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Sorabella RA, Gray WH, Dabal RJ, Padilla LA, Hock K, Clark MG, O'Meara C, Hawkins J, Richter RP, Borasino S, Byrnes JW. Central Extracorporeal Membrane Oxygenation Support Following Calcium Channel Blocker Overdose in Children. ASAIO J 2024; 70:e92-e96. [PMID: 37976539 DOI: 10.1097/mat.0000000000002102] [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: 11/19/2023] Open
Abstract
Refractory vasodilatory shock (RVS) following massive calcium channel blocker (CCB) overdose remains a challenging clinical entity. Peripheral venoarterial extracorporeal membrane oxygenation (ECMO) has proven useful in several cases of CCB intoxication, however, its use in the pediatric population poses unique challenges given the generally small size of pediatric peripheral vasculature in comparison to the high flow rates necessary for adequate mechanical circulatory support. As a result of these challenges, our group has adopted a "primary" central ECMO cannulation approach to the treatment of children and adolescents admitted to our center with profound RVS after CCB ingestion. We present four cases within the last year using this approach. All patients were successfully discharged from the hospital with no late morbidity at most recent follow-up. Central ECMO support in cases of massive vasodilatory shock following CCB overdose is safe and effective and should be considered early in the clinical course of these critically ill patients.
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Affiliation(s)
- Robert A Sorabella
- From the Division of Cardiothoracic Surgery, Section of Pediatric Cardiac Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - William H Gray
- From the Division of Cardiothoracic Surgery, Section of Pediatric Cardiac Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Robert J Dabal
- From the Division of Cardiothoracic Surgery, Section of Pediatric Cardiac Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Luz A Padilla
- From the Division of Cardiothoracic Surgery, Section of Pediatric Cardiac Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Kristal Hock
- Division of Pediatric Cardiology, Section of Cardiac Critical Care Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Matthew G Clark
- Division of Pediatric Cardiology, Section of Cardiac Critical Care Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Carlisle O'Meara
- Department of Cardiovascular Perfusion, Children's of Alabama, Birmingham, Alabama
| | - Jeremy Hawkins
- Department of Cardiovascular Perfusion, Children's of Alabama, Birmingham, Alabama
| | - Robert P Richter
- Division of Pediatric Critical Care, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Santiago Borasino
- Division of Pediatric Cardiology, Section of Cardiac Critical Care Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Jonathan W Byrnes
- Division of Pediatric Cardiology, Section of Cardiac Critical Care Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
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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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Wang C, Zhu Q, Tan D, Walline J, Wang Y. Acute High-Output Heart Failure with Pulmonary Hypertension and Severe Liver Injury Caused by Amlodipine Poisoning: A Case Report. Cardiovasc Toxicol 2024; 24:513-518. [PMID: 38530625 DOI: 10.1007/s12012-024-09849-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 03/06/2024] [Indexed: 03/28/2024]
Abstract
Acute high-output heart failure (HOHF) with pulmonary hypertension and liver injury caused by amlodipine poisoning is very rare. We report a 52-year-old woman who suffered from severe shock after an overdose of amlodipine. Hemodynamic monitoring showed that while her left ventricular systolic function and cardiac output were elevated, her systemic vascular resistance decreased significantly. At the same time, the size of her right heart, her central venous pressure, and the oxygen saturation of her central venous circulation all increased abnormally. The patient's circulatory function and right ventricular dysfunction gradually improved after large doses of vasopressors and detoxification measures. However, her bilirubin and transaminase levels increased significantly on hospital day 6, with a CT scan showing patchy, low-density areas in her liver along with ascites. After liver protective treatment and plasma exchange, the patient's liver function gradually recovered. A CT scan 4 months later showed all her liver abnormalities, including ascites, had resolved. The common etiologies of HOHF were excluded in this case, and significantly reduced systemic vascular resistance caused by amlodipine overdose was thought to be the primary pathophysiological basis of HOHF. The significant increase in venous return and pulmonary blood flow is considered to be the main mechanism of right ventricular dysfunction and pulmonary hypertension. Hypoxic hepatitis caused by a combination of hepatic congestion and distributive shock may be the most important factors causing liver injury in this patient. Whether amlodipine has other mechanisms leading to HOHF and pulmonary hypertension needs to be further studied. Considering the significant increase of right heart preload, aggressive fluid resuscitation should be done very cautiously in patients with HOHF and shock secondary to amlodipine overdose.
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Affiliation(s)
- Chenlong Wang
- Department of Emergency, Clinical Medical College, Yangzhou University (Northern Jiangsu People's Hospital), No.98, Nantong West Road, Guangling District, Yangzhou City, 225001, Jiangsu Province, China
| | - Qingcheng Zhu
- Department of Emergency, Clinical Medical College, Yangzhou University (Northern Jiangsu People's Hospital), No.98, Nantong West Road, Guangling District, Yangzhou City, 225001, Jiangsu Province, China
| | - Dingyu Tan
- Department of Emergency, Clinical Medical College, Yangzhou University (Northern Jiangsu People's Hospital), No.98, Nantong West Road, Guangling District, Yangzhou City, 225001, Jiangsu Province, China.
| | - Joseph Walline
- Department of Emergency Medicine, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Yachao Wang
- Department of Emergency, Clinical Medical College, Yangzhou University (Northern Jiangsu People's Hospital), No.98, Nantong West Road, Guangling District, Yangzhou City, 225001, Jiangsu Province, China
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Omar S, Parris P, Gurke CR. Hemoadsorption Therapy for Calcium Channel Blocker Overdose: A Case Report. J Emerg Med 2024; 66:e463-e466. [PMID: 38461133 DOI: 10.1016/j.jemermed.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/24/2023] [Accepted: 11/23/2023] [Indexed: 03/11/2024]
Abstract
BACKGROUND Modern resin hemoadsorption/hemoperfusion for calcium channel blocker overdose is yet to be reported. The characteristics of calcium channel blockers make them unamenable to removal by hemodiafiltration or charcoal hemoperfusion; however, elimination, using styrene bead adsorption in an ex vivo model, has been demonstrated. Its clinical use is described. CASE REPORT A man in his 20s was admitted with shock into the Intensive Care Unit (ICU) after an overdose of amlodipine and risperidone. Resuscitation and supportive care were administered, but hypotension did not resolve despite the administration of intravenous fluids, infusions of calcium, adrenaline, and hyperinsulinemic-euglycemic therapy. Methylene blue was then administered to maintain the mean arterial pressures. However, the hemodynamic effect did not allow the weaning of the adrenaline. Drug clearance using hemoadsorption/hemoperfusion was attempted using a styrene resin filter (Jafron HA230; Jafron Biomedical Co., Ltd., Guangdong, China). During the two hemoperfusion sessions (6 h duration each, and 18 h apart) the patient had successfully weaned off all supportive measures, with lactate levels returning to normal and was later discharged home. At the end of each session, significant amlodipine concentrations were detected in blood aspirated from both filters, suggesting enhanced clearance. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case illustrates a temporal relationship between resin hemoperfusion therapy, resolution of hemodynamic instability, and shock without proving causation. Significant amlodipine elimination was suggested by high concentrations found in blood from the filter. At the same time, shock resolution after initiation of hemoperfusion occurred in less than one elimination half-life of amlodipine.
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Affiliation(s)
- Shahed Omar
- Department of Critical Care, School of Clinical Medicine/University of Witwatersrand/Chris Hani Baragwanath, Johannesburg, South Africa.
