Diferencia entre revisiones de «Calcium channel blocker toxicity»

(insulin resistance)
Línea 48: Línea 48:


== Treatment  ==
== Treatment  ==
*Monotherapy only successful for trivial overdoses
''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 and other therapies such as include calcium, dopamine, norepinephrine, and lipid emulsion therapy may be beneficial but are poorly studied<ref>St-Onge M, et al. Treatment for calcium channel blocker poisoning: a systematic review. Clin Toxicol 2014 [http://informahealthcare.com/doi/pdf/10.3109/15563650.2014.965827 PDF]</ref>


*Monotherapy only successful for trivial overdoses
===Charcoal===
*Charcoal 1g/kg (max 50g) x1  
*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 &lt;3 administer 20mEq IV  
##If &lt;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  
*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  
##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)

Revisión del 22:08 9 oct 2014

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 (due to insulin resistance)

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


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 and other therapies such as include calcium, dopamine, norepinephrine, and lipid emulsion therapy may be beneficial but are poorly studied[1]

Charcoal

  • 1g/kg (max 50g) x1
    • Consider if present w/in 1-2hr w/ delayed-release preparation

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
    2. Requires frequent glucose and K checks
  4. Potassium
    1. If <3 administer 20mEq IV

Calcium

  1. Calcium gluconate 3g (30-60mL of 10% soln)
  2. Calcium chloride 1g (10-20mL of 10% soln (requires large IV/central line)

Vasopressors

  1. Norepinephrine is agent of choice

Glucagon

  1. 5mg IV bolus q10min x 2

Fluids

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

Atropine

    1. Adult: 0.5-1mg IV q2-3min to max of 3g
    2. Ped: 0.02mg/kg (minimum is 0.1mg)
  2. 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
    3. 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

  1. ↑ St-Onge M, et al. Treatment for calcium channel blocker poisoning: a systematic review. Clin Toxicol 2014 PDF
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