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Finn D, Stevens J, Tolkacz M, Robinson J, Mangla J, Iacco A. Calcium Channel Blocker Overdose: What Role Does Extracorporeal Membrane Oxygenation Have in Support? A Systematic Review of the Literature. ASAIO J 2024; 70:404-408. [PMID: 38165982 DOI: 10.1097/mat.0000000000002129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) has had increasing prevalence and indications in the last decade. Calcium channel blocker overdose (CCBOD) can lead to significant cardiopulmonary dysfunction and has also increased in recent years. CCBOD results in cardiac depression, vasoplegia, and hyperglycemia. Expert consensus recommends treatment with calcium, high-dose insulin, inotropes, and vasopressors. Our systematic review evaluated when to initiate ECMO in the CCBOD population and the mortality rate associated with use. Electronic literature review identified all relevant studies for CCBOD and ECMO. PRISMA guidelines for systematic review were followed. Three independent authors reviewed abstracts and full texts, and only CCB ingestion without polypharmacy was included. Two authors independently collected data, which included demographics, current medical treatments, ECMO type, and survival. From 314 abstracts, 25 papers were included with a median publication year of 2019. Twenty-six patients were included with an average age of 32.7 years and 42%/58% male/female. Average time on ECMO 4.3 days. VA and VV ECMO use were 92.3% and 7.7%, respectively, and 84.6% of patients survived to hospital discharge. Before ECMO, most patients received 4-5 medical treatments (53.8%). Our systematic review demonstrates ECMO is a newly used, yet valuable therapy for CCBOD when medical treatment fails. Survival to discharge after ECMO for CCBOD is substantially higher than standard VV or VA ECMO. Medical management is still the mainstay therapy for CCBOD, but we show that a persistently unstable patient may benefit from prompt evaluation at an ECMO center for treatment.
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Affiliation(s)
- Daniel Finn
- From the Department of General Surgery and Surgical Critical Care, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
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2
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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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Amlodipine Overdose: Is High Dose Insulin Ready for Prime Time. HEARTS 2022. [DOI: 10.3390/hearts4010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Overdose of amlodipine, a dihydropyridine calcium channel blocker (CCB), is distinguished from other CCBs due to longer plasma half-life of 30 to 58 h. As current management strategies of CCB overdose are diverse and institution dependent, this retrospective observational study aimed to compare treatment and outcomes data extracted from published case reports of amlodipine overdose with a cohort of patients diagnosed with amlodipine overdose at an urban tertiary medical center. Particular attention was paid to the use of high dose insulin euglycemic therapy (HIET) in treatment of amlodipine overdose. Data was extracted from actual adult patients hospitalized for amlodipine overdose at an urban tertiary medical center up to 2018, and from case reports of amlodipine overdose published between 1997 and 2020. We found a tendency towards earlier and more frequent initiation of HIET over time in management of amlodipine overdose, facilitating hospital discharge. Given the lack of randomized controlled trials comparing vasopressors, HIET, or other therapies, optimal treatment for amlodipine overdose has yet to be definitively established. Based on currently available evidence, a reasonable approach to management of the hemodynamically unstable patient presenting with amlodipine overdose includes vasopressors and inotropes with earlier initiation of HIET.
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4
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Cole JB, Lee SC, Prekker ME, Kunzler NM, Considine KA, Driver BE, Puskarich MA, Olives TD. Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines. Clin Toxicol (Phila) 2022; 60:1205-1213. [DOI: 10.1080/15563650.2022.2131565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Jon B. Cole
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Samantha C. Lee
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Matthew E. Prekker
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Nathan M. Kunzler
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
| | | | - Brian E. Driver
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Travis D. Olives
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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5
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Sedaghattalab M. Treatment of critical aluminum phosphide (rice tablet) poisoning with high-dose insulin: a case report. J Med Case Rep 2022; 16:192. [PMID: 35578361 PMCID: PMC9112492 DOI: 10.1186/s13256-022-03425-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Aluminum phosphide (rice tablet) is a highly efficient agent for preserving grains against rodents and insects. It accounts for a large number of poisoning cases. Aluminum phosphide poisoning has a high mortality rate of about 90%, and to date, no antidote is available. It releases phosphine gas after exposure to moisture, and this reaction is catalyzed by the acidity of the stomach. Phosphine is then absorbed throughout the respiratory or gastrointestinal tracts and causes toxicity through inhibition of cytochrome c oxidase and formation of highly reactive free radicals. Treatment of patients with aluminum phosphide poisoning is supportive, including mechanical ventilation and vasopressors. The usage of infusion of glucose-insulin-potassium in rice tablet poisoning has been suggested, after its positive beneficial cardiac inotropic effects in patients with beta-blocker and calcium channel blocker poisoning. CASE PRESENTATION We report the case of a 30-year-old Iranian woman with critical aluminum phosphide poisoning, presented with hypotension and other signs of shock and severe metabolic acidosis, successfully treated with high-dose regular insulin and hypertonic dextrose and discharged from hospital in good condition. In contrast to our previous experiences, in which nearly all patients with critical aluminum phosphide poisoning died, this patient was saved with glucose-insulin-potassium. CONCLUSION Aluminum phosphide poisoning has a high mortality rate, and to date, no antidote is available. Administration of high-dose intravenous regular insulin and dextrose is suggested as a potential life-saving treatment for patients with critical aluminum phosphide poisoning.
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Affiliation(s)
- Moslem Sedaghattalab
- Department of Internal Medicine, Emam Sajad Hospital, Yasuj University of Medical Sciences, Yasuj, Iran.
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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7
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 328] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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8
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Gawedzki P, Paloucek FP. Additional Considerations for Persistent Hyperinsulinemia. J Med Toxicol 2021; 17:233-234. [PMID: 33606186 DOI: 10.1007/s13181-021-00828-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/08/2021] [Accepted: 01/29/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Paula Gawedzki
- Department of Pharmacy, University of Chicago, Chicago, IL, 60612, USA. .,Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, Chicago, IL, 60612, USA.
| | - Frank P Paloucek
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, Chicago, IL, 60612, USA
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Mégarbane B, Oberlin M, Alvarez JC, Balen F, Beaune S, Bédry R, Chauvin A, Claudet I, Danel V, Debaty G, Delahaye A, Deye N, Gaulier JM, Grossenbacher F, Hantson P, Jacobs F, Jaffal K, Labadie M, Labat L, Langrand J, Lapostolle F, Le Conte P, Maignan M, Nisse P, Sauder P, Tournoud C, Vodovar D, Voicu S, Claret PG, Cerf C. Management of pharmaceutical and recreational drug poisoning. Ann Intensive Care 2020; 10:157. [PMID: 33226502 PMCID: PMC7683636 DOI: 10.1186/s13613-020-00762-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/09/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis. METHODS A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology. RESULTS The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature. CONCLUSIONS The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.