| | - Pano Parris
- Department of Critical Care, School of Clinical Medicine/University of Witwatersrand/Chris Hani Baragwanath, Johannesburg, South Africa
| | - Chloe Rose Gurke
- Department of Critical Care, School of Clinical Medicine/University of Witwatersrand/Chris Hani Baragwanath, Johannesburg, South Africa
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Brahmi N, Ben Ghezala H, Mrad A, Ben Jazia A. High-dose norepinephrine infusion (100 µg/kg/min) in a near-fatal amlodipine and perindopril poisoning: are there any limits? Clin Toxicol (Phila) 2024; 62:273-274. [PMID: 38668746 DOI: 10.1080/15563650.2024.2339483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/01/2024] [Indexed: 05/31/2024]
Affiliation(s)
- Nozha Brahmi
- Department of Medical and Toxicological Intensive Care Unit, Mahmoud Yaacoub Emergency Medical Center, Montfleury, University Tunis El Manar, Tunis, Tunisia
| | - Hassen Ben Ghezala
- Department of Medical and Toxicological Intensive Care Unit, Mahmoud Yaacoub Emergency Medical Center, Montfleury, University Tunis El Manar, Tunis, Tunisia
| | - Aymen Mrad
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, Paris
| | - Amira Ben Jazia
- Department of Medical and Toxicological Intensive Care Unit, Mahmoud Yaacoub Emergency Medical Center, Montfleury, University Tunis El Manar, Tunis, Tunisia
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Gutierrez GC, Dayton C, Attridge RL, Smedley L, Saikumar H, Everett C, Rodriguez A, Varney S. Angiotensin II Use in Treatment of Refractory Shock Due to Benazepril and Amlodipine Toxic Ingestion. J Pharm Pract 2024; 37:513-516. [PMID: 36314764 DOI: 10.1177/08971900221137389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Introduction: Calcium channel blockers (CCB) are a leading cause of ingestion-associated fatality. Angiotensin-converting enzyme inhibitor (ACEi) overdose as part of co-ingestion is common and associated with refractory shock. Treatment options to manage this profound vasoplegia are limited. We describe the first case of use of newly formulated Angiotensin II for treatment of severe ACEi and CCB poisoning. Case Report: A 57-year-old man presented after suicide attempt by ingesting 20 tablets each of amlodipine 10 mg and benazepril 20 mg. His hypotension was initially managed with 35 mL/kg of crystalloid, norepinephrine, and hyperinsulinemic euglycemic therapy (HIET). His hemodynamics further deteriorated, and he developed lactic acidosis, electrolyte derangements, and renal dysfunction. Further complications of his ingestion included cardiac arrest, subsequent requirement for emergency cricothyrotomy, and renal replacement therapy. Maximal hemodynamic support with HIET therapy insulin drip 4.4 units/kg/hour, norepinephrine 2 mcg/kg/min, epinephrine 1 mcg/kg/min, vasopressin .06 units/hour, and intravenous lipid emulsion was unsuccessful. Ang II was started and titrated to maximal doses with dramatic improvement in hemodynamics. Within hours of starting Ang II, epinephrine was stopped and norepinephrine decreased by 50%. He was downgraded from the intensive care unit without any ongoing end-organ dysfunction. Discussion: Isolated CCB overdoses have high complication rates and well-established treatments. Therefore, management of CCB and ACEi co-ingestion is typically driven by CCB poisoning algorithm. There are multiple reports of CCB and ACEi co-ingestions causing treatment-refractory shock. Therapeutic options are limited by toxicities and availability of salvage therapies. Ang II is a safe and highly effective option to manage these patients.
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Affiliation(s)
- G Christina Gutierrez
- University Health, Pharmacotherapy and Pharmacy Services, San Antonio, TX, USA
- UT Health San Antonio, Pharmacotherapy Education and Research Center, San Antonio, TX, USA
| | - Christopher Dayton
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, San Antonio, TX, USA
- South Texas Poison Center, San Antonio, TX, USA
| | - Rebecca L Attridge
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, San Antonio, TX, USA
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA
| | - Lucas Smedley
- University Health, Pharmacotherapy and Pharmacy Services, San Antonio, TX, USA
- UT Health San Antonio, Pharmacotherapy Education and Research Center, San Antonio, TX, USA
| | - Haritha Saikumar
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, San Antonio, TX, USA
| | - Christopher Everett
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, San Antonio, TX, USA
| | - Abraham Rodriguez
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, San Antonio, TX, USA
| | - Shawn Varney
- South Texas Poison Center, San Antonio, TX, USA
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Emergency Medicine, San Antonio, TX, USA
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Goldfine CE, Troger A, Erickson TB, Chai PR. Beta-blocker and calcium-channel blocker toxicity: current evidence on evaluation and management. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:247-253. [PMID: 37976176 DOI: 10.1093/ehjacc/zuad138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023]
Abstract
Beta-blocker and calcium-channel blocker overdoses are associated with severe morbidity and mortality; therefore, it is important to recognize and appropriately treat individuals with toxicity. The most common clinical findings in toxicity are bradycardia and hypotension. In addition to supportive care and cardiac monitoring, specific treatment includes administration of calcium salts, vasopressors, and high-dose insulin euglycaemia treatment. Other advanced treatments (e.g. ECMO) may be indicated depending on the severity of toxicity and specific agents involved.
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Affiliation(s)
- Charlotte E Goldfine
- Division of Medical Toxicology, Department of Emergency Medicine, Mass General Brigham Boston, 75 Francis St, Boson, MA 02115, USA
- Harvard Medical School, 25 Shattuck St, Boson, MA 02115, USA
| | - Andrew Troger
- Harvard Medical School, 25 Shattuck St, Boson, MA 02115, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Timothy B Erickson
- Division of Medical Toxicology, Department of Emergency Medicine, Mass General Brigham Boston, 75 Francis St, Boson, MA 02115, USA
- Harvard Medical School, 25 Shattuck St, Boson, MA 02115, USA
- Department of Global Health and Population, Harvard Humanitarian Institute, Harvard T.H. Chan School of Public Health, Cambridge, USA
| | - Peter R Chai
- Division of Medical Toxicology, Department of Emergency Medicine, Mass General Brigham Boston, 75 Francis St, Boson, MA 02115, USA
- Harvard Medical School, 25 Shattuck St, Boson, MA 02115, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, USA
- The Koch Institute for Integrated Cancer Research, Massachusetts Institute of Technology, Cambridge, USA
- The Fenway Institute, Boston, USA
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Saeed A, Naghshzan A. Successful treatment of severe calcium channel blocker poisoning, new experience with the guidance of invasive hemodynamic monitoring in a 17-year-old girl: a case report. J Med Case Rep 2024; 18:68. [PMID: 38308385 PMCID: PMC10837995 DOI: 10.1186/s13256-024-04345-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/29/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Calcium channel blocker poisoning is one of the most lethal cardiac drugs overdoses. Calcium and high-dose insulin infusion are the first-line therapy for symptomatic patients, and Intralipid emulsion infusion is useful for refractory cases. CASE PRESENTATION In this report, we describe a 17-year-old Iranian girl who took 250 mg of the drug for a suicidal attempt and presented with refractory hypotension and non-cardiogenic pulmonary edema treated successfully with the guidance of invasive hemodynamic parameters. CONCLUSION For complicated cases, in addition to supportive care and adjuvant therapy such as high-dose insulin and Intralipid, it is mandatory to utilize advanced hemodynamic monitoring to treat hypotension in severe calcium channel blocker poisoning to guide the treatment.
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Affiliation(s)
- Amir Saeed
- Scientific Association of Intensive Care and ICU of Iran, Tehran, Iran
| | - Amir Naghshzan
- Cardiovascular and Neonatology Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
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Rafeq R, Salzman M. Use of Concentrated Insulin in the Management of Calcium Channel Blocker Overdose: A Case Report. J Pharm Pract 2023; 36:1519-1522. [PMID: 35862179 DOI: 10.1177/08971900221116189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Hyperinsulinemia-euglycemia therapy [HIE] is a first line therapy recommended in symptomatic calcium channel blocker overdose patients. HIE, particularly if administered in concentrations typically used for glycemic control, would result in a substantial amount of hypotonic fluid administration, which places patients at risk of volume overload. Therefore, it may be beneficial to utilize a concentrated insulin as a strategy to mitigate fluid overload risks. We report the case of a 73 years old, 69.9 kg female, who presented to the emergency department after an accidental ingestion of 70 mg amlodipine and was treated with HIE utilizing a uniquely concentrated insulin infusion. CASE PRESENTATION HIE at 10 units/kg/hr. was used for approximately 17 hours. Insulin was changed from a 1 unit/mL concentration to 16 unit/mL. Dextrose 10% infusion was initiated up to a max of 650 mL/hr. and norepinephrine infusion up to a max of 10 mcg/min. DISCUSSION Approximate fluid requirements from the 16 unit/mL concentration of insulin totaled 1 L as compared to a 1 unit/mL concentration which would have required 17 L, a total savings of 16 L. This savings potentially decreased the risk of cerebral or pulmonary edema associated with fluid overload. CONCLUSION Use of a concentrated insulin in the setting of a calcium channel blocker or beta blocker overdose provides a unique strategy to mitigate the effects associated with fluid overload.
