Calcium channel blocker toxicity: Difference between revisions
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==Background== | ==Background== | ||
*Hemodialysis is ineffective | *[[Hemodialysis]] is ineffective | ||
*Precipitous deterioration is common (esp | *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=== | ||
====Dihydropyridines==== | ====Dihydropyridines==== | ||
*Nifedipine, Amlodipine, Nicardipine | *[[Nifedipine]], [[Amlodipine]], [[Nicardipine]] | ||
**Systemic vasodilation, mild effect on heart | **Systemic vasodilation, mild effect on heart | ||
* Toxicity = Hypotension, reflex tachycardia | *Toxicity = [[Hypotension]], reflex [[tachycardia]] | ||
*With higher doses of toxicity peripheral selectivity is lost | *With higher doses of toxicity peripheral selectivity is lost | ||
**I.e. may see decreased | **I.e. may see decreased inotropy, [[bradycardia]] | ||
====Non-dihydropyridines | ====Non-dihydropyridines==== | ||
*[[Verapamil]], [[Diltiazem]] | |||
*Stronger effect on heart, weak vasodilators | *Stronger effect on heart, weak vasodilators | ||
*Toxicity = Bradycardia, decreased inotropy | *Toxicity = [[Bradycardia]], decreased inotropy | ||
==Clinical Features== | ==Clinical Features== | ||
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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 | ||
**Respiratory depression | **[[Respiratory arrest|Respiratory depression]] | ||
**[[Pulmonary edema]] | **[[Pulmonary edema]] | ||
*GI | *GI | ||
**[[Nausea/vomiting]] | **[[Nausea/vomiting]] | ||
*Neurologic | *Neurologic | ||
**Lethargy, confusion, coma | **[[Lethargy]], [[confusion]], [[coma]] | ||
*Metabolic | *Metabolic | ||
**[[Hyperglycemia]] ( | **[[Hyperglycemia]] (inhibits insulin release from pancreatic islet cells) | ||
***Helps to differentiate from [[Beta-Blocker Toxicity]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Symptomatic bradycardia}} | |||
== | ==Evaluation== | ||
*[[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 | ||
** | **[[Bradycardia|Bradyarrhythmia]] | ||
*Glucose | *Glucose | ||
**[[hyperglycemia]], may help distinguish [[β-blocker toxicity]] | |||
*Chemistry | *Chemistry | ||
**Serum calcium is often normal | **Serum calcium is often normal | ||
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*Monotherapy only successful for trivial overdoses | *Monotherapy only successful for trivial overdoses | ||
===[[Charcoal]] | ===GI decontamination=== | ||
*1g/kg (max 50g) x1 | *[[Charcoal]] | ||
**Consider if present | **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=== | ===Calcium=== | ||
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*[[Calcium chloride]] 1-3g IV bolus (10-20mL of 10% soln (requires large IV/central line) | *[[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 <ref>Tintinalli's 7th Ed.</ref> | **Preferred over calcium gluconate because it provides triple the amount of calcium on a weight-to-weight basis <ref>Tintinalli's 7th Ed.</ref> | ||
** | **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]]=== | |||
*5mg IV bolus q10min x 2 | |||
*will often cause severe [[nausea/vomiting]], give [[Zofran]] prior | |||
===[[Vasopressors]]=== | ===[[Vasopressors]]=== | ||
*[[Norepinephrine]] is agent of choice | *[[Norepinephrine]] is agent of choice | ||
**Start at 2mcg/min, uptitrate rapidly, goal MAP 65mmHg | |||
===[[ | ===[[High dose insulin therapy| 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 | |||
* | *[[Dextrose|Glucose]]: | ||
**Adult: 50mL of D50W | |||
**Ped: 2.5mL/kg of D10 | |||
*Adult: | *[[Insulin]] bolus 1 unit/kg given with 1amp of D50, then 0.5 – 1 unit/kg/hr continuous infusion | ||
*Ped: 0. | **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 | |||
===[[Intralipid|Intravenous lipid emulsion]]=== | ===[[Intralipid|Intravenous lipid emulsion]]=== | ||
*1.5mL/kg bolus of 20% lipid followed by 0.25mL/kg/minute | *1.5mL/kg bolus of 20% lipid followed by 0.25mL/kg/minute | ||
==Disposition== | ==Disposition== | ||
*Admit all symptomatic | *Admit all symptomatic patients | ||
*Admit all sustained-release ingestions | *Admit all sustained-release ingestions | ||
* | *Discharge if asymptomatic x 6-8hrs | ||
==See Also== | ==See Also== |
Revision as of 14:30, 19 October 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 inotropy, bradycardia
Non-dihydropyridines
- Verapamil, Diltiazem
- Stronger effect on heart, weak vasodilators
- Toxicity = Bradycardia, decreased inotropy
Clinical Features
- Cardiovascular
- Hypotension (any CCB overdose)
- Bradycardia (usually only seen with verapamil/diltiazem)
- AV/sinus block
- CHF
- Pulmonary
- GI
- Neurologic
- Metabolic
- Hyperglycemia (inhibits insulin release from pancreatic islet cells)
- Helps to differentiate from Beta-Blocker Toxicity
- Hyperglycemia (inhibits insulin release from pancreatic islet cells)
Differential Diagnosis
Symptomatic bradycardia
- Cardiac
- Inferior MI (involving RCA)
- Sick sinus syndrome
- Neurocardiogenic/reflex-mediated
- Increased ICP
- Vasovagal reflex
- Hypersensitive carotid sinus syndrome
- Intra-abdominal hemorrhage (i.e. ruptured ectopic)
- Metabolic/endocrine/environmental
- Hyperkalemia
- Hypothermia (Osborn waves on ECG)
- Hypothyroidism
- Hypoglycemia (neonates)
- Toxicologic
- Infectious/Postinfectious
- Other
Evaluation
- ECG
- PR prolongation (varying degrees of AV block)
- AV block occurs more commonly with verapamil
- Bradyarrhythmia
- PR prolongation (varying degrees of AV block)
- 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
- 5mg IV bolus q10min x 2
- will often cause severe nausea/vomiting, give Zofran prior
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
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