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Affiliation(s)
- Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Mathieu Oberlin
- Emergency Department, HuManiS Laboratory (EA7308), University Hospital, Strasbourg, France
| | - Jean-Claude Alvarez
- Department of Pharmacology and Toxicology, Inserm U-1173, FHU Sepsis, Raymond Poincaré Hospital, AP-HP, Paris-Saclay University, Garches, France
| | - Frederic Balen
- Emergency Department, Toulouse University Hospital, Toulouse, France
| | - Sébastien Beaune
- Department of Emergency Medicine, Ambroise Paré Hospital, AP-HP, INSERM UMRS-1144, Paris-Saclay University, Boulogne-Billancourt, France
| | - Régis Bédry
- Hospital Secure Unit, Pellegrin University Hospital, Bordeaux, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, AP-HP, Paris, France
| | - Isabelle Claudet
- Pediatric Emergency Department Children’s Hospital CHU Toulouse, Toulouse, France
| | - Vincent Danel
- Department of Emergency Medicine, University Hospital of Grenoble, Grenoble, France
| | - Guillaume Debaty
- 5525, University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-IMAG UMR, Grenoble, France
| | | | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM U942, University of Paris, Paris, France
| | - Jean-Michel Gaulier
- Laboratory of Toxicology, EA 4483 - IMPECS - IMPact de L’Environnement Chimique Sur La Santé Humaine, University of Lille, Lille, France
| | | | - Philippe Hantson
- Intensive Care Department, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Frédéric Jacobs
- Polyvalent Intensive Care Unit, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, Clamart, France
| | - Karim Jaffal
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Magali Labadie
- Poison Control Centre of Bordeaux, University Hospital of Bordeaux, Bordeaux, France
| | - Laurence Labat
- Laboratory of Toxicology, Federation of Toxicology APHP, Lariboisière Hospital, INSERM UMRS-1144, University of Paris, Paris, France
| | - Jérôme Langrand
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Inserm, U942, Avicenne Hospital, AP-HP, Paris-13 University, Bobigny, France
| | - Philippe Le Conte
- Department of Emergency Medicine, University Hospital of Nantes, Nantes, France
| | - Maxime Maignan
- Emergency Department, Grenoble University Hospital, INSERM U1042, Grenoble Alpes University, Grenoble, France
| | - Patrick Nisse
- Poison Control Centre, University Hospital of Lille, Lille, France
| | - Philippe Sauder
- Intensive Care Unit, University Hospital of Strasbourg, Strasbourg, France
| | | | - Dominique Vodovar
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Pierre-Géraud Claret
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Charles Cerf
- Intensive Care Unit, Foch Hospital, Suresnes, France
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10
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Oghabian Z, Ahmadi J, Pakravan S, Dabaghzadeh F, Heidari MR, Tajaddini S, Karami-Mohajeri S. Successful treatment of aluminium phosphide poisoning by dihydroxyacetone: A two-case report study. J Clin Pharm Ther 2020; 45:1194-1198. [PMID: 32526065 DOI: 10.1111/jcpt.13194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/26/2020] [Accepted: 05/14/2020] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Aluminium phosphide (AlP) is an agricultural fumigant which produces phosphine gas in the presence of moisture. Phosphine inhibits oxidative phosphorylation and causes cell death by inhibiting cytochrome C oxidase. Clinical manifestations of AlP poisoning are refractory hypotension, tachycardia, low oxygen saturation and severe metabolic acidosis. CASE SUMMARY Two cases received dihydroxyacetone (DHA) in addition to routine management of AlP poisoning. Administration of DHA (7 gr in 50 mL sodium bicarbonate, gavage) 2 times at a 1-hour interval improved the clinical signs. WHAT IS NEW AND CONCLUSION This is the first case report to highlight the safe and successful treatment of AlP poisoning with DHA. However, more clinical studies are recommended to determine the precise mechanism of DHA action.
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Affiliation(s)
- Zohereh Oghabian
- Pharmaceutical Research Center, Institute of Neuropharmacology and Department of Clinical Toxicology, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Jafar Ahmadi
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Kerman University of Medical Sciences, Kerman, Iran
| | - Shahrzad Pakravan
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Kerman University of Medical Sciences, Kerman, Iran
| | - Fatemeh Dabaghzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohmoud Reza Heidari
- Department of Pharmacology and Toxicology, Faculty of Pharmacy and Pharmaceutical Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Shahrad Tajaddini
- Department of Clinical Toxicology, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Somayyeh Karami-Mohajeri
- Department of Pharmacology and Toxicology, Faculty of Pharmacy and Pharmaceutical Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
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11
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Pannu AK, Bhalla A, Gantala J, Sharma N, Kumar S, Dhibar DP. Glucose-insulin-potassium infusion for the treatment of acute aluminum phosphide poisoning: an open-label pilot study. Clin Toxicol (Phila) 2020; 58:1004-1009. [DOI: 10.1080/15563650.2020.1719131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- A. K. Pannu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - A. Bhalla
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - J. Gantala
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - N. Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S. Kumar
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - D. P. Dhibar
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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12
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Sutar A, Venkategowda PM, Murthy A, Chikkaswamy SB. Severe Amlodipine Toxicity: A Case Rescued with Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020; 24:365-366. [PMID: 32728332 PMCID: PMC7358859 DOI: 10.5005/jp-journals-10071-23423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Amlodipine is a widely prescribed drugs for the management of hypertension. Its toxicity is associated with severe myocardial depression and refractory hypotension. We present a case of a 28-year-old female known case of seizure disorder and depression who got admitted to our hospital with a history of consumption of 80 tablets of 5 mg amlodipine (total 400 mg). Patient presented to our hospital after 23 hours following consumption of the drug. Patient was managed in the intensive care unit (ICU) with mechanical ventilation support and intravenous infusion of noradrenalin, adrenalin, insulin-dextrose, and calcium gluconate. Due to refractory hypotension, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated on the same day. Patient was successfully managed and discharged home on the 8th day. This report highlights a rare case of a massive amlodipine overdose (400 mg) and ECMO as a rescue therapy. How to cite this article Sutar A, Venkategowda PM, Murthy A, Chikkaswamy SB. Severe Amlodipine Toxicity: A Case Rescued with Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020;24(5):365-366.
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Affiliation(s)
- Anand Sutar
- Department of Critical Care Medicine, Apollo Hospital, Sheshadripuram, Bengaluru, Karnataka, India
| | - Pradeep M Venkategowda
- Department of Critical Care Medicine, Apollo Hospital, Sheshadripuram, Bengaluru, Karnataka, India
| | - Ashwini Murthy
- Department of Critical Care Medicine, Apollo Hospital, Sheshadripuram, Bengaluru, Karnataka, India
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Tschirdewahn J, Eyer F. [Diagnostics and treatment of selected clinically relevant, acute drug intoxications]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:1313-1323. [PMID: 31578621 DOI: 10.1007/s00103-019-03024-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute drug poisoning due to accidental or self-damaging overdoses is responsible for 5-10% of emergency medical interventions in Germany. The treatment of asymptomatic to life-threatening courses requires extensive expertise. On the basis of a selective literature search, this article gives an overview of selected clinically relevant, acute drug poisonings with regard to epidemiology, symptomatology, diagnostics, and therapy.Intoxications with psychotropic drugs are the most common drug intoxications. Poisoning with tricyclic antidepressants causes anticholinergic, central nervous, and cardiovascular symptoms. Less toxic are selective serotonin reuptake inhibitors (SSRIs); the intoxication may be characterized by serotonin syndrome. Malignant neuroleptic syndrome is a severe complication of neuroleptic poisoning.Poisoning with analgesics is clinically relevant due to its high availability. For paracetamol poisoning, intravenous acetylcysteine is available as an antidote. Hemodialysis may be indicated for severe salicylate intoxication. Poisoning with nonsteroidal anti-inflammatory drugs is usually only associated with mild signs of intoxication.Poisoning with cardiac drugs (β-blockers and calcium antagonists) can cause life-threatening cardiovascular events. In addition to symptomatic therapy, insulin glucose therapy also plays an important role.The majority of acute drug poisonings can be treated adequately by symptomatic and partly intensive care therapy - if necessary with the application of primary and secondary toxin elimination. Depending on the severity of the intoxication, pharmacology-specific therapy must be initiated.
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Affiliation(s)
- Julia Tschirdewahn
- Abteilung für Klinische Toxikologie & Giftnotruf München, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Florian Eyer
- Abteilung für Klinische Toxikologie & Giftnotruf München, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
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14
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Farkhondeh T, Mehrpour O. Can hypoinsulinemia induced by calcium channel blockers be associated with cardiac events? Hum Exp Toxicol 2019; 39:111-113. [PMID: 31578094 DOI: 10.1177/0960327119878260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tahereh Farkhondeh
- Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Omid Mehrpour
- Rocky Mountain Poison and Drug Safety, Denver Health, Denver, CO, USA
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15
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Bartlett JW, Walker PL. Management of Calcium Channel Blocker Toxicity in the Pediatric Patient. J Pediatr Pharmacol Ther 2019; 24:378-389. [PMID: 31598101 DOI: 10.5863/1551-6776-24.5.378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Calcium channel blockers (CCBs) are commonly prescribed cardiovascular medications used in several disease states including hypertension, coronary artery disease, and atrial fibrillation. Inadvertent exposure or intentional overdose of CCBs may result in hypotension, bradycardia, dysrhythmias, conduction disturbances, and hyperglycemia. In the most severe cases, CCB toxicity can lead to rapid cardiovascular collapse. Given the risk of significant morbidity and mortality associated with CCB toxicity, it is important that health care professionals are able to recognize and treat patients who present with a potentially toxic ingestion. Due to the paucity of literature in managing pediatric patients with severe CCB toxicity, treatment strategies for pediatric patients are mostly limited to case reports and extrapolation from expert consensus recommendations for adults. All pediatric patients with a potentially toxic CCB ingestion should be evaluated in the emergency department. Activated charcoal may be considered for asymptomatic patients presenting within an hour of ingestion. Symptomatic patients should be placed under cardiac monitoring and treatments to stabilize the patient's hemodynamics should not be delayed. Traditional first-line IV therapies include small boluses of fluids, calcium, and vasopressors. High-dose insulin has been proposed to independently increase inotropy and improve CCB-induced hypoinsulinemia and insulin resistance that results from CCB inhibition of insulin release from pancreatic β-islet cells. High-dose insulin is recommended as first-line therapy for adults and shows promising efficacy and safety in several pediatric case reports. Intravenous lipid emulsion may be considered in patients who are refractory to first-line therapies, although the data for pediatric patients are extremely limited.