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Affiliation(s)
- Rachel Rafeq
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ, USA
| | - Matthew Salzman
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ, USA
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Simpson MD, Watson CJ, Whitledge JD, Monuteaux MC, Burns MM. Intensive Care Interventions Among Children With Toxicologic Exposures to Cardiovascular Medications. Pediatr Crit Care Med 2023; 24:893-900. [PMID: 37133321 DOI: 10.1097/pcc.0000000000003274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Interventions requiring a PICU are rare in toxicologic exposures, but cardiovascular medications are high-risk exposures due to their hemodynamic effects. This study aimed to describe prevalence of and risk factors for PICU interventions among children exposed to cardiovascular medications. DESIGN Secondary analysis of Toxicology Investigators Consortium Core Registry from January 2010 to March 2022. SETTING International multicenter research network of 40 sites. PATIENTS Patients 18 years old or younger with acute or acute-on-chronic toxicologic exposure to cardiovascular medications. Patients were excluded if exposed to noncardiovascular medications or if symptoms were documented as unlikely related to exposure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,091 patients in the final analysis, 195 (17.9%) received PICU intervention. One hundred fifty-seven (14.4%) received intensive hemodynamic interventions and 602 (55.2%) received intervention in general. Children less than 2 years old were less likely to receive PICU intervention (odds ratio [OR], 0.42; 95% CI, 0.20-0.86). Exposures to alpha-2 agonists (OR, 2.0; 95% CI, 1.11-3.72) and antiarrhythmics (OR, 4.26; 95% CI, 1.41-12.90) were associated with PICU intervention. In the sensitivity analysis removing atropine from the composite outcome PICU intervention, only exposures to calcium channel antagonists (OR, 2.12; 95% CI, 1.09-4.11) and antiarrhythmics (OR, 4.82; 95% CI, 1.57-14.81) were independently associated with PICU intervention. No independent association was identified between PICU intervention and gender, polypharmacy, intentionality or acuity of exposure, or the other medication classes studied. CONCLUSIONS PICU interventions were uncommon but were associated with exposure to antiarrhythmic medications, calcium channel antagonists, and alpha-2 agonists. As demonstrated via sensitivity analysis, exact associations may depend on institutional definitions of PICU intervention. Children less than 2 years old are less likely to require PICU interventions. In equivocal cases, age and exposure to certain cardiovascular medication classes may be useful to guide appropriate disposition.
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Affiliation(s)
- Michael D Simpson
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - C James Watson
- Department of Emergency Medicine, Maine Medical Center, Portland, ME
| | - James D Whitledge
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Michele M Burns
- Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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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: 3] [Impact Index Per Article: 3.0] [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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Rasheed AHA, Vellanki K, Woo F, Leehey DJ. Hyponatremia in a Patient With Vasodilatory Shock Due to Overdose of Antihypertensive Medications: A Case Report. Cureus 2023; 15:e45053. [PMID: 37829951 PMCID: PMC10567059 DOI: 10.7759/cureus.45053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
Vasodilatory shock can be caused by septic shock, neurogenic shock, anaphylaxis, drugs, and toxins. Vasopressin is commonly used for the restoration of vasomotor tone in vasodilatory shock due to sepsis. This agent exerts its vasoconstrictive effect via smooth muscle V1 receptors and has antidiuretic activity via kidney V2 receptors. Stimulation of V2 receptors results in the integration of aquaporin 2 channels into the apical membrane of collecting ducts leading to free water reabsorption. This antidiuretic action of vasopressin predisposes to hyponatremia. Yet, the development of hyponatremia with the use of vasopressin in critically ill patients with sepsis is rare. A 75-year-old female presented after a suicidal attempt by ingestion of amlodipine and lisinopril. Despite adequate intravenous fluids administration, she remained hypotensive, requiring the initiation of vasopressors. She developed hyponatremia after initiation of vasopressin due to the absence of endotoxemia, and her serum sodium normalized once vasopressin was discontinued. We recommend monitoring for hyponatremia as a complication of vasopressin, especially in patients without sepsis.
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Affiliation(s)
| | - Kavitha Vellanki
- Medicine/Nephrology, Edward Hines, Jr. VA Hospital, Hines, USA
- Medicine/Nephrology, Loyola University Medical Center, Maywood, USA
| | - Frank Woo
- Internal Medicine - Pediatrics, Loyola University Medical Center, Maywood, USA
| | - David J Leehey
- Medicine/Nephrology, Edward Hines, Jr. VA Hospital, Hines, USA
- Medicine/Nephrology, Loyola University Medical Center, Maywood, USA
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Xiao L, Chen XJ, Feng JK, Li WN, Yuan S, Hu Y. Natural products as the calcium channel blockers for the treatment of arrhythmia: Advance and prospect. Fitoterapia 2023; 169:105600. [PMID: 37419421 DOI: 10.1016/j.fitote.2023.105600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/09/2023]
Abstract
Arrhythmia is one of the commonly heart diseases with observed abnormal heart-beat rhythm that caused by the obstacles of cardiac activity and conduction. The arrhythmic pathogenesis is complex and capricious and related with other cardiovascular diseases that may lead to heart failure and sudden death. In particular, calcium overload is recognized as the main reason causing arrhythmia through inducing apoptosis in cardiomyocytes. Moreover, calcium channel blockers have been widely used as the routine drugs for the treatment of arrhythmia, but the different arrhythmic complications and adverse effects limit their further applications and demand new drug discovery. Natural products have always been the rich minerals for the development of new drugs that could be employed as the versatile player for the discovery of safe and effective anti-arrhythmia drugs with new mechanisms. In this review, we summarized natural products with the activity against calcium signaling and the relevant mechanism of actions. We are expected to provide an inspiration for the pharmaceutical chemists to develop more potent calcium channel blockers for the treatment of arrhythmia.
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Affiliation(s)
- Lu Xiao
- China Academy of Chinese Medical Sciences Guang'anmen Hospital, Beijing 100053, China
| | - Xing-Juan Chen
- China Academy of Chinese Medical Sciences Guang'anmen Hospital, Beijing 100053, China
| | | | - Wei-Na Li
- China Academy of Chinese Medical Sciences Guang'anmen Hospital, Beijing 100053, China
| | - Shuo Yuan
- Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou 450018, China.
| | - Ying Hu
- China Academy of Chinese Medical Sciences Guang'anmen Hospital, Beijing 100053, China; Beijing University of Chinese Medicine, Beijing 100029, China.
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14
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Liu W, Yang W, Niu R, Cong L, Jiang M, Bai G. Costunolide covalently targets and inhibits CaMKII phosphorylation to reduce ischemia-associated brain damage. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 115:154822. [PMID: 37087789 DOI: 10.1016/j.phymed.2023.154822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Chronic cerebral hypoperfusion (CCH) is a leading cause of disability and mortality worldwide. Restoring cerebral blood flow (CBF) through vasodilatation is particularly important in the treatment of CCH. Costunolide (Cos) is a natural sesquiterpenoid compound with vasodilatory effect, but its mechanism is unclear. PURPOSE This study aimed to investigate the vasodilatory mechanism of Cos and provide a new therapeutic regimen for treating CCH. METHODS The therapeutic effect of Cos on CCH was assessed in a rat model of permanent common carotid artery occlusion. The direct target protein for improving CBF was identified by drug affinity responsive target stability combined with quantitative differential proteomics analysis. The molecular mechanism of Cos acting on its target protein was analyzed by multidisciplinary approaches. The signalling involved was assessed using site-directed pharmacological intervention. RESULTS Cos has a significant therapeutic effect on ischemic brain injury by restoring CBF. Multifunctional calcium/calmodulin-dependent protein kinase II (CaMKII) was identified as a direct target of the natural small molecule Cos with a therapeutic effect on CCH. Mechanistic studies revealed that the α,β-unsaturated-γ-lactone ring of Cos covalently binds to the Cys116 residue of CaMKII. It then inhibits the phosphorylation of CaMKII and reduces the calcium concentration in vascular smooth muscle cells, thus playing a role in vasodilation and increasing CBF. Notably, this covalent binding between Cos and CaMKII can exert a long-term vasodilator activity. CONCLUSION We reported for the first time that Cos reduced ischemia-associated brain damage by covalently binding to the Cys116 residue of CaMKII, inhibiting CaMKII phosphorylation, and exerting long-term vasodilatory activity. This study not only found a new covalent inhibitor against the phosphorylation of CaMKII but also suggested that pharmacologically targeting CaMKII is a promising therapeutic strategy for CCH.
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Affiliation(s)
- Wenjuan Liu
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, 300353, China
| | - Wei Yang
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, 300353, China
| | - Ruixue Niu
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, 300353, China
| | - Longfei Cong
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, 300353, China
| | - Min Jiang
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, 300353, China.
| | - Gang Bai
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy and Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, 300353, China
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15
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Mégarbane B. High-dose insulin should be used before vasopressors/inotropes in calcium-channel blocker toxicity. Br J Clin Pharmacol 2023; 89:1269-1274. [PMID: 36604796 DOI: 10.1111/bcp.15641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/09/2021] [Accepted: 10/15/2021] [Indexed: 01/07/2023] Open
Abstract
High-dose insulin (HDI) therapy with adapted glucose supplementation to maintain euglycaemia has been suggested to treat calcium-channel blocker (CCB) poisonings. Its underlying mechanisms of action are now well documented. We present a narrative review of the published experimental studies, case reports and experts' opinions to support the effectiveness and safety of HDI in the treatment of CCB poisoning. Our review strongly encourages the use of HDI as first-line therapy in CCB-poisoned patients in the presence of cardiovascular compromise, especially if cardiac function impairment has been diagnosed, before, but without delaying, the administration of vasopressors/inotropic drugs.
