr w/ delayed-release preparation
- High-dose insulin and glucose
- Takes 30-60min for effect
- Glucose:
- Adult: 50mL of D50W
- Ped: 2.5mL/kg of D10
- Insulin bolus 1 unit/kg followed by 0.5units/kg/hr
- Titrate infusion until hypotension is corrected or max 2u/kg/hr
- Requires frequent glucose and K checks
- Potassium
- If <3 administer 20mEq IV
- Calcium
- Calcium gluconate 3g (30-60mL of 10% soln)
- Calcium chloride 1g (10-20mL of 10% soln (requires large IV/central line)
- Vasopressors
- Norepinephrine is agent of choice
- Glucagon
- 5mg IV bolus q10min x 2
- Fluids
- Atropine
- Adult: 0.5-1mg IV q2-3min to max of 3g
- Ped: 0.02mg/kg (minimum is 0.1mg)
7. Intravenous lipid emulsion (when standard treatment fails
1. 1.5mL/kg of 20% lipid followed by 0.25mL/kg/minute
2. Data show significant benefit in animals and case reports show promise in humans
***** If used, report on http://www.lipidrescue.org to contribute to the database ******
Disposition
- Admit all symptomatic pts
- Admit all sustained-release ingestions
- D/C if asymptomatic x 6-8hrs
See Also
Source
Rosen's