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Beavers JR, Stollings JL, Rice TW. Hyponatremia induced by hyperinsulinemia-euglycemia therapy. Am J Health Syst Pharm 2019; 74:1062-1066. [PMID: 28687552 DOI: 10.2146/ajhp160262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE A case of symptomatic hyponatremia induced by hyperinsulinemia-euglycemia (HIE) therapy is reported. SUMMARY A 59-year-old, 81.65-kg woman with hypertension, major depressive disorder, and anxiety arrived at a tertiary medical center 1.5 hours after an intentional overdose of oral amlodipine 200 mg, metoprolol tartrate 2,000 mg, and isosorbide mononitrate 1,200 mg. Upon arrival, her pulse was 63 beats/min and blood pressure was 106/56 mm Hg. The patient's blood pressure was refractory to fluids, calcium gluconate, and norepinephrine, resulting in initiation of HIE therapy. She had recurrent episodes of hypoglycemia, which required increases of the dextrose infusion and resulted in the patient receiving a total of 6.9 L of dextrose with free water. Seventeen hours into the hospitalization, the patient became obtunded due to hyponatremia (serum sodium concentration, 121 mmol/L). HIE therapy was discontinued, an infusion of 5% dextrose injection with sodium bicarbonate added was started, and a bolus of 3% sodium chloride was administered. Nine hours after the presentation of hyponatremia, the patient's serum sodium concentration normalized (137 mmol/L), and her symptoms resolved. The patient's blood pressure, pulse, and mental status continued to improve, and the patient was transferred out of the medical intensive care unit 41 hours after her arrival at the hospital. CONCLUSION A woman who overdosed on amlodipine, metoprolol tartrate, and isosorbide mononitrate was treated with HIE therapy and developed symptomatic hyponatremia. Hyponatremia resolved after administration of dextrose with sodium bicarbonate infusion and 3% sodium chloride infusion and cessation of HIE therapy.
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Affiliation(s)
- Jennifer R Beavers
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Todd W Rice
- Division of Allergy/Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
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Katzung KG, Leroy JM, Boley SP, Stellpflug SJ, Holger JS, Engebretsen KM. A randomized controlled study comparing high-dose insulin to vasopressors or combination therapy in a porcine model of refractory propranolol-induced cardiogenic shock. Clin Toxicol (Phila) 2019; 57:1073-1079. [PMID: 30806099 DOI: 10.1080/15563650.2019.1580372] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Context: Although cerebral perfusion (CP) is preserved across a wide range of mean arterial pressures (MAP) through cerebral-vascular autoregulation, the relationship between MAP and CP in refractory poison-induced cardiogenic shock (PICS) has never been studied. We compared the effects of therapies used in PICS: high-dose insulin (HDI), HDI plus norepinephrine (NE), and vasopressors alone (NE plus epinephrine (Epi)) on cerebral tissue oxygenation (PtO2). Methods: Fifteen swine were randomized to either HDI, HDI + NE, or NE + Epi. All animals received a propranolol infusion using an established model of toxicity. At primary toxicity (P1), defined as a 25% reduction in heart rate (HR) multiplied by MAP, the HDI and HDI + NE groups received HDI and the NE + Epi group received NE. Once a sustained MAP < 55 mmHg was reached (P2), the HDI group received saline (NS), the HDI + NE group received NE and the NE + Epi group received Epi until death or censoring. PtO2 and hemodynamic parameters including MAP, cardiac output (CO) and central venous pressure (CVP) were measured every 10 minutes. Glucose and potassium were measured at predetermined intervals. Results: Animals treated with HDI + NE maintained PtO2 over time more than the HDI-alone group. Due to rapid hemodynamic collapse, we were unable to analyze PtO2 data in the vasopressor only animals. Mean survival time was 1.9, 2.9 and 0.1 hours for the HDI, HDI + NE and NE + Epi groups, respectively. Survival time from P2 (sustained MAP <55 mmHg) to death or censoring was not different between HDI and HDI + NE groups. Conclusions: HDI + NE treatment was superior to HDI-alone at preserving PtO2 when MAP < 55 mmHg. We were unable to compare the PtO2 between the NE + Epi to the HDI or HDI + NE due to rapid decline in CO and death. If MAP is sustained at < 55 mmHg after maximizing HDI, adjunctive treatment with NE should be considered to preserve PtO2.
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Affiliation(s)
- Katherine G Katzung
- Department of Emergency Medicine, Abbott Northwestern Hospital , Minneapolis , MN , USA
| | - Jenna M Leroy
- Department of Emergency Medicine, Regions Hospital , St. Paul , MN , USA
| | - Sean P Boley
- Department of Emergency Medicine, United Hospital , St. Paul , MN , USA
| | | | - Joel S Holger
- Department of Emergency Medicine, Regions Hospital , St. Paul , MN , USA
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Maclaren G, Butt W, Cameron P, Preovolos A, McEgan R, Marasco S. Treatment of Polypharmacy Overdose with Multimodality Extracorporeal Life Support. Anaesth Intensive Care 2019; 33:120-3. [PMID: 15957701 DOI: 10.1177/0310057x0503300118] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 45-year-old woman presented to the emergency department of a tertiary referral hospital after taking an overdose of verapamil, doxepin, quetiapine, diazepam, temazepam, and clonazepam. She rapidly developed shock refractory to pharmacological support and was placed on percutaneous venoarterial extracorporeal membrane oxygenation (ECMO). She had a severe metabolic acidosis from a combination of shock and drug intoxication that improved with continuous venovenous haemodialysis. Forty-eight hours after presentation, while still on ECMO, the patient had complete cardiac standstill for three and a half hours, attributable to slow-release verapamil, that resolved after the commencement of plasmapheresis. The role of plasmapheresis in verapamil overdose requires further study.
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Affiliation(s)
- G Maclaren
- The Intensive Care Unit, The Alfred Hospital, Commercial Rd, Melbourne, Vic. 3004
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19
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Kumar S, Thakur D, Gupta RK, Sharma A. Unresponsive shock due to amlodipine overdose: An unexpected cause. J Cardiovasc Thorac Res 2018; 10:246-247. [PMID: 30680086 PMCID: PMC6335991 DOI: 10.15171/jcvtr.2018.43] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 11/16/2018] [Indexed: 11/09/2022] Open
Abstract
Amlodipine is a dihydropyridine calcium channel blocker which is widely used as an antihypertensive
drug. Amlodipine overdose have been infrequently reported with occurrence of
serious complications and even death in a few cases. We report an interesting case of a young lady
who presented with refractory shock with acute kidney injury, which did not respond to therapy
despite optimal fluid replacement and vasopressor support. The etiology of shock could not be
ascertained and the patient was questioned again to elucidate the missing clue in the history.
It was finally revealed that the patient had consumed 900 mg of amlodipine in a suicide bid,
for her poor performance in academics. The targeted therapy in the form of IV calcium and
hyperinsulinemia-euglycemia therapy (HIET) was started and the patient dramatically improved
with shock reversal and improvement in renal function.