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Affiliation(s)
- Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris, France.,Inserm UMRS 1144, University of Paris, France
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16
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Rietjens SJ, van Riemsdijk TE, Sikma MA, de Lange DW. High-dose insulin should NOT be used without vasopressors in calcium channel blocker toxicity. Br J Clin Pharmacol 2023; 89:1275-1278. [PMID: 36604782 DOI: 10.1111/bcp.15642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/05/2022] [Indexed: 01/07/2023] Open
Affiliation(s)
- Saskia J Rietjens
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Tessa E van Riemsdijk
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Maaike A Sikma
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Dylan W de Lange
- Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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17
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Danial P, Olivier ME, Bréchot N, Ponnaiah M, Schoell T, D'Alessandro C, Demondion P, Clément M, Juvin C, Carillion A, Bouglé A, Combes A, Leprince P, Lebreton G. Association Between Shock Etiology and 5-Year Outcomes After Venoarterial Extracorporeal Membrane Oxygenation. J Am Coll Cardiol 2023; 81:897-909. [PMID: 36858709 DOI: 10.1016/j.jacc.2022.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/17/2022] [Accepted: 12/02/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND Outcomes of patients requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) vary greatly by etiology, but large studies that incorporate the spectrum of shock supported with ECMO are rare. OBJECTIVES The purpose of this study was to describe the etiology-related outcome of patients with shock supported with peripheral VA-ECMO. METHODS All consecutive adults with peripheral VA-ECMO between January 2015 and August 2018 at Pitié-Salpêtrière Hospital (Paris, France) were included in this retrospective observational study. The indication for VA-ECMO was cardiogenic shock. Rates of hospital death and neurological, renal, and pulmonary complications were evaluated according to etiology. RESULTS Among 1,253 patients, hospital and 5-year survival rates were, respectively, 73.3% and 57.3% for primary graft failure, 58.6% and 54.0% for drug overdose, 53.2% and 45.3% for dilated cardiomyopathy, 51.6% and 50.0% for arrhythmic storm, 46.8% and 38.3% for massive pulmonary embolism, 44.4% and 42.4% for sepsis-induced cardiogenic shock, 37.9% and 32.9% for fulminant myocarditis, 37.3% and 31.5% for acute myocardial infarction, 34.6% and 33.3% for postcardiotomy excluding primary graft failure, 25.7% and 22.8% for other/unknown etiology, and 11.1% and 0.0% for refractory vasoplegia shock. Renal failure requiring hemodialysis developed in 50.0%, neurological complications in 16.0%, and hydrostatic pulmonary edema in 9.0%. CONCLUSIONS Although the outcome differs depending on etiology, this difference is related more to the severity of the situation associated with the cause rather than the cause of the shock per se. Survival to 5 years varied by cause, which may reflect the natural course of the chronic disease and illustrates the need for long-term follow-up.
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Affiliation(s)
- Pichoy Danial
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France.
| | - Maud-Emmanuel Olivier
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Nicolas Bréchot
- Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France; Department of Anaesthesiology and Surgical Intensive Care, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Maharajah Ponnaiah
- Sorbonne University, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Thibaut Schoell
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Cosimo D'Alessandro
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Pierre Demondion
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Marina Clément
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Charles Juvin
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Aude Carillion
- Department of Anaesthesiology and Surgical Intensive Care, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Adrien Bouglé
- Department of Anaesthesiology and Surgical Intensive Care, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France; Sorbonne University, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Alain Combes
- Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France; Sorbonne University, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France; Department of Anaesthesiology and Surgical Intensive Care, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Guillaume Lebreton
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France; Department of Anaesthesiology and Surgical Intensive Care, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
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18
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Chan YC, Tse ML. Clinical toxicology in emergency medicine: 20 Years and beyond. HONG KONG J EMERG ME 2023. [DOI: 10.1177/10249079231154241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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19
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Haque OI, Mahar S, Hussain S, Sloane P. Pharmacokinetic interaction between verapamil and ritonavir-boosted nirmatrelvir: implications for the management of COVID-19 in patients with hypertension. BMJ Case Rep 2023; 16:16/1/e252677. [PMID: 36639196 PMCID: PMC9843211 DOI: 10.1136/bcr-2022-252677] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
A woman in her 80s was brought to the emergency department for acute onset of generalised weakness, lethargy and altered mental state. The emergency medical service found her to have symptomatic bradycardia, and transcutaneous pacing was done. Medical history was notable for hypertension, hyperlipidaemia, type 2 diabetes, and a recently diagnosed SARS-CoV-2 (COVID-19) infection for which she was prescribed ritonavir-boosted nirmatrelvir (Paxlovid) two days before the presentation. On arrival at the hospital, she was found to have marked bradycardia with widened QRS, hyperglycaemia and metabolic acidosis. Transvenous pacing along with pressor support and insulin were initiated, and she was admitted to the intensive care unit. Drug interaction between ritonavir-boosted nirmatrelvir and verapamil leading to verapamil toxicity was suspected of causing her symptoms, and both drugs were withheld. She reverted to sinus rhythm on the fourth day, and the pacemaker was discontinued.
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Affiliation(s)
- Obaid Imtiyazul Haque
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA,Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samantha Mahar
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Shahzad Hussain
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Peter Sloane
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
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20
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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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21
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Stanton MT. Part
II
: Interactive case: Toxicology and poison control. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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22
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Vodovar D, Dufayet L, Mégarbane B. Assessing effectiveness of whole bowel irrigation in poisoning: A laudable effort but still insufficient evidence. Aust Crit Care 2022; 36:295-296. [PMID: 36379838 DOI: 10.1016/j.aucc.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/02/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Dominique Vodovar
- UFR de Médecine, Université Paris-Cité, 75010, Paris, France; Centre Antipoison de Paris, Hôpital Fernand-Widal, Assistance Publique - Hôpitaux de Paris, 75010, Paris, France; INSERM UMRS-1144, Faculté de Pharmacie, 75006, France.
| | - Laurène Dufayet
- UFR de Médecine, Université Paris-Cité, 75010, Paris, France; Centre Antipoison de Paris, Hôpital Fernand-Widal, Assistance Publique - Hôpitaux de Paris, 75010, Paris, France; Unité Médico Judiciaire, Hôpital Hôtel-Dieu, Assistance Publique - Hôpitaux de Paris, 75004, Paris, France
| | - Bruno Mégarbane
- UFR de Médecine, Université Paris-Cité, 75010, Paris, France; INSERM UMRS-1144, Faculté de Pharmacie, 75006, France; Réanimation Médicale et Toxicologique, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, 75010, Paris, France
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23
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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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24
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Li G, Shi Y, Zhang L, Yang C, Wan T, Lv H, Jian W, Li J, Li M. Efficacy of acupuncture in animal models of vascular dementia: A systematic review and network meta-analysis. Front Aging Neurosci 2022; 14:952181. [PMID: 36062145 PMCID: PMC9434110 DOI: 10.3389/fnagi.2022.952181] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/14/2022] [Indexed: 12/09/2022] Open
Abstract
Background and purpose Acupuncture is widely used in clinical practice for the treatment of vascular diseases. However, the protocol, efficacy, and mechanism of acupuncture in animal models of vascular dementia are still controversial. Based on the above problems, we initiated this comprehensive study. Methods To analyze the literatures included in this study, 4 databases were searched and the SYRCLE's Risk of bias tool was employed. To perform the subgroup analysis of different acupuncture methods and the Review Manager 5.3 was applied. Meanwhile, the pairwise and network meta-analysis were conducted using Addis 1.16.8. The outcomes included escape latency, number of crossings, time spent in the target quadrant, and swimming speed. Results Forty-two studies with a total of 1,486 animals were included in this meta-analysis. According to the results from subgroup analysis, GV20 + ST36 (Baihui + bilateral Zusanli) combined with 14-day manual acupuncture can obtain best improvement of the rats cognitive function among all acupuncture regimens (MD: -23.41; 95%CI: -26.66, -20.15; I2 = 0%; P < 0.001). The heterogeneity of other acupuncture treatments was significantly higher than that of GV20 + ST36, because the treatment courses were not uniform. Pair-wise and network comparisons are highly consistent. The major results of the network meta-analysis were as follows, In comparison to the impaired group, the acupuncture group showed significantly reduced escape latency (MD: -25.87; 95%CI: -30.75, -21.12), increased number of original platform crossings (MD: 2.63; 95%CI: 1.94, 3.34) and time spent in the target quadrant (MD: 7.88; 95%CI: 4.25, 11.44). The overall results of the network meta-analysis are as follows: the normal and sham-operated groups performed the best, followed by medicine and acupuncture, while no effect was found in the impaired group treated with non-acupoint and palliative. Conclusions Acupuncture significantly improves cognitive function in rats with vascular dementia. Compared to other acupuncture plans, (GV20 + ST36, MA) and 14 -day manual acupuncture can be used to obtain better results. The main mechanism of acupuncture in the treatment of vascular dementia is reduced oxidative stress, neuronal inflammation, and apoptosis, as well as the increased synaptic plasticity and neurotransmitters. Systematic review registration https://inplasy.com/inplasy-2021-11-0036/, identifier: INPLASY2021110036.
