Life in the Fast Lane CCB OD Stuff

Chris Nickson, one of my favorite EM bloggers, wrote with some great additional resources on calcium channel blocker overdose.


I love that story about the successful use of ONE THOUSAND units of insulin in severe CCB toxicty – without any adverse effects. Indeed, the early use of high-dose insulin euglycemic therapy (HIET) for CCB overdoses is a subject close to my heart (http://lifeinthefastlane.com/2009/09/insulin-for-verapamil-overdose/).

Also, I’ve got a “case-based Q and A” that EmCrit listeners may find useful for learning/ testing their knowledge on CCB overdose and HIET here: http://lifeinthefastlane.com/2010/02/toxicology-conundrum-028/ (…where an infamous Australian pharmacist-blogger almost meets his demise).

Hope EmCrit listeners find the LitFL links useful.

Cheers,
Chris

 

 

Also, asked Leon for a review article and he recommended this one:

Calcium and Beta-Blocker OD Review

EMCrit Podcast 27 – Calcium Channel Blocker Overdose

This week, I am joined by Leon Gussow, MD of the excellent blog: The Poison Review (TPR). TPR is my source for new toxicology articles; I highly recommend it as an incredible read. I got to meet Leon for a few beers a month ago; he is a great guy.

My Canadian pal, Ram, suggested calcium channel blocker OD as a podcast episode. Ram, here you go.

Calcium Channel Blocker OD

CCB Classes

Nifedipine and other dihydropyridines (amlodipine, felodipine, isradipine, nicardipine, nimodipine, nisoldipine) will cause profound hypotension without bradycardia, due to poor affinity for myocardial calcium channels.  This selectivity is not lost in overdose.  They may actually present with reflex tachycardia

How to tell CCB OD from B-Blocker

CCBs do not cause AMS

CCBs block receptor in B-Islet cells, preventing insulin release, so can see hyperglycemia as opposed to the normal-low sugar in B-Blockers

Presentation

Weak/Dizzy, mild confusion, bradycardia progressing to severe hypotension and shock

Selectivity is lost in overdose (except dihydropyridines)

Treatment

·        Activated Charcoal x 1

·        Whole bowel-Irrigation is not recommended by Leon’s group

·        Frequent glucose and k checks

·        Atropine (can try it once, but it will limit gastric motility and probably won’t work)

·        Calcium, 1 g of CaCl or 3 g of CaGluc.  Give slowly over 3 minutes for CaCl and 10 min for CaGluc.

·        Glucagon 5 mg bolus, probably won’t do much, unlike in beta blocker OD

·        IVF

·       High Dose Insulin. Start with 1 unit/kg push followed by 0.5-1 unit/kg/hr. Fingersticks q30 minutes and adequate glucose replacement if needed. Check potassium; supplement if < 2.5. (Crit Care 2006;10:212) You can see our protocol on High-Dose Insulin Euglycemic Therapy (for informational purposes only, don’t use clinically until approved by your P&T committee).

·        May need to use norepinephrine or dopamine (alternatively Epi). May need much higher doses of epi or norepi. Dopamine must be stopped at 20 mcg/kg/min, which is kind of a joke in this OD. Switch to one of the others if you get this high.

·        Levosimendan may have a role, but not available in the US.

·        IABP, CP Bypass

<photo by ilovespoons>
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