Today, we discuss a case of a patient who 45 mintues prior to arrival took took 150 Labetalol 100mg and 70 Amlodipine 10mg.
Hemodynamically Neutral Intubation
3 Presentations for CCB or BB OD
- Vasodilatory
- Negative-Inotropy (& Chronotropy)
- Combined Picture
Vasopressor-Only Management
For me this is only appropriate for primarily vasodilatory shock (PMID 23642908, Skoog et al., Levine et al.)
Tum-E-Vac Commercial Device for Gastric Lavage
If you believe in lavage…
Prior Post on Calcium Channel Blocker OD
Tox & Hound on Mechanism of Insulin
Now on to the Podcast…
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Scott Weingart
An ED Intensivist from NY. No conflicts of interest (coi).
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Superb! What a great feeling to see that lady leave the hospital after coming so close to the void. Is FOAM at the point yet where cases can be shared in a structured manner that will allow the stats geeks to tease out the harm/ benefit of various interventions in these high stakes but relatively low frequency presentations? I’m imagining a kind of google doc in which everybody chimes in, is then validated by a hardworking team of med students or whatnot, then maybe we could finally put to rest the stuff that hurts more than it helps and make room in everyone’s brains for the beneficial cutting edge therapies?
Although after listening to this case, I feel that having the logistics down cold is more of a benefit than any one specific therapy…
Thanks for sharing a great case Scott! Really enjoyed the case format to the podcast, looking forward to hearing more of them, cheers
Case study was awesome!! Keep them comin!!!
Wow, excellent case! Thank you for walking through the clinical reasoning and the progression. I am new to this podcast and look forward to more.
I’m curious though as to why you were skeptical of Intralipids. We had a similar case in our emergency room with a patient who ingested 700-900mg of amlodipine. The team discussed the use of lipid emulsion, but also did not use it. Upon further digging into the efficacy of lipid emulsion for lipophilic drug overdose, both labetalol and amlodipine have high lipophilicity and membrane permeability. I believe it could have been helpful. There are dozens of case reports documenting successful lipophilic drug overdose reversals using lipid emulsion on http://www.lipidrescue.org. I can provide you the resources I’ve found if interested. Additionally, lipids seem to be relatively clean from a side effect standpoint. Aside from transaminitis and electrolyte abnormalities, the option for lipids seems to only provide benefit.
I’d love to know your thoughts on this. Keep up the good work!
thanks for your comments, Chris. Unfortunately, all of the case reports are muddied by numerous co-interventions and confounders. Consensus in the tox community is not there on intralipids for non-LAST. I would reserve them for a Hail Mary in places without ECMO.
Thanks for the response, Scott! It’s true the case reports are muddied with other interventions. However when all else fails, I think it’s still a great option to keep in your back pocket. Looking forward to more of your podcast – Chris
Excellent. I have a question. Do you see any role for temporary pacemaker in these kind of situations. Also, it may sound going over the board but would you ever consider leaving swan ganz in place for close monitoring of shock status ( vasodilatory vs. cardiogenic ) rather than going by echo and physical examination to determine the need for ECMO ? Will appreciate your response.
all the tox folks tell me pacemaker will not work. if I get one that is severely brady, I am going to give it a shot if I am placing a line anyway
Wow ! What a great case !! Thank you so much for sharing
Do you think there’s any role to a Vasopressin Drip in the set-up of a non-septic distributive shock with max dosed norepi ?
I love the case study format !
Have a nice day
Fred
Vasopressin gtt is actually very effective in my clinical experience. A witnessed a severe Nicardipene overdose in the setting of CABG during the harvesting of saphenous. Scenario: An non-working IV pump was being changed, and my colleague assumed that the gtt line was clamped…nope. 40mg of Nicardipene infused rapidly into central line – straight to the heart. SEVERE vasoplegia. Pushed 100 mcg Epi and 100 mcg Levophed into central line – no change in blood pressure. The heart rate began to brady down to 20 and 3 mg of vasopressin was pushed into central line – brought the blood pressure up to 80/40s buying us 5 minutes of time to heparinize and go on bypass. During bypass, we struggled with vasoplegia and ran a vasopressin gtt in addition to a norepinephrine gtt in the background (the perfusionist dose of phenylephrine didn’t touch the pressure for several hours.) Calcium + high dose insulin helped restore inotrophy, but vasopressin saved us.
Vasopressin gtt is actually very effective in my clinical experience. A witnessed a severe Nicardipene overdose in the setting of CABG during the harvesting of saphenous. Scenario: A non-working IV pump was being changed, and my colleague assumed that the gtt line was clamped…nope. 40mg of Nicardipene infused rapidly into central line – straight to the heart. SEVERE vasoplegia. Pushed 100 mcg Epi and 100 mcg Levophed into central line – no change in blood pressure. The heart rate began to brady down to 20 and 3 mg of vasopressin was pushed into central line – brought the blood pressure up to 80/40s buying us 5 minutes of time to heparinize and go on bypass. During bypass, we struggled with vasoplegia and ran a vasopressin gtt in addition to a norepinephrine gtt in the background (the perfusionist dose of phenylephrine didn’t touch the pressure for several hours.) Calcium + high dose insulin helped restore inotrophy, but vasopressin saved us.
This case brings up an EMS question on ODs. Suppose while on scene, she is alert with stable VS but very recently ingested the pills <20-30 min. How about having her placing her fingers down the throat and induce immediate vomiting. Sometimes, truly suicidal patients have such trashed egos, they will do anything they are commanded to do. I'm not advocating ipecac (glad those days are over). Would this be a reasonable intervention to try on scene?
[…] EMCrit 264 – Case Discussion of Combined CCB and BB Overdose […]
Vasopressin gtt is actually very effective in my clinical experience. A witnessed a severe Nicardipene overdose in the setting of CABG during the harvesting of saphenous. Scenario: A non-working IV pump was being changed, and my colleague assumed that the gtt line was clamped…nope. 40mg of Nicardipene infused rapidly into central line – straight to the heart. SEVERE vasoplegia. Pushed 100 mcg Epi and 100 mcg Levophed into central line – no change in blood pressure. The heart rate began to brady down to 20 and 3 mg of vasopressin was pushed into central line – brought the blood pressure up to 80/40s buying us 5 minutes of time to heparinize and go on bypass. During bypass, we struggled with vasoplegia and ran a vasopressin gtt in addition to a norepinephrine gtt in the background (the perfusionist dose of phenylephrine didn’t touch the pressure for several hours.) Calcium + high dose insulin helped restore inotrophy, but vasopressin saved us.
Hey Scott, Thank you so much for sharing this awesome case, loved all the hemodynamics stuff involved in this case.. i wish you’d share more cases with us here on EMCrit..