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Affiliation(s)
- Guangyao Li
- Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuling Shi
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Lu Zhang
- Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Chuanghui Yang
- Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ting Wan
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hang Lv
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenxuan Jian
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jinghu Li
- Department of Massage, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Min Li
- Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
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25
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Alshaya OA, Alhamed A, Althewaibi S, Fetyani L, Alshehri S, Alnashmi F, Alharbi S, Alrashed M, Alqifari SF, Alshaya AI. Calcium Channel Blocker Toxicity: A Practical Approach. J Multidiscip Healthc 2022; 15:1851-1862. [PMID: 36065348 PMCID: PMC9440664 DOI: 10.2147/jmdh.s374887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022] Open
Abstract
Calcium channel blockers (CCBs) are widely prescribed medications for various clinical indications in adults and children. They are available in both immediate and long-acting formulations and are generally classified into dihydropyridines and nondihydropyridines, with nondihydropyridines having more cardioselectivity. CCB toxicity is common given the widespread use which leads to serious adverse clinical outcomes, especially in children. Severe CCB toxicities may present with life-threatening bradycardia, hypotension, hyperglycemia, and renal insufficiency. Dihydropyridine toxicity, however, may present with reflex tachycardia instead of bradycardia. Initial patient evaluation and assessment are crucial to identify the severity of CCB toxicity and design the best management strategy. There are different strategies to overcome CCB toxicity that requires precise dosing and close monitoring in various patient populations. These strategies may include large volumes of IV fluids, calcium salts, high insulin euglycemia therapy (HIET), and vasopressors. We hereby summarize the evidence behind the management of CCB toxicity and present a practical guide for clinicians to overcome this common drug toxicity.
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Affiliation(s)
- Omar A Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Correspondence: Omar A Alshaya, Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Saudi Arabia, Email
| | - Arwa Alhamed
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Nursing, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sara Althewaibi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Lolwa Fetyani
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shaden Alshehri
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fai Alnashmi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shmeylan Alharbi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohammed Alrashed
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmacy Department, Northwest Medical Center, Tucson, AZ, USA
| | - Saleh F Alqifari
- Department of Pharmacy Practice, College of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
| | - Abdulrahman I Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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26
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García-Ramos S, Fernandez I, Zaballos M. Lipid emulsions in the treatment of intoxications by local anesthesics and other drugs. Review of mechanisms of action and recommendations for use. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:421-432. [PMID: 35871141 DOI: 10.1016/j.redare.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/25/2021] [Indexed: 06/15/2023]
Abstract
Intravenous lipid emulsions (ILEs) have been used widely for the treatment of local anesthetic (LA) poisoning and have been proposed as a treatment for intoxication by other drugs. However, the degree of evidence for this kind of therapy is not strong, as it comes mostly from clinical cases. The aim of this narrative review is to describe the proposed mechanisms of action for ILEs in poisoning by LA and other drugs and to evaluate recent studies in animals that support the recommendations for their use and the experience in humans that support the use of ILESs in both LA and other drug poisoning. For this purpose, a search was performed in the Embase, Medline and Google Scholar databases covering relevant articles over the last 10 years. In the case of AL poisoning, we recommend applying the protocols dictated by international guidelines, knowing that the degree of evidence is not very high. In poisoning by other drugs, ILEs are recommended in serious situations induced by liposoluble xenobiotics that do not respond to standard treatment.
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Affiliation(s)
- S García-Ramos
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | - I Fernandez
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - M Zaballos
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, Spain; Departamento de Toxicología, Universidad Complutense de Madrid, Madrid, Spain
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27
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Duburcq T, Goutay J, Preau S, Mugnier A, Rousse N, Moussa MD, Vincentelli A, Cuny J, Parmentier-Decrucq E, Poissy J. Venoarterial Extracorporeal Membrane Oxygenation in Severe Drug Intoxication: A Retrospective Comparison of Survivors and Nonsurvivors. ASAIO J 2022; 68:907-913. [PMID: 34560717 DOI: 10.1097/mat.0000000000001583] [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: 11/25/2022] Open
Abstract
Selecting patients most likely to benefit from venoarterial extracorporeal membrane oxygenation (V-A ECMO) to treat refractory drug-induced cardiovascular shock remains a difficult challenge for physicians. This study reported short-term survival outcomes and factors associated with mortality in V-A ECMO-treated patients for poisoning. Twenty-two patients placed on V-A ECMO after drug intoxication from January 2014 to December 2020 were retrospectively analyzed. The primary endpoint of this study was survival at hospital discharge. Univariate descriptive analysis was performed to compare survivors and nonsurvivors during hospitalization. The overall survival at hospital discharge was 45.4% (n = 10/22). Survival rate tended to be higher in patients treated for refractory shock (n = 7/10) compared with those treated for refractory cardiac arrest (n = 3/12, p = 0.08). Low-flow duration and time from admission to ECMO cannulation were shorter in survivors ( p = 0.02 and p = 0.03, respectively). Baseline characteristics before ECMO, including the class of drugs involved in the poisoning, between survivors and nonsurvivors were not statistically different except pH, bicarbonate, serum lactate, Sequential Organ Failure Assessment, and Survival After Veno-arterial-ECMO (SAVE) score. All patients with SAVE-score risk classes II/III survived whereas 85.7% (n = 12/14) of those with SAVE-score risk classes IV/V died. A lactic acid >9 mmol/L predicts mortality with a sensitivity/specificity ratio of 83.3%/100%. V-A ECMO for severe drug intoxication should be reserved for highly selected poisoned patients who do not respond to conventional therapies. Shortening the timing of V-A ECMO initiation should be a key priority in improving outcomes. Low-flow time >60min, lactic acid >9mmol/L, and SAVE-score may be good indicators of a worse prognosis.
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Affiliation(s)
| | - Julien Goutay
- From the Department of Intensive Care, CHU Lille, Lille, France
| | - Sebastien Preau
- From the Department of Intensive Care, CHU Lille, Lille, France
- University of Lille, Inserm U1167, Institut Pasteur de Lille, Lille, France
| | - Agnes Mugnier
- Department of Cardiovascular Surgery, CHU Lille, Lille, France
| | - Natacha Rousse
- Department of Cardiovascular Surgery, CHU Lille, Lille, France
| | - Mouhamed D Moussa
- Cardiovascular Intensive Care Unit, CHU Lille, Lille, France
- University of Lille, Inserm U1011, Institut Pasteur de Lille, EGID, Lille, France
| | - André Vincentelli
- Department of Cardiovascular Surgery, CHU Lille, Lille, France
- University of Lille, Inserm U1011, Institut Pasteur de Lille, EGID, Lille, France
| | - Jerome Cuny
- Emergency Department and SAMU, CHU Lille, Lille, France
| | | | - Julien Poissy
- From the Department of Intensive Care, CHU Lille, Lille, France
- University of Lille, Inserm U1285, CNRS UMR 8576, Lille, France
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28
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Gautam S, Chamlagain M, Yadav GK, Acharya S. Once was not enough: A case report of the concomitant intoxication of amlodipine (calcium channel blocker) and clonazepam (benzodiazepine). Clin Case Rep 2022; 10:e6042. [PMID: 35846941 PMCID: PMC9272439 DOI: 10.1002/ccr3.6042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/09/2022] [Accepted: 06/26/2022] [Indexed: 11/23/2022] Open
Abstract
We report a case of concurrent ingestion of Clonazepam and Amlodipine in a 25‐year‐old man, in a second attempt to take his life, which resulted in unconsciousness, hypotension, and hypokalemia. The clinical and/or biochemical presentation varied from the individual pattern when ingested. In the scarcity of consensus recommendations, supportive treatment helped. Supportive treatment is the rule of management of concomitant ingestion of Amlodipine and Clonazepam. The clinical and/or biochemical presentation of benzodiazepine and calcium channel blocker may vary from the individual pattern.