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Affiliation(s)
- Shailesh Kumar
- Department of Medicine, Dr RML Hospital and PGIMER, Delhi, India
| | - Devyani Thakur
- Department of Medicine, Dr RML Hospital and PGIMER, Delhi, India
| | | | - Alka Sharma
- Department of Medicine, Dr RML Hospital and PGIMER, Delhi, India
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20
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Krenz JR, Kaakeh Y. An Overview of Hyperinsulinemic-Euglycemic Therapy in Calcium Channel Blocker and β-blocker Overdose. Pharmacotherapy 2018; 38:1130-1142. [PMID: 30141827 DOI: 10.1002/phar.2177] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- James R. Krenz
- Purdue University College of Pharmacy; West Lafayette Indiana
| | - Yaman Kaakeh
- Purdue University College of Pharmacy; West Lafayette Indiana
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21
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Cole JB, Arens AM, Laes JR, Klein LR, Bangh SA, Olives TD. High dose insulin for beta-blocker and calcium channel-blocker poisoning. Am J Emerg Med 2018; 36:1817-1824. [DOI: 10.1016/j.ajem.2018.02.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/31/2018] [Accepted: 02/04/2018] [Indexed: 02/06/2023] Open
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22
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Fadhlillah F, Patil S. Pharmacological and mechanical management of calcium channel blocker toxicity. BMJ Case Rep 2018; 2018:bcr-2018-225324. [PMID: 30150339 PMCID: PMC6119390 DOI: 10.1136/bcr-2018-225324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2018] [Indexed: 11/04/2022] Open
Abstract
Cardiovascular instability associated with calcium channel blocker toxicity comprises a small percentage of overdose presentations, yet they are associated with a high mortality rate. We detail the management of a 64-year-old man who took an intentional overdose of 840 mg nimodipine. We include the treatment he received and highlight the scarcity of evidence behind the use of gastric decontamination, calcium, glucagon, intravenous lipid emulsion, high-dose insulin therapy, sodium bicarbonate, vasopressors and methylene blue in calcium channel blocker toxicity. Additionally, the article explores the use of electrical pacing and venoarterial extracorporeal membrane oxygenation (VA-ECMO). Following successful weaning of VA-ECMO, the patient was successfully extubated but remained neurologically impaired due to hypoxic-ischaemic brain injury, critical care polyneuropathy and renal failure requiring dialysis. He has cerebral performance category 3; he has mild cognitive impairment but able to perform some activities of daily living independently and communicate his thoughts and needs. He requires no respiratory or cardiovascular support.
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Affiliation(s)
- Fiqry Fadhlillah
- Emergency Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Shashank Patil
- Emergency Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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23
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Kumar K, Biyyam M, Bajantri B, Nayudu S. Critical Management of Severe Hypotension Caused by Amlodipine Toxicity Managed With Hyperinsulinemia/Euglycemia Therapy Supplemented With Calcium Gluconate, Intravenous Glucagon and Other Vasopressor Support: Review of Literature. Cardiol Res 2018; 9:46-49. [PMID: 29479386 PMCID: PMC5819629 DOI: 10.14740/cr646w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 12/12/2017] [Indexed: 12/13/2022] Open
Abstract
Calcium channel blocker (CCB ) overdose, whether intentional or accidental, is a common clinical scenario and can be very lethal. Conventional treatments for CCB overdose include intravenous (IV) fluids, calcium salts, dopamine, dobutamine, norepinephrine, phosphodiesterase inhibitors, and glucagon. However, the conventional therapies are unsuccessful in reversing the cardiovascular toxicity of CCB, so they commonly fail to improve the hemodynamic condition of the patient. Blockade of the L-type calcium channels that mediate the antihypertensive effect of CCBs also decreases the release of insulin from pancreatic β-islet cells and reduces glucose uptake by tissues (insulin resistance). By targeting this insulin-mediated pathway, hyperinsulinemia/euglycemia therapy (HIET) appears to have a distinct role, and its clinical potential is underrecognized in the management of severe CCB toxicity. We present a case of young man with amlodipine toxicity successfully managed with high dose of IV insulin therapy.
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Affiliation(s)
- Kishore Kumar
- Division of Gastroenterology, Department of Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
| | - Madhavi Biyyam
- Division of Gastroenterology, Department of Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
| | - Bharat Bajantri
- Division of Pulmonary and Critical Care, Department of Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
| | - Sureshkumar Nayudu
- Division of Gastroenterology, Department of Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA
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24
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Reuter-Rice KE, Peterson BM. Conventional and Unconventional Lifesaving Therapies in an Adolescent With Amlodipine Ingestion. Crit Care Nurse 2018; 36:64-9. [PMID: 27481803 DOI: 10.4037/ccn2016524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Amlodipine, a dihydropyridine calcium channel blocker, is commonly prescribed for the treatment of hypertension. Ingestion of an overdose leads to severe hypotension; if the hypotension is not treated, death may be imminent. Conventional and unconventional interventions were used to treat an adolescent who ingested a life-threatening dose of amlodipine. Severe hypotension resistant to conventional treatment with intralipids and hyperinsulinemia-euglycemia therapy led to the use of plasmapheresis and a pneumatic antishock garment as lifesaving measures. Plasmapheresis has been described in only one other case of severe amlodipine overdose, and the use of a pneumatic antishock garment has never been described in the management of a calcium channel blocker overdose. Because short-term use of a pneumatic antishock garment has associated risks, the critical care nurse's anticipation of side effects and promotion of safe use of the garment were instrumental in the patient's care and outcome. (Critical Care Nurse 2016; 36[4]:64-69).
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Affiliation(s)
- Karin E Reuter-Rice
- Karin E. Reuter-Rice is an associate professor and a Robert Wood Johnson Foundation scholar, School of Nursing and School of Medicine, Department of Pediatrics, Duke University, Durham, North Carolina. She is also a pediatric nurse practitioner in critical care at Duke University Health System and formerly at Rady Children's Hospital, San Diego, California.Bradley M. Peterson is a senior consultant to the pediatric intensive care unit, Rady Children's Hospital.
| | - Bradley M Peterson
- Karin E. Reuter-Rice is an associate professor and a Robert Wood Johnson Foundation scholar, School of Nursing and School of Medicine, Department of Pediatrics, Duke University, Durham, North Carolina. She is also a pediatric nurse practitioner in critical care at Duke University Health System and formerly at Rady Children's Hospital, San Diego, California.Bradley M. Peterson is a senior consultant to the pediatric intensive care unit, Rady Children's Hospital
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25
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Bartlett D. β-Blocker and Calcium Channel Blocker Poisoning: High-Dose Insulin/Glucose Therapy. Crit Care Nurse 2018; 36:45-50. [PMID: 27037338 DOI: 10.4037/ccn2016370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Overdoses of β-blockers and calcium channel blockers can produce significant morbidity and mortality, and conventional therapies often do not work as treatments for these poisonings. High-dose insulin/glucose therapy has been successful in reversing the cardiotoxic effects of these drugs in cases where the standard therapies have failed, and it appears to be relatively safe. Many successes have been well documented, but the clinical experience consists of case reports, the mechanisms of action are not completely understood, and guidelines for use of the therapy are empirically derived and not standardized. Regardless of these limitations, high-dose insulin/glucose therapy can be effective, it is often recommended by clinical toxicologists and poison control centers, and critical care nurses should be familiar with when and how the therapy is used.
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Affiliation(s)
- Dana Bartlett
- Dana Bartlett is an information specialist at the Connecticut Poison Control Center, Farmington, Connecticut.
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26
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Fung HT, Lai CH, Wong OF, Lam KK, Kam CW. The Use of Glucagon and other Antidotes in a Case of Beta-Blocker and Calcium Channel Blocker Overdose. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790701400210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We report a case of metoprolol and nifedipine overdose complicated by hypotension which responded to intravenous boluses of calcium chloride and glucagon. The blood pressure was subsequently stabilised by continuous glucagon infusion with the aid of an insulin-dextrose drip. The discussion is focused on the role of antidotes and catecholamine inotropes in the management of beta-blocker and calcium channel blocker poisoning.
