Management in Calcium Channel Blocker Overdose Patients Reported to Ramathibodi Poison Center
Article Sidebar
Main Article Content
Abstract
Besides supportive care, specific managements of severe calcium channel blocker (CCB) overdose are varied, including calcium, high-dose insulin euglycemic therapy (HIE), and high-dose vasopressor. The objective of this study is to describe management and outcome of CCB poisoning in Thailand. Methods. This is a retrospective study of CCB poisoning cases consulted to Ramathibodi Poison Center, during 2012 to 2016. Results. One-hundred and forty-five CCB poisoning cases were retrieved. Most common scenario was intentional amlodipine ingestion. Common manifestations were hypotension and tachyarrhythmia. In 30 cases with severe poisoning, the prescribed specific treatment included, IV calcium (76.7%), high-dose vasopressor (33.3%), HIE (16.7%), glucagon (10.0%), and lipid emulsion (6.7%). There were 6 deaths. Two cases received usual maximum dose of vasopressor without further titration. One was treated with IV insulin drip 1 u/kg/h and usual dose of vasopressor without further titration of insulin and vasopressor. One got delayed increasing dose of vasopressor more than 12 hours. One had cardiac arrest from rebound hyperkalemia while decrease HIE. One was recovered from poisoning, but later died from pneumonia. Conclusion. Common prescribed specific treatments were IV calcium, high-dose vasopressor, and HIE. Unfamiliar and underused of high-dose vasopressor and HIE may related to worse outcome.
Article Details
In the case that some parts are used by others The author must Confirm that obtaining permission to use some of the original authors. And must attach evidence That the permission has been included
References
Auchet T, Regnier MA, Girerd N, Levy B. Outcome of patients with septic shock and high-dose vasopressor therapy. Ann Intensive Care 2017. Doi: 10.1186/s13613-017-0261-x.
Bassi E, Park M, Azevedo LCP. Therapeutic Strategies for High-Dose Vasopressor-Dependent Shock. Crit Care Res Pract 2013. Doi: 10.1155/2013/654708.
Ellison DH, Shneidman R, Morris C, McCarron DA. Effect of Calcium Infusion on Blood Pressure in Hypertensive and Normotensive Humans. Hypertension 1986; 8(6):497-505.
Engebretsen KM, Kaczmarek KM, Holger JS. High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning. Clin Toxicol (Phila) 2011; 49:277-283.
Gleason E, Fitzgerald J. Standard infusion concentration: critical care medications. 2013 Nov. Available at http://portal.hartfordanesthesia.net/Portals/25/Content/Standard%20Infusions.pdf.
Graudins A, Najafi J, Rur-SC MP. Treatment of experimental verapamil poisoning with levosimendan utilizing a rodent model of drug toxicity. Clin Toxicol (Phila) 2008; 46(1): 50-56.
Graudins A, Wong KK. Comparative hemodynamic effects of levosimendan alone and in conjunction with 4-aminopyridine or calcium chloride in a rodent model of severe verapamil poisoning. J Med Toxicol 2010; 6(2): 85-93.
Hariman RJ, Mangiardi LM, McAllister RGJr, Surawicz B, Shabetai R, Kishida H. Reversal of the cardiovascular effects of verapamil by calcium and sodium: differences between electrophysiologic and hemodynamic responses. Circulation 1979; 59(4):797-804.
Hofer CA, Smith KJ, Tenholder MF. Verapamil intoxication: a literature review of overdoses and discussion of therapeutic options. Am J Med 1993; 95(4):431-438.
Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank’s Toxicologic Emergencies. 10th ed. New York: McGraw-Hill, 2015.
Holstege C, Kirk M, Furbee R. Wide complex dysrhythmia in calcium channel blocker overdose responsive to sodium bicarbonate therapy [abstract]. J Toxicol Clin Toxicol 1998; 36(5):509.
Horowitz BZ, Rhee KJ. Massive verapamil ingestion: a report of two cases and a review of the literature. Am J Emerg Med 1989; 7:624-631.
Hung YM, Olson KR. Acute amlodipine overdose treated by high dose intravenous calcium in a patient with severe renal insufficiency. Clin Toxicol (Phila) 2007; 45(3):301-303.