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Affiliation(s)
- Swotantra Gautam
- Department of Critical Care Medicine Nidan Hospital Lalitpur Nepal
| | | | - Gopal Kumar Yadav
- Department of Emergency Medicine Kakani Primary Health Care Centre Nuwakot Nepal
| | - Santosh Acharya
- Department of Anesthesiology and Critical Care Nidan Hospital Lalitpur Nepal
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29
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Hamzić J, Raos D, Radulović B. HIGH-DOSE INSULIN EUGLYCEMIC THERAPY. Acta Clin Croat 2022; 61:73-77. [PMID: 36304811 PMCID: PMC9536162 DOI: 10.20471/acc.2022.61.s1.12] [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] [Indexed: 11/06/2022] Open
Abstract
Calcium channel blockers and beta-blockers toxicity/poisoning are one of the most common causes of poisoning. More importantly, they are among the deadliest types of poisoning caused by cardiac drugs that emergency physicians can encounter. Common toxidrome caused by these medications includes the following symptoms: hypotension, bradycardia, hypoglycemia/hyperglycemia, hypothermia, arrhythmia, and seizures. Treatment is usually complex, It consists of administration of various medications, such as crystalloids, intravenous calcium, glucagon, vasopressors/inotropes, and especially high-dose insulin euglycemic therapy. In this paper, we will review the mechanism for this type of treatment, propose a potential protocol for its application and address possible adverse effects. High-dose insulin euglycemic therapy should be an integral part of the treatment protocol for calcium channel blockers and beta-blockers toxicity.
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Affiliation(s)
- Jasmin Hamzić
- Emergency Department, University Hospital Center Zagreb, Croatia
| | - Dora Raos
- Emergency Department, University Hospital Center Zagreb, Croatia
| | - Bojana Radulović
- Emergency Department, University Hospital Center Zagreb, Croatia
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30
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Osman AF, Prasad RM, Marein S, O'Brien C. Multi-organ dysfunction as a presentation of calcium channel blocker intoxication. BMJ Case Rep 2022; 15:15/1/e245711. [PMID: 35039350 PMCID: PMC8768057 DOI: 10.1136/bcr-2021-245711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
SummaryWe report the case of a 73-year-old woman who intentionally ingested 400 mg of amlodipine in a suicidal attempt who initially presented with hypotension which persisted despite aggressive therapy with fluid resuscitation, multiple pressor support, high-dose insulin therapy and calcium infusion. Her haemodynamic instability evolved to include bradycardia requiring atropine and transcutaneous pacing. Eventually she required salvage therapy with intravenous lipid emulsion (ILE) therapy . Despite all aggressive therapy, she developed multi-organ failure resulting in death. The literature on high-dose insulin euglycaemic therapy (HIET) and ILE therapy shows mixed results with some showing significant improvement in haemodynamic status. In our case, it had no significant positive impact on the outcome.
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Affiliation(s)
| | | | - Shawn Marein
- Department of Pulmonary & Critical care, Sparrow Health System, Lansing, Michigan, USA
| | - Corey O'Brien
- Department of Pulmonary & Critical care, Sparrow Health System, Lansing, Michigan, USA
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31
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Essink J, Berg S, Montange J, Sankey A, Taylor V, Salomon J. Single-Pass Albumin Dialysis as Rescue Therapy for Pediatric Calcium Channel Blocker Overdose. J Investig Med High Impact Case Rep 2022; 10:23247096221105251. [PMID: 35856321 PMCID: PMC9309771 DOI: 10.1177/23247096221105251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Calcium channel blocker ingestions remain one of the leading causes of death
related to cardiovascular medication ingestion in both adults and pediatric
patients. We report a case of a 17-year-old, 103 kg female presenting after an
intentional polypharmacy ingestion, including 500 to 550 mg of amlodipine. She
presented with profound vasoplegia and cardiovascular collapse requiring
high-dose inotropes and eventual life support with extracorporeal membrane
oxygenation (ECMO). Current available treatments, designed for adults, including
lipid emulsion and methylene blue, provided no sustained clinical improvement.
This resulted in the initiation of single-pass albumin dialysis (SPAD). We aim
to describe the clinical implications, amlodipine toxic dose effects, and
clinical challenges associated with large pediatric patients and high-dose
medications. We also discuss several challenges encountered related to dosing
and concentration of medications, which led to fluid overload. Given the ongoing
obesity epidemic, we routinely see pediatric patients of adult size. This will
continue to challenge pediatric use of adult dosing and concentrations to avoid
excessive fluid administration for high-dose medications, such as insulin and
vasoactive agents. To our knowledge, this is the first successful case of using
SPAD in conjunction with ECMO for salvage therapy after refractory
life-threatening calcium channel blocker toxicity.
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Affiliation(s)
- Jenna Essink
- Children’s Hospital & Medical Center, Omaha, NE, USA
- University of Nebraska Medical Center, Omaha, USA
| | - Sydney Berg
- Children’s Hospital & Medical Center, Omaha, NE, USA
| | - Jaka Montange
- Children’s Hospital & Medical Center, Omaha, NE, USA
| | - Andrew Sankey
- Children’s Hospital & Medical Center, Omaha, NE, USA
| | - Veronica Taylor
- Children’s Hospital & Medical Center, Omaha, NE, USA
- University of Nebraska Medical Center, Omaha, USA
| | - Jeffrey Salomon
- Children’s Hospital & Medical Center, Omaha, NE, USA
- University of Nebraska Medical Center, Omaha, USA
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Pellegrini JR, Munshi R, Tiwana MS, Abraham T, Tahir H, Sayedy N, Iqbal J. "Feeling the Blues": A Case of Calcium Channel Blocker Overdose Managed With Methylene Blue. Cureus 2021; 13:e19114. [PMID: 34868762 PMCID: PMC8627593 DOI: 10.7759/cureus.19114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
Amlodipine is a dihydropyridine calcium channel blocker (CCB) commonly used to treat hypertension. In the United States, approximately 9,500 cases of CCB intoxication due to deliberate or inadvertent overdose were reported to poison centers in 2002. We present a case of a patient who presented with CCB overdose complicated by acute respiratory distress syndrome (ARDS) and recalcitrant shock all of which resolved with methylene blue therapy. We present a case of a 56-year-old African American woman who presented to the emergency department (ED) after intentional ingestion of large amounts of multiple pills likely consisting of cyclobenzaprine, amlodipine, losartan, and ibuprofen following an argument with her boyfriend. Treatment included insulin drip, 10% dextrose, and norepinephrine drip which was titrated up. First insulin drip and 10% dextrose were titrated up; however, vasopressor-resistant hypotension persisted, and the decision was made to administer methylene blue. Over 9,500 cases of CCB toxicity were reported to poison centers in the US in 2002. Although no definitive treatment is outlined, first-line therapy consists of IV calcium, high-dose insulin, and vasopressor support with either norepinephrine or epinephrine. Traditionally, methylene blue is used for methemoglobinemia and in cardiothoracic ICUs for post coronary artery bypass vasoplegia. It acts by selectively inhibiting nitric oxide-activated cyclic guanylate cyclase leading to decreased vasodilation of arteriolar smooth muscles improving vascular tone and systemic vascular resistance. In severe amlodipine overdose, experimental models demonstrate methylene blue improves HR and mean arterial pressure (MAP), improving survival rate. With few adverse side effects (green-tinged discoloration of urine, saliva, tears, and bodily fluids), methylene blue should be explored and implemented in the treatment of CCB overdose with refractory hypotension and ARDS.
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Affiliation(s)
| | - Rezwan Munshi
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Muhammad S Tiwana
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Tinu Abraham
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Hira Tahir
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Najia Sayedy
- Pulmonary and Critical Care, Nassau University Medical Center, East Meadow, USA
| | - Javed Iqbal
- Pulmonary and Critical Care, Nassau University Medical Center, East Meadow, USA
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33
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Tinsman AE, Bellis TJ. Hyperinsulinemia/euglycemia and intravenous lipid emulsion therapy for the management of severe amlodipine toxicosis in a cat. Clin Case Rep 2021; 9:e05175. [PMID: 34934496 PMCID: PMC8650752 DOI: 10.1002/ccr3.5175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/23/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022] Open
Abstract
Calcium-channel blockers (CCBs) are widely used in people and animals. Overdose can result in cardiovascular collapse and death. Hyperinsulinemia/euglycemia therapy (HIET) and intralipid therapy (ILT) are reported treatment options in people. This is the first report describing HIET and ILT as treatments for amlodipine toxicosis in a cat.