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27
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Page CB, Ryan NM, Isbister GK. The safety of high-dose insulin euglycaemia therapy in toxin-induced cardiac toxicity. Clin Toxicol (Phila) 2017; 56:389-396. [DOI: 10.1080/15563650.2017.1391391] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Colin B. Page
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, Australia
| | - Nicole M. Ryan
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| | - Geoffrey K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, Australia
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28
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Baker KA, Austin EB, Wang GS. Antidotes: Familiar Friends and New Approaches for the Treatment of Select Pediatric Toxicological Exposures. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Kao R, Landry Y, Chick G, Leung A. Bilateral blindness secondary to optic nerve ischemia from severe amlodipine overdose: a case report. J Med Case Rep 2017; 11:211. [PMID: 28768527 PMCID: PMC5541695 DOI: 10.1186/s13256-017-1374-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 07/02/2017] [Indexed: 12/02/2022] Open
Abstract
Background Calcium channel blockers are commonly prescribed medications; calcium channel blocker overdose is becoming increasingly prevalent. The typical presentation of a calcium channel blocker overdose is hypotension and decreased level of consciousness. We describe a case of a calcium channel blocker overdose that led to bilateral cortical blindness, a presentation that has not previously been reported. Case presentation A 49-year-old white woman with known bilateral early optic atrophy presented to our hospital with hypotension and obtundation following a known ingestion of 150 mg of amlodipine. She was transferred to our intensive care unit where she was intubated, mechanically ventilated, and required maximal vasopressor support (norepinephrine 40 mcg/minute, epinephrine 40 mcg/minute, and vasopressin 2.4 units/hour) along with intravenously administered crystalloid boluses. Despite these measures, she continued to deteriorate with persistent hypotension and tachycardia, as well as anuria. Intralipid emulsion therapy was subsequently administered to which no initial response was observed. A chest X-ray revealed diffuse pulmonary edema; intravenous diuresis as well as continuous renal replacement therapy was initiated. Following the initiation of continuous renal replacement therapy, her oxygen requirements as well as urine output began to improve, and 3 days later she was liberated from mechanical ventilation. Following extubation, she complained of new onset visual impairment, specifically seeing only red-green colors, but no objects. An ophthalmologic examination revealed that this was due to bilateral optic atrophy from prolonged hypotension during the first 24 hours after the overdose. Conclusion Persistent hypotension in the setting of a calcium channel blocker overdose can lead to worsening optic atrophy resulting in bilateral cortical blindness.
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Affiliation(s)
- Raymond Kao
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada. .,Division of Critical Care, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada.
| | - Yves Landry
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Division of Critical Care, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada
| | - Genevieve Chick
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Division of Critical Care, Department of Medicine, London Health Sciences Centre, Western University, London, ON, Canada
| | - Andrew Leung
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Department of Radiology, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
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30
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St-Onge M, Anseeuw K, Cantrell FL, Gilchrist IC, Hantson P, Bailey B, Lavergne V, Gosselin S, Kerns W, Laliberté M, Lavonas EJ, Juurlink DN, Muscedere J, Yang CC, Sinuff T, Rieder M, Mégarbane B. Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Crit Care Med 2017; 45:e306-e315. [PMID: 27749343 PMCID: PMC5312725 DOI: 10.1097/ccm.0000000000002087] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide a management approach for adults with calcium channel blocker poisoning. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION Following the Appraisal of Guidelines for Research & Evaluation II instrument, initial voting statements were constructed based on summaries outlining the evidence, risks, and benefits. DATA SYNTHESIS We recommend 1) for asymptomatic patients, observation and consideration of decontamination following a potentially toxic calcium channel blocker ingestion (1D); 2) as first-line therapies (prioritized based on desired effect), IV calcium (1D), high-dose insulin therapy (1D-2D), and norepinephrine and/or epinephrine (1D). We also suggest dobutamine or epinephrine in the presence of cardiogenic shock (2D) and atropine in the presence of symptomatic bradycardia or conduction disturbance (2D); 3) in patients refractory to the first-line treatments, we suggest incremental doses of high-dose insulin therapy if myocardial dysfunction is present (2D), IV lipid-emulsion therapy (2D), and using a pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block without significant alteration in cardiac inotropism (2D); 4) in patients with refractory shock or who are periarrest, we recommend incremental doses of high-dose insulin (1D) and IV lipid-emulsion therapy (1D) if not already tried. We suggest venoarterial extracorporeal membrane oxygenation, if available, when refractory shock has a significant cardiogenic component (2D), and using pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block in the absence of myocardial dysfunction (2D) if not already tried; 5) in patients with cardiac arrest, we recommend IV calcium in addition to the standard advanced cardiac life-support (1D), lipid-emulsion therapy (1D), and we suggest venoarterial extracorporeal membrane oxygenation if available (2D). CONCLUSION We offer recommendations for the stepwise management of calcium channel blocker toxicity. For all interventions, the level of evidence was very low.
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Affiliation(s)
- Maude St-Onge
- 1Centre antipoison du Québec, CHU de Quebec Research Center, Population Health and Optimal Health Practices, Department of Family Medicine and Emergency medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Ville de Québec, Quebec, Canada. 2Department of Emergency Medicine, ZNA Stuivenberg, Antwerp, Belgium 3School of Pharmacy, University of California, San Francisco, San Francisco, CA. 4Heart and Vascular Institute, Penn State Hershey Medical Center, Hershey, PA. 5Department of Intensive Care, Cliniques St-Luc, Université Catholique de Louvain, Leuven, Belgium. 6Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada. 7Department of Medical Biology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada. 8Centre antipoison du Québec, Department of Medicine, McGill University, Department of Emergency Medicine, McGill University Health Centre, Montreal, QC, Canada. 9Division of Medical Toxicology, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC. 10Quebec Poison Centre, Department of Emergency Medicine, McGill University Health Centre, Montreal, QC, Canada. 11Department of Emergency Medicine, Denver Health and Hospital Authority, University of Colorado, Boulder, CO. 12Ontario Poison Centre, Sunnybrook Health Sciences Centre, Departments of Medicine and Pediatrics, University of Toronto, Toronto, ON, Canada. 13Kingston General Hospital, Queens' University, Kingston, ON, Canada. 14Institute of Environmental & Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan. 15Division of Clinical Toxicology & Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. 16Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. 17Department of Paediatrics, Physiology and Pharmacology and Medicine, Western University, London, ON, Canada. 18Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM U1144, Paris-Diderot University, Paris, France
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Mullins ME, Zane Horowitz B. In our experience. TOXICOLOGY COMMUNICATIONS 2017. [DOI: 10.1080/24734306.2017.1293950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Michael E. Mullins
- Division of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - B. Zane Horowitz
- Oregon Poison Center, Oregon Health & Science University, Portland, OR, USA
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Abstract
BACKGROUND Different protocols have been suggested to treat aluminum phosphide (ALP) poisoning. We aimed to evaluate the possible therapeutic effect of hyperinsulinemia/euglycemia (HIE) in treatment of ALP poisoning. METHODS In a prospective interventional study, a total of 88 ALP-poisoned patients were included and assigned into HIE group undergoing glucose/insulin/potassium (GIK) protocol and a control group that was managed by routine conventional treatments. The 2 groups were then compared regarding the signs and symptoms of toxicity and their progression, development of complications, and final outcome to detect the possible effect of GIK protocol on the patients' course of toxicity and outcome. RESULTS The 2 groups were similar in terms of demographic characteristics and on-arrival vital signs and lab tests. Using GIK protocol resulted in significantly longer hospital stays (24 vs 60 hours; P < 0.001) and better outcomes (72.7% vs 50% mortality; P = 0.03). Regression analysis showed that GIK duration was an independent variable that could prognosticate mortality (odds ratio [95% confidence interval] = 1.045 [1.004,1.087]). The risk of mortality decreased by 4.5% each hour after initiation of GIK. CONCLUSION GIK protocol improves the outcome of ALP poisoning and increases the length of hospital stay.