Jang DH, Donovan S, Nelson LS, Bania TC, Hoffman RS, Chu J. Efficacy of Methylene Blue in an Experimental Model of Calcium Channel Blocker Induced Shock. Ann Emerg Med 2015; 65(4): 410-415.
Jang DH, Nelson LS, Hoffman RS. Methylene blue in the treatment of refractory shock from an amlodipine overdose. Ann Emerg Med 2011; 58(6): 565-567.
Jović-Stošić J, Putić V, Živanović D, et al. Failure of intravenous lipid emulsion in treatment of cardiotoxicity caused by mixed overdose including dihydroperidine calcium channel blockers. Vojnosanit Pregl 2016; 73(1): 88-91.
Kerns W. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am 2007; 25:309-331.
Kline JA, Leonova E, Raymond RM. Beneficial myocardial metabolic effects of insulin during verapamil toxicity in the anesthetized canine. Crit Care Med 1995; 23:1251-1263.
Lam YM, Tse HF, Lau CP. Continuous calcium chloride infusion for massive nifedipine overdose. Chest 2001; 119(4):1280-1282.
Levine M, Curry SC, Jones AP, Ruha AM. Critical Care Management of Verapamil and Diltiazem Overdose with a Focus on Vasopressors: A 25-Year Experience at a Single Center. Ann Emerg Med 2013; 62(3):252-258.
Luscher TF, Noll G, Sturmer T, Huser B, Wenk M. Calcium gluconate in severe verapamil intoxication. N Eng J Med 1994; 330(10):718-720.
Osthoff M, Bernsmeier C, Marsch SC, Hunziker PR. Levosimendan as treatment option in severe verapamil intoxication: a case report and review of the literature. Case Rep Med 2010. Doi: 10.1155/2010/546904.
Page CB, Ryan NM, Isbister GK. The safety of high-dose insulin euglycemia therapy in toxin-induced cardiac toxicity. Clin Toxicol (Phila) 2017. Doi: 10.1080/15563650.2017.1391391.
Perichon D, Turfus S, Gerostamoulos D, Graudins A. An assessment of the in vivo effects of intravenous lipid emulsion on blood drug concentration and haemodynamics following oro-gastric amitriptyline overdose. Clin Toxicol (Phila) 2013; 51(4): 208-215.
Persson HE, Sjoberg GK, Haines JA, Pronczuk dG. Poisoning Severity Score: Grading of acute poisoning. Clin Toxicol (Phila) 1998; 36:205-213.
Rana C, Das M, Traficante D, Kashani J. Massive Overdose of Calcium Channel Antagonist an successful Management: A Case Report and Review of Management. J Clin Toxicol 2016; 6(5):Doi: 10.4172/2161-0495.1000319.
Rietjens SJ, de Lange DW, Donker DW, Meulenbelt J. Practical recommendations for calcium channel antagonist poisoning. Neth J Med 2016; 74(2):60-67.
Rizvi I, Ahmad A, Gupta A, Zaman S. Life-threatening calcium channel blocker overdose and its management. BMJ Case Rep 2012. Doi: 10.1136/bcr.01.2012.5643.
Shah SK, Goswami SK, Babu RV, Sharma G, Duarte AG. Management of Calcium Channel Antagonist Overdose with Hyperinsulinemia-Euglycemia Therapy: Case Series and Review of the Literature. Case Rep Crit Care 2012. Doi: 10.1155/2012/927040.
Spiller HA, Meyers A, Ziemba T, Riley M. Delayed onset of cardiac arrhythmias from sustained-release verapamil. Ann Emerg Med 1991; 20:201-203.
St-Onge M, Dubé PA, Gosselin S, et al. Treatment for calcium channel blocker poisoning: a systemic review. Clin Toxicol (Phila) 2014; 52:926-944.
Tanen DA, Ruha AM, Curry SC, et al. Hypertonic sodium bicarbonate is effective in the acute management of verapamil toxicity in a swine model. Ann Emerg Med 2000; 36(6):547-553.
Young AC, Velez LI, Kleinschmidt KC. Intravenous fat emulsion therapy for intentional sustained-release verapamil overdose. Resuscitation 2009; 80: 591-593.
Zhou H, Liu Y, Li GQ, Wei LQ. A novel dosing regimen for calcium infusion in a patient of massive overdose of sustained-release nifedipine. Am J Med Sci 2013; 345(3):248-251