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Affiliation(s)
| | - Tara J. Bellis
- Emergency & Critical CareGarden State Veterinary ServicesIselinNJUSA
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34
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Madias JE. Takotsubo Cardiomyopathy: Current Treatment. J Clin Med 2021; 10:3440. [PMID: 34362223 PMCID: PMC8347171 DOI: 10.3390/jcm10153440] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023] Open
Abstract
Management of takotsubo syndrome (TTS) is currently empirical and supportive, via extrapolation of therapeutic principles worked out for other cardiovascular pathologies. Although it has been emphasized that such non-specific therapies for TTS are consequent to its still elusive pathophysiology, one wonders whether it does not necessarily follow that the absence of knowledge of TTS' pathophysiological underpinnings should prevent us for searching, designing, or even finding, therapies efficacious for its management. Additionally, it is conceivable that therapy for TTS may be in response to pathophysiological/pathoanatomic/pathohistological consequences (e.g., "myocardial stunning/reperfusion injury"), common to both TTS and coronary artery disease, or other cardiovascular disorders). The present review outlines the whole range of management principles of TTS during its acute phase and at follow-up, including considerations pertaining to the recurrence of TTS, and commences with the idea that occasionally management of TTS should consist of mere observation along the "first do no harm" principle, while self-healing is under way. Finally, some new therapeutic hypotheses (i.e., large doses of insulin infusions in association with the employment of intravenous short- and ultrashort-acting β-blockers) are being entertained, based on previous extensive animal work and limited application in patients with neurogenic cardiomyopathy and TTS.
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Affiliation(s)
- John E. Madias
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; ; Tel.: +1-(718)-334-5005; Fax: +1-(718)-334-5990
- Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY 11373, USA
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35
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Success in early treatment with lipid emulsion for antihypertension drug overdose patient. Am J Emerg Med 2021; 50:814.e3-814.e5. [PMID: 34217562 DOI: 10.1016/j.ajem.2021.06.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/26/2021] [Accepted: 06/20/2021] [Indexed: 11/22/2022] Open
Abstract
Intravenous lipid emulsion (ILE) is typically applied as a rescue therapy after the use of conventional treatments for beta blocker (BBs) or calcium channel blocker (CCB) overdoses. We describe the case of a 72-year-old man who presented to our ED after attempting suicide by antihypertensive drug overdose. His blood pressure dropped upon arrival at the ED, and we consequently administered multitherapy including relatively early ILE to prevent prolonged hypotension. He regained stable hemodynamic status on the third day and was later discharged without major sequelae.
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36
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St-Onge M. Cardiovascular Drug Toxicity. Crit Care Clin 2021; 37:563-576. [PMID: 34053706 DOI: 10.1016/j.ccc.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Managing unstable poisoned patients is often associated with clinician cognitive overload. This article summarizes the mechanisms of toxicity; clinical presentations; and the current evidence available for the treatment of cardiovascular drug toxicity due to calcium channel blockers, beta-blockers, cardiac glycosides, and sodium channel blockers. In addition, management approaches are proposed.
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Affiliation(s)
- Maude St-Onge
- CIUSSSCN, Optimal Health Practice Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec Research Centre, CHU de Québec - Université Laval, Faculty of Medicine, Université Laval, Centre Antipoison du Québec, 1270 Chemin Sainte-Foy, Pavillon Jeffrey-Hale, 3e étage, Québec G1S 2M4, Canada.
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37
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García-Ramos S, Fernandez I, Zaballos M. Lipid emulsions in the treatment of intoxications by local anesthesics and other drugs. Review of mechanisms of action and recommendations for use. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00143-2. [PMID: 34140161 DOI: 10.1016/j.redar.2021.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/24/2021] [Accepted: 03/25/2021] [Indexed: 11/21/2022]
Abstract
Intravenous lipid emulsions (ILEs) have been used widely for the treatment of local anesthetic (LA) poisoning and have been proposed as a treatment for intoxication by other drugs. However, the degree of evidence for this kind of therapy is not strong, as it comes mostly from clinical cases. The aim of this narrative review is to describe the proposed mechanisms of action for ILEs in poisoning by LA and other drugs and to evaluate recent studies in animals that support the recommendations for their use and the experience in humans that support the use of ILESs in both LA and other drug poisoning. For this purpose, a search was performed in the Embase, Medline and Google Scholar databases covering relevant articles over the last 10 years. In the case of AL poisoning, we recommend applying the protocols dictated by international guidelines, knowing that the degree of evidence is not very high. In poisoning by other drugs, ILEs are recommended in serious situations induced by liposoluble xenobiotics that do not respond to standard treatment.
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Affiliation(s)
- S García-Ramos
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, España.
| | - I Fernandez
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, España
| | - M Zaballos
- Servicio de Anestesia y Reanimación, Hospital Universitario Gregorio Marañón, Madrid, España; Departamento de Toxicología, Universidad Complutense de Madrid, Madrid, España
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38
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Li Y, Cao C, Luo X, Huang L. Successful treatment of severe myocardial injury complicated with refractory cardiogenic shock caused by AOPP using extracorporeal membrane oxygenation: A case report. Medicine (Baltimore) 2021; 100:e26318. [PMID: 34115044 PMCID: PMC8202611 DOI: 10.1097/md.0000000000026318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/25/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Acute organophosphorus pesticide poisoning (AOPP) is a common critical illness observed in clinical practice, and severe AOPP can cause serious cardiac toxicity. PATIENT CONCERNS This patient was a 43-year-old woman who was admitted to the emergency department with acute respiratory failure and hypotension 13 hours after oral consumption of 300 mL of phoxim pesticide. DIAGNOSES Acute organophosphorus pesticide poisoning, cardiogenic shock. INTERVENTIONS We conducted veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy as the patient did not respond to conventional measures. OUTCOMES This patient was successfully rescued with VA-ECMO therapy and discharged. LESSONS We suggest that for patients with severe myocardial injury complicated with cardiogenic shock caused by AOPP, the use of VA-ECMO therapy can improve the prognosis.
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39
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Vodovar D, Mégarbane B. Does MARS™ beneficially affect hemodynamics in refractory vasoplegic shock due to calcium-channel blocker poisoning? Evidence is missing. Int J Artif Organs 2021; 44:527-528. [PMID: 34030501 DOI: 10.1177/03913988211019757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Dominique Vodovar
- Centre antipoison de Paris, Fédération de toxicologie de l'APHP, Hôpital Fernand Widal, Paris, France.,Université de Paris, Paris, France.,UMRS 1144, INSERM, Paris, France
| | - Bruno Mégarbane
- Université de Paris, Paris, France.,UMRS 1144, INSERM, Paris, France.,Réanimation Médicale et Toxicologique, Fédération de Toxicologie de l'APHP, Hôpital Lariboisière, Paris, France
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40
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Beyls C, Mahjoub Y. MARS™ therapy: A potential tool for hemodynamic stabilization in calcium-channel blocker poisoning. Int J Artif Organs 2021; 44:529-530. [PMID: 34030514 DOI: 10.1177/03913988211019759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Christophe Beyls
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Yazine Mahjoub
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
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41
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Matsushime S, Kuriyama A. Vasopressin for persistent hypotension due to amlodipine and olmesartan overdose: A case report. Ann Med Surg (Lond) 2021; 65:102292. [PMID: 33981424 PMCID: PMC8082198 DOI: 10.1016/j.amsu.2021.102292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 11/21/2022] Open
Abstract
Background While there are consensus recommendations for managing calcium channel blocker (CCB) toxicity, reports on angiotensin II receptor blocker (ARB) toxicity and management are limited. Herein, we report a case of catecholamine-refractory hypotension due to CCB and ARB overdose. Case presentation A 54-year-old woman with underlying hypertension was brought to the emergency department after she attempted suicide by ingesting 345 mg of amlodipine, a CCB, and 340 mg of olmesartan, an ARB. She was hypotensive, which was considered vasodilatory because of high cardiac and low systemic vascular resistance indices. Hypotension persisted despite the administration of norepinephrine and epinephrine. Intravenous calcium gluconate, glucagon, and high-dose insulin euglycemia therapy, which were initiated because CCB toxicity was suspected, failed to raise her blood pressure. The presence of normal anion-gap metabolic acidosis and the fact that the patient remained hypotensive suggested that the hypotension might have been due to the effect of ARB. Vasopressin was finally administered, which improved her hemodynamic status. She was weaned off all vasopressors on day 3. Discussion There is no consensus recommendation for ARB toxicity. Since chronic use of ARBs at conventional doses can block the sympathetic nervous and renin–angiotensin systems, catecholamines may not effectively increase blood pressure in cases of hypotension due to ARB overdose, for which vasopressin could be indicated. Conclusions Vasopressin could be an option for treating hypotension secondary to ARB and CCB toxicity when catecholamines and treatment for CCB toxicity fail. Chronic use of ARBs blocks the sympathetic nervous and renin–angiotensin systems. There is no consensus recommendation for angiotensin II receptor blocker (ARB) toxicity. Catecholamines may not effectively raise blood pressure in hypotension due to ARB toxicity. Vasopressin could be an option for treating hypotension secondary to ARB toxicity.