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Affiliation(s)
- Hossein Hassanian-Moghaddam
- Toxicological Research Center, Department of Clinical Toxicology, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences
- Excellence Center of Clinical Toxicology, Iranian Ministry of Health, Tehran, Iran
- Correspondence: Hossein Hassanian-Moghaddam, Department of Clinical Toxicology, Loghman-Hakim Hospital, Karegar Street, Tehran, Iran (e-mail: )
| | - Nasim Zamani
- Toxicological Research Center, Department of Clinical Toxicology, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences
- Excellence Center of Clinical Toxicology, Iranian Ministry of Health, Tehran, Iran
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33
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Laskey D, Vadlapatla R, Hart K. Stability of high-dose insulin in normal saline bags for treatment of calcium channel blocker and beta blocker overdose. Clin Toxicol (Phila) 2016; 54:829-832. [PMID: 27432286 DOI: 10.1080/15563650.2016.1209766] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
CONTEXT High-dose insulin has become a first-line therapy for treating severe calcium channel blocker and beta blocker toxicity. Insulin infusions used to treat other conditions (e.g., diabetic ketoacidosis) may be used, but this may lead to pulmonary compromise due to fluid volume overload. An obvious solution would be to use a more concentrated insulin infusion; however, data describing the stability of insulin in polyvinyl chloride bags at concentrations >1 unit/mL are not readily available. OBJECTIVE To determine the stability of insulin at 16 units/mL in 0.9% saline solution. MATERIALS AND METHODS Eight-hundred units of regular insulin (8 mL from a stock vial containing 100 units/mL) were added to 42 mL of 0.9% saline solution in a polyvinyl chloride bag to make a final concentration of 16 units/mL. Two bags were stored at 4 °C (refrigerated) and two at 25 °C (room temperature). Samples were withdrawn and tested for insulin concentration periodically over 14 days. RESULTS Concentrated regular insulin in a polyvinyl chloride bag remained within 90% of equilibrium concentration at all time points, indicating the 16 units/mL concentration was sufficiently stable both refrigerated and at room temperature for 14 days. DISCUSSION Administration of high-dose insulin can cause fluid volume overload when using traditional insulin formulations. The 16 units/mL concentration allows for the treatment of a patient with severe calcium channel blocker or beta blocker toxicity for a reasonable period of time without administering excessive fluid. CONCLUSION Insulin at a concentration of 16 units/mL is stable for 14 days, the maximum timeframe currently allowed under US Pharmacopeia rules for compounding of sterile preparations. This stability data will allow institutions to issue beyond-use dating for intravenous fluids containing concentrated insulin and used for treating beta blocker and calcium channel blocker toxicity.
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Affiliation(s)
- Dayne Laskey
- a University of Saint Joseph School of Pharmacy , Hartford , CT , USA
| | - Rajesh Vadlapatla
- b Marshall B. Ketchum University College of Pharmacy , Fullerton , CA , USA
| | - Katherine Hart
- c Hartford Hospital , Hartford , CT , USA.,d Connecticut Poison Control Center , Farmington , CT , USA
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34
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Graudins A, Lee HM, Druda D. Calcium channel antagonist and beta-blocker overdose: antidotes and adjunct therapies. Br J Clin Pharmacol 2015; 81:453-61. [PMID: 26344579 DOI: 10.1111/bcp.12763] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/25/2015] [Accepted: 08/26/2015] [Indexed: 12/26/2022] Open
Abstract
Management of cardiovascular instability resulting from calcium channel antagonist (CCB) or beta-adrenergic receptor antagonist (BB) poisoning follows similar principles. Significant myocardial depression, bradycardia and hypotension result in both cases. CCBs can also produce vasodilatory shock. Additionally, CCBs, such as verapamil and diltiazem, are commonly ingested in sustained-release formulations. This can also be the case for some BBs. Peak toxicity can be delayed by several hours. Provision of early gastrointestinal decontamination with activated charcoal and whole-bowel irrigation might mitigate this. Treatment of shock requires a multimodal approach to inotropic therapy that can be guided by echocardiographic or invasive haemodynamic assessment of myocardial function. High-dose insulin euglycaemia is commonly recommended as a first-line treatment in these poisonings, to improve myocardial contractility, and should be instituted early when myocardial dysfunction is suspected. Catecholamine infusions are complementary to this therapy for both inotropic and chronotropic support. Catecholamine vasopressors and vasopressin are used in the treatment of vasodilatory shock. Optimizing serum calcium concentration can confer some benefit to improving myocardial function and vascular tone after CCB poisoning. High-dose glucagon infusions have provided moderate chronotropic and inotropic benefits in BB poisoning. Phosphodiesterase inhibitors and levosimendan have positive inotropic effects but also produce peripheral vasodilation, which can limit blood pressure improvement. In cases of severe cardiogenic shock and/or cardiac arrest post-poisoning, extracorporeal cardiac assist devices have resulted in successful recovery. Other treatments used in refractory hypotension include intravenous lipid emulsion for lipophilic CCB and BB poisoning and methylene blue for refractory vasodilatory shock.
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Affiliation(s)
- Andis Graudins
- Monash Health Clinical Toxicology and Addiction Medicine Service, Monash Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia.,Monash Emergency Program, Monash Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia.,School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Monash Medical Centre, Clayton, VIC, 3168, Australia
| | - Hwee Min Lee
- Monash Health Clinical Toxicology and Addiction Medicine Service, Monash Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia.,Monash Emergency Program, Monash Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia.,School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Monash Medical Centre, Clayton, VIC, 3168, Australia
| | - Dino Druda
- Monash Health Clinical Toxicology and Addiction Medicine Service, Monash Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia.,Monash Emergency Program, Monash Health, Dandenong Hospital, David Street, Dandenong, VIC, 3175, Australia
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35
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Burkes R, Wendorf G. A multifaceted approach to calcium channel blocker overdose: a case report and literature review. Clin Case Rep 2015; 3:566-9. [PMID: 26273444 PMCID: PMC4527798 DOI: 10.1002/ccr3.300] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 04/21/2015] [Accepted: 04/23/2015] [Indexed: 11/26/2022] Open
Abstract
Calcium channel blocker toxicity can be devastating. Initial therapy with fluid, calcium, and adrenoreceptor agonists should be prompt and novel therapies can be added if no response. Determining cardiogenic shock versus vasoplegia with echocardiogram or other hemodynamic monitoring may guide treatment options.
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Affiliation(s)
- Robert Burkes
- University of Louisville Internal Medicine Residency Training Program Louisville, Kentucky, USA
| | - Gregg Wendorf
- University of Louisville Internal Medicine Residency Training Program Louisville, Kentucky, USA
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36
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Lai F, Zhang Y, Xie DP, Li F, Han Y. Successful treatment with integrated Chinese and western medicine for severe overdose of amlodipine: A case report. Chin J Integr Med 2015; 21:703-6. [PMID: 25877462 DOI: 10.1007/s11655-015-2130-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Indexed: 10/23/2022]
Affiliation(s)
- Fang Lai
- Intensive Care Unit, Fangcun Branch Hospital, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510145, China
| | - Yan Zhang
- Intensive Care Unit, Fangcun Branch Hospital, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510145, China
| | - Dong-Ping Xie
- Intensive Care Unit, Fangcun Branch Hospital, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510145, China
| | - Fang Li
- Intensive Care Unit, Fangcun Branch Hospital, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510145, China
| | - Yun Han
- Intensive Care Unit, Fangcun Branch Hospital, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510145, China.
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37
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Lee IH, Kang GW. Amlodipine intoxication complicated by acute kidney injury and rhabdomyolysis. Yeungnam Univ J Med 2015. [DOI: 10.12701/yujm.2015.32.1.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- In Hee Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Gun Woo Kang
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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38
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St-Onge M, Dubé PA, Gosselin S, Guimont C, Godwin J, Archambault PM, Chauny JM, Frenette AJ, Darveau M, Le Sage N, Poitras J, Provencher J, Juurlink DN, Blais R. Treatment for calcium channel blocker poisoning: a systematic review. Clin Toxicol (Phila) 2014; 52:926-44. [PMID: 25283255 PMCID: PMC4245158 DOI: 10.3109/15563650.2014.965827] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 09/10/2014] [Indexed: 11/25/2022]
Abstract
CONTEXT Calcium channel blocker poisoning is a common and sometimes life-threatening ingestion. OBJECTIVE To evaluate the reported effects of treatments for calcium channel blocker poisoning. The primary outcomes of interest were mortality and hemodynamic parameters. The secondary outcomes included length of stay in hospital, length of stay in intensive care unit, duration of vasopressor use, functional outcomes, and serum calcium channel blocker concentrations. METHODS Medline/Ovid, PubMed, EMBASE, Cochrane Library, TOXLINE, International pharmaceutical abstracts, Google Scholar, and the gray literature up to December 31, 2013 were searched without time restriction to identify all types of studies that examined effects of various treatments for calcium channel blocker poisoning for the outcomes of interest. The search strategy included the following Keywords: [calcium channel blockers OR calcium channel antagonist OR calcium channel blocking agent OR (amlodipine or bencyclane or bepridil or cinnarizine or felodipine or fendiline or flunarizine or gallopamil or isradipine or lidoflazine or mibefradil or nicardipine or nifedipine or nimodipine or nisoldipine or nitrendipine or prenylamine or verapamil or diltiazem)] AND [overdose OR medication errors OR poisoning OR intoxication OR toxicity OR adverse effect]. Two reviewers independently selected studies and a group of reviewers abstracted all relevant data using a pilot-tested form. A second group analyzed the risk of bias and overall quality using the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist and the Thomas tool for observational studies, the Institute of Health Economics tool for Quality of Case Series, the ARRIVE (Animal Research: Reporting In Vivo Experiments) guidelines, and the modified NRCNA (National Research Council for the National Academies) list for animal studies. Qualitative synthesis was used to summarize the evidence. Of 15,577 citations identified in the initial search, 216 were selected for analysis, including 117 case reports. The kappa on the quality analysis tools was greater than 0.80 for all study types. RESULTS The only observational study in humans examined high-dose insulin and extracorporeal life support. The risk of bias across studies was high for all interventions and moderate to high for extracorporeal life support. High-dose insulin. High-dose insulin (bolus of 1 unit/kg followed by an infusion of 0.5-2.0 units/kg/h) was associated with improved hemodynamic parameters and lower mortality, at the risks of hypoglycemia and hypokalemia (low quality of evidence). Extracorporeal life support. Extracorporeal life support was associated with improved survival in patients with severe shock or cardiac arrest at the cost of limb ischemia, thrombosis, and bleeding (low quality of evidence). Calcium, dopamine, and norepinephrine. These agents improved hemodynamic parameters and survival without documented severe side effects (very low quality of evidence). 4-Aminopyridine. Use of 4-aminopyridine was associated with improved hemodynamic parameters and survival in animal studies, at the risk of seizures. Lipid emulsion therapy. Lipid emulsion was associated with improved hemodynamic parameters and survival in animal models of intravenous verapamil poisoning, but not in models of oral verapamil poisoning. Other studies. Studies on decontamination, atropine, glucagon, pacemakers, levosimendan, and plasma exchange reported variable results, and the methodologies used limit their interpretation. No trial was documented in humans poisoned with calcium channel blockers for Bay K8644, CGP 28932, digoxin, cyclodextrin, liposomes, bicarbonate, carnitine, fructose 1,6-diphosphate, PK 11195, or triiodothyronine. Case reports were only found for charcoal hemoperfusion, dialysis, intra-aortic balloon pump, Impella device and methylene blue. CONCLUSIONS The treatment for calcium channel blocker poisoning is supported by low-quality evidence drawn from a heterogeneous and heavily biased literature. High-dose insulin and extracorporeal life support were the interventions supported by the strongest evidence, although the evidence is of low quality.
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Affiliation(s)
- M St-Onge
- Ontario and Manitoba Poison Centre , Toronto, ON , Canada
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Shenoy S, Lankala S, Adigopula S. Management of calcium channel blocker overdoses. J Hosp Med 2014; 9:663-8. [PMID: 25066023 DOI: 10.1002/jhm.2241] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 07/01/2014] [Accepted: 07/08/2014] [Indexed: 11/09/2022]
Abstract
Calcium channel blockers (CCBs) are some of the most commonly used medications in clinical practice to treat hypertension, angina, cardiac arrhythmias, and some cases of heart failure. Recent data show that CCBs are the most common of the cardiovascular medications noted in intentional or unintentional overdoses.(1) Novel treatment approaches in the form of glucagon, high-dose insulin therapy, and intravenous lipid emulsion therapies have been tried and have been successful. However, the evidence for these are limited to case reports and case series. We take this opportunity to review the various treatment options in the management of CCB overdoses with a special focus on high-dose insulin therapy as the emerging choice for initial therapy in severe overdoses.
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Affiliation(s)
- Sundeep Shenoy
- Division of Inpatient Medicine, University of Arizona, Tucson, Arizona
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40
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Toxicologic emergencies in the intensive care unit: management using reversal agents and antidotes. Crit Care Nurs Q 2014; 36:335-44. [PMID: 24002424 DOI: 10.1097/cnq.0b013e3182a10cbd] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To review the most common drugs implicated in overdoses admitted to the intensive care unit focusing on antidotes and reversal agents used in their management. SUMMARY Poisonings and overdoses due to pharmaceutical agents result in more than 100 000 critical care unit admissions each year. Ingestion of toxic alcohols, calcium channel blockers, beta-adrenergic antagonists, benzodiazepines, opioids, acetaminophen, tricyclic antidepressants, and salicylates are associated with a high rate of morbidity and mortality. Reviewing the mechanism of toxicity due to specific agents along with the mechanism of action, dosing, and adverse effects of appropriate antidotes is important for the successful management of these patients within the critical care unit. CONCLUSION Understanding the most prevalent overdoses and their management using reversal agents and antidotes is essential to the overall treatment of these critically ill patients.
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41
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Thakrar R, Shulman R, Bellingan G, Singer M. Management of a mixed overdose of calcium channel blockers, β-blockers and statins. BMJ Case Rep 2014; 2014:bcr-2014-204732. [PMID: 24907219 DOI: 10.1136/bcr-2014-204732] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a case of extreme mixed overdose of calcium channel blockers, β-blockers and statins. The patient was successfully treated with aggressive resuscitation including cardiac pacing and multiorgan support, glucagon and high-dose insulin for toxicity related to calcium channel blockade and β-blockade, and ubiquinone for treating severe presumed statin-induced rhabdomyolysis and muscle weakness.
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Affiliation(s)
- Reena Thakrar
- Department of Critical Care, University College London Hospital Foundation Trust, London, UK
| | - Rob Shulman
- Pharmacy Department, University College London Hospital Foundation Trust, London, UK
| | - Geoff Bellingan
- Department of Critical Care, University College London Hospital Foundation Trust, London, UK Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
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42
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Woodward C, Pourmand A, Mazer-Amirshahi M. High dose insulin therapy, an evidence based approach to beta blocker/calcium channel blocker toxicity. ACTA ACUST UNITED AC 2014; 22:36. [PMID: 24713415 PMCID: PMC3985540 DOI: 10.1186/2008-2231-22-36] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 03/26/2014] [Indexed: 11/10/2022]
Abstract
Poison-induced cardiogenic shock (PICS) as a result of beta-blocker (β-blocker) or calcium channel blocker (CCB) overdose is a common and potentially life-threatening condition. Conventional therapies, including fluid resuscitation, atropine, cardiac pacing, calcium, glucagon, and vasopressors often fail to improve hemodynamic status. High-dose insulin (HDI) is an emerging therapeutic modality for PICS. In this article, we discuss the existing literature and highlight the therapeutic success and potential of HDI. Based on the current literature, which is limited primarily to case series and animal models, the authors conclude that HDI can be effective in restoring hemodynamic stability, and recommend considering its use in patients with PICS that is not responsive to traditional therapies. Future studies should be undertaken to determine the optimal dose and duration of therapy for HDI in PICS.
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Affiliation(s)
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University, Washington, DC 20037, USA.
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43
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Kline JA. Insulin for calcium channel toxicity. Ann Emerg Med 2014; 63:92-3. [PMID: 24355376 DOI: 10.1016/j.annemergmed.2013.10.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 10/23/2013] [Accepted: 10/24/2013] [Indexed: 11/20/2022]
Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN
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44
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Abstract
Amlodipine is a commonly prescribed calcium channel blocker. Its toxicity is the leading cause of drug overdose seen in the practice of cardiovascular medicine. It can lead to profound hypotension and shock. Management involves early and aggressive supportive measures and calcium infusion in large doses to overcome competitive blockade. We report one such case that presented with amlodipine overdose and was successfully managed.
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Affiliation(s)
- Vimal Upreti
- From: Department of Endocrinology, Command Hospital (Air Force), Bangalore, India
| | - V. R. Ratheesh
- Department of Medicine, Command Hospital (Air Force), Bangalore, India
| | - Pawan Dhull
- Department of Neurology, Command Hospital (Air Force), Bangalore, India
| | - Ajay Handa
- Department of Pulmonology, Command Hospital (Air Force), Bangalore, India
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45
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Critical Care Management ofVerapamil and Diltiazem Overdose With a Focus on Vasopressors: A 25-Year Experience at a Single Center. Ann Emerg Med 2013; 62:252-8. [DOI: 10.1016/j.annemergmed.2013.03.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 03/04/2013] [Accepted: 03/12/2013] [Indexed: 11/21/2022]
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46
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Weinberg RL, Bouchard NC, Abrams DC, Bacchetta M, Dzierba AL, Burkart KM, Brodie D. Venoarterial extracorporeal membrane oxygenation for the management of massive amlodipine overdose. Perfusion 2013; 29:53-6. [PMID: 23863493 DOI: 10.1177/0267659113498807] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 50-year-old man was admitted to the intensive care unit with respiratory failure and shock after suffering a massive overdose of amlodipine, lisinopril and hydrochlorothiazide. Despite mechanical ventilation, vasopressors, calcium gluconate, hyperinsulinemia-euglycemia therapy, methylene blue and intravenous fat emulsion, the patient's respiratory and hemodynamic status deteriorated. Venoarterial extracorporeal membrane oxygenation (ECMO) was initiated to provide cardiopulmonary support in the setting of profound respiratory failure and refractory shock. The patient was placed on ECMO 19 hours after arrival to the hospital, after which vasopressor and ventilatory requirements decreased significantly. The patient was decannulated from ECMO after 8 days and was discharged home after a 56-day hospitalization. Early institution of ECMO should be considered for the management of respiratory failure and refractory shock in the setting of calcium channel blocker overdose when medical therapies are insufficient.
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Affiliation(s)
- R L Weinberg
- 1Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, Division of Cardiology, Department of Medicine, New York, NY, USA
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Spiller HA, Milliner BA, Bosse GM. Amlodipine fatality in an infant with postmortem blood levels. J Med Toxicol 2012; 8:179-82. [PMID: 22271567 DOI: 10.1007/s13181-011-0207-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Amlodipine is a dihydropyridine calcium channel blocker used in the treatment of hypertension and angina pectoris. Toxic effects reported from amlodipine include hypotension, reflex tachycardia, metabolic acidosis, and pulmonary edema. We report a rare fatality in an infant after ingestion of amlodipine with benazepril, with postmortem blood concentrations. CASE REPORT An 11-month-old, 10.88-kg boy ingested 10 to 45 mg amlodipine with 40 to 180 mg benazepril. No action was taken initially because the parents believed only one or two capsules had been ingested. A later count revealed a maximum of nine capsules missing. The child was observed at home and vomited once with possible capsule fragments. Forty-five minutes post-ingestion, the child was noted to be suddenly unresponsive and was brought the local emergency department by a private vehicle. Upon arrival (90 min post-ingestion), the child was unresponsive with the following vital signs HR 133 bpm, BP 67/42 mmHg, respiratory rate 40/min, and temperature 97.5°F. Pertinent abnormal laboratory values were HCO(3) 13 mmol/l and glucose 302 mg/dl. The child was placed on oxygen via a non-rebreather mask and was intubated 45 min post-arrival. The patient became progressively bradycardic, and 55 min after arrival, the patient was in asystole with no palpable blood pressure. Resuscitation measures included chest compressions, epinephrine atropine, sodium bicarbonate, and calcium gluconate. Rescue insulin therapy was begun with 4 units IVP followed by 10 units per hour. Resuscitation efforts persisted for 1 h without success. An autopsy revealed pulmonary edema and no gross or microscopic evidence of natural disease. Stomach contents revealed food matter with small white fragments. Analysis of postmortem heart blood showed amlodipine 1,300 ng/ml (therapeutic <20 ng/ml). Benazepril levels were not available. DISCUSSION We believe this is the first reported fatality in an infant from amlodipine. While benazepril may have contributed, ACE inhibitors have not been previously associated with rapid cardiovascular collapse. CONCLUSION Small doses of amlodipine (0.9 to 4.1 mg/kg) may produce rapid and fatal cardiovascular collapse in an infant.
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Affiliation(s)
- Henry A Spiller
- Kentucky Regional Poison Control Center of Kosair Children's Hospital, Louisville, KY 40232-5070, USA.
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Rizvi I, Ahmad A, Gupta A, Zaman S. Life-threatening calcium channel blocker overdose and its management. BMJ Case Rep 2012; 2012:bcr.01.2012.5643. [PMID: 22669854 DOI: 10.1136/bcr.01.2012.5643] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A young woman presented to the emergency department with complaints of nausea, vomiting, pain in the abdomen and difficulty in breathing after ingestion of 56 tablets of amlodipine 5 mg each (total 280 mg of amlodipine). She was managed using hyperinsulinaemia/euglycaemia therapy and other measures like calcium gluconate, glucagon and vasopressors. She was discharged from hospital in a stable condition after 5 days.
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Affiliation(s)
- Imran Rizvi
- Department of General Medicine, J N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India.
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Marraffa JM, Cohen V, Howland MA. Antidotes for toxicological emergencies: a practical review. Am J Health Syst Pharm 2012; 69:199-212. [PMID: 22261941 DOI: 10.2146/ajhp110014] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Appropriate therapies for commonly encountered poisonings, medication overdoses, and other toxicological emergencies are reviewed, with discussion of pharmacists' role in ensuring their ready availability and proper use. SUMMARY Poisoning is the second leading cause of injury-related morbidity and mortality in the United States, with more than 2.4 million toxic exposures reported each year. Recently published national consensus guidelines recommend that hospitals providing emergency care routinely stock 24 antidotes for a wide range of toxicities, including toxic-alcohol poisoning, exposure to cyanide and other industrial agents, and intentional or unintentional overdoses of prescription medications (e.g., calcium-channel blockers, β-blockers, digoxin, isoniazid). Pharmacists can help reduce morbidity and mortality due to poisonings and overdoses by (1) recognizing the signs and symptoms of various types of toxic exposure, (2) guiding emergency room staff on the appropriate use of antidotes and supportive therapies, (3) helping to ensure appropriate monitoring of patients for antidote response and adverse effects, and (4) managing the procurement and stocking of antidotes to ensure their timely availability. CONCLUSION Pharmacists can play a key role in reducing poisoning and overdose injuries and deaths by assisting in the early recognition of toxic exposures and guiding emergency personnel on the proper storage, selection, and use of antidotal therapies.
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Affiliation(s)
- Jeanna M Marraffa
- Upstate New York Poison Center, 750 East Adams Street, Syracuse, NY 13210, USA.
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Toxic bradycardias in the critically ill poisoned patient. Emerg Med Int 2012; 2012:852051. [PMID: 22545217 PMCID: PMC3321542 DOI: 10.1155/2012/852051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 11/15/2011] [Accepted: 01/18/2012] [Indexed: 11/17/2022] Open
Abstract
Cardiovascular drugs are a common cause of poisoning, and toxic bradycardias can be refractory to standard ACLS protocols. It is important to consider appropriate antidotes and adjunctive therapies in the care of the poisoned patient in order to maximize outcomes. While rigorous studies are lacking in regards to treatment of toxic bradycardias, there are small studies and case reports to help guide clinicians' choices in caring for the poisoned patient. Antidotes, pressor support, and extracorporeal therapy are some of the treatment options for the care of these patients. It is important to make informed therapeutic decisions with an understanding of the available evidence, and consultation with a toxicologist and/or regional Poison Control Center should be considered early in the course of treatment.
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