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Affiliation(s)
- Susumu Matsushime
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa Kurashiki Okayama, 710-8602, Japan
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa Kurashiki Okayama, 710-8602, Japan
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Beyls C, Malaquin S, Huette P, Mary A, Besserve P, Roger PA, Bernasinski M, Guilbart M, Abou-Arab O, Dupont H, Mahjoub Y. Hemodynamic impact of molecular adsorbent recirculating system in refractory vasoplegic shock due to calcium channel blocker poisoning. Int J Artif Organs 2021; 44:944-951. [PMID: 33818171 DOI: 10.1177/03913988211007865] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report the hemodynamic effect of to the molecular adsorbent recirculating system (MARS™) therapy for patients in refractory vasoplegic shock due to calcium channel blocker (CCB) poisoning. METHODS We report a retrospective cohort of patients who were hospitalized for CCB poisoning with refractory vasoplegic shock and treated by MARS therapy, at Amiens Hospital University, from January 2010 to December 2019. Improvement in hemodynamic was assessed by dynamic changes in mean arterial pressure (MAP) and norepinephrine levels over a 24-h period after MARS therapy. Cardiac function was assessed by transthoracic echocardiography. RESULTS MARS therapy was performed on seven patients for CCB poisoning. CCB poisoning included nicardipine (n = 3, 43%) amlodipine (n = 3, 43%), and verapamil (n = 1, 14%). The median time to start MARS therapy was 24 [14-27] h after drug ingestion and 6 [2-9] h after ICU admission. Cardiac output was preserved for all patients. MAP values improved from 56 [43-58] to 65 [61-78] 16 mmHg (p = 0.005). Norepinephrine dose significantly decreased from 3.2 [0.8-10] µg/kg/min to 1.2 [0.1-1.9] µg/kg/min (p = 0.008) and lactate level decreased from 3.2 [2.4-3.4] mmol/l-1 to 1.6 [0.9-2.2] mmol/l-1 (p = 0.008). The median length of ICU stay was 4 (2-7) days and hospital stay was 4 (4-16) days. No complication related to the MARS therapy were reported. No patient died and all were discharged from the hospital. CONCLUSION We reported the largest case-series of MARS therapy for refractory vasoplegic shock due to CCB poisoning. We observed that MARS therapy was associated with an improvement of hemodynamic parameters.
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Affiliation(s)
- Christophe Beyls
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Stéphanie Malaquin
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Pierre Huette
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Aurélien Mary
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Patricia Besserve
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Pierre-Alexandre Roger
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Michaël Bernasinski
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Mathieu Guilbart
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Yazine Mahjoub
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
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Fletcher DJ, Boller M. Fluid Therapy During Cardiopulmonary Resuscitation. Front Vet Sci 2021; 7:625361. [PMID: 33585610 PMCID: PMC7876065 DOI: 10.3389/fvets.2020.625361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/31/2020] [Indexed: 11/16/2022] Open
Abstract
Cardiopulmonary arrest (CPA), the acute cessation of blood flow and ventilation, is fatal if left untreated. Cardiopulmonary resuscitation (CPR) is targeted at restoring oxygen delivery to tissues to mitigate ischemic injury and to provide energy substrate to the tissues in order to achieve return of spontaneous circulation (ROSC). In addition to basic life support (BLS), targeted at replacing the mechanical aspects of circulation and ventilation, adjunctive advanced life support (ALS) interventions, such as intravenous fluid therapy, can improve the likelihood of ROSC depending on the specific characteristics of the patient. In hypovolemic patients with CPA, intravenous fluid boluses to improve preload and cardiac output are likely beneficial, and the use of hypertonic saline may confer additional neuroprotective effects. However, in euvolemic patients, isotonic or hypertonic crystalloid boluses may be detrimental due to decreased tissue blood flow caused by compromised tissue perfusion pressures. Synthetic colloids have not been shown to be beneficial in patients in CPA, and given their documented potential for harm, they are not recommended. Patients with documented electrolyte abnormalities such as hypokalemia or hyperkalemia benefit from therapy targeted at those disturbances, and patients with CPA induced by lipid soluble toxins may benefit from intravenous lipid emulsion therapy. Patients with prolonged CPA that have developed significant acidemia may benefit from intravenous buffer therapy, but patients with acute CPA may be harmed by buffers. In general, ALS fluid therapies should be used only if specific indications are present in the individual patient.
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Affiliation(s)
- Daniel J Fletcher
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Manuel Boller
- Faculty of Veterinary and Agricultural Sciences, Melbourne Veterinary School, University of Melbourne, Werribee, VIC, Australia
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Severe Noncardiogenic Pulmonary Edema Secondary to Massive Verapamil Overdose and Treatment with Venovenous Extracorporeal Membrane Oxygenation. Case Rep Crit Care 2020; 2020:8842303. [PMID: 33425397 PMCID: PMC7781727 DOI: 10.1155/2020/8842303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 11/26/2020] [Accepted: 12/14/2020] [Indexed: 11/27/2022] Open
Abstract
Calcium channel blocker (CCB) poisoning frequently presents with cardiovascular complications such as cardiogenic shock and arrhythmia. We present a case of massive verapamil overdose causing refractory noncardiogenic pulmonary edema successfully treated with extracorporeal membrane oxygenation. To our knowledge, this is the first case with these features reported in literature. A 27-year-old female patient presented with an overdose of 18,000 mg of verapamil. Her clinical condition deteriorated to severe hypoxic respiratory failure despite being treated with calcium, high-dose insulin, and full invasive ventilation support. She eventually required venovenous extracorporeal membrane oxygenation (VV-ECMO) for three days with full recovery. Large ingestion of verapamil could lead to noncardiogenic pulmonary edema. VV-ECMO might play an important role to support the treatment in severe cases with refractory hypoxia.
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Calcium Channel Blocker Intoxication: A Critical Care Transport Perspective. Air Med J 2020; 40:69-72. [PMID: 33455631 DOI: 10.1016/j.amj.2020.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
Calcium channel blockers (CCBs) have seen an increase in rate of non-therapeutic exposure that is both accidental and intentional in nature. Patients experiencing the toxic effects of a CCB overdose are resource intensive and can quickly outstrip the capabilities of local health systems, necessitating transfer to larger tertiary or quaternary care centers. We present a case of intentional non-dihydropyridine CCB overdose and toxicity in a 20-year-old patient requiring initial stabilization at a referring critical access emergency department with continuation of treatment and support during a 60-minute rotor wing transport from the referring hospital to an academic quaternary care center. Emphasis is placed on the unique challenges in resuscitation and ongoing critical care administration during the transport phase of care. Proper stabilization of patients, planning, and consideration of potential problems associated with transport can help minimize stresses and risk of the transport, improving the outcome of extremely ill patients even under challenging circumstances.
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Saha BK, Bonnier A, Chong W. Rapid reversal of vasoplegia with methylene blue in calcium channel blocker poisoning. Afr J Emerg Med 2020; 10:284-287. [PMID: 33299766 PMCID: PMC7700985 DOI: 10.1016/j.afjem.2020.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/17/2020] [Accepted: 06/30/2020] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION Calcium channel blockers (CCBs) are a potent class of medications that exert its action by blocking 'L-type' calcium channels. CCB overdose can be fatal even with appropriate and aggressive therapy. Death ensues from heart block, myocardial suppression, vasoplegia, and shock. Early use of methylene blue (MB) might provide additional means to improve outcomes. CASE PRESENTATION A 25-year-old female presented after an attempted suicide. The patient ingested a substantial amount of diltiazem, promethazine, and trazodone. Seven hours following the ingestion, she became profoundly vasoplegic and hypotensive. Despite guideline-based therapy and high doses of vasopressors, she suffered from worsening lactic acidosis and multiorgan failure. Administration of an intravenous bolus dose of MB resulted in a rapid and sustained improvement of vasoplegia, and the patient subsequently went on to make a complete recovery. DISCUSSION In addition to calcium channel blockade, CCBs cause vascular smooth muscle relaxation by the production of nitric oxide (NO). In cases of overdose, NO production can be significant. MB is a safe and inexpensive medication with the potential to reverse NO-mediated vasoplegia that is responsible for CCB induced shock state. In parts of the world where access to advanced medical care is not readily available, early use of MB might have a significant role in the management of CCB overdose.
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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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Abstract
This article examines, using an organ-systems based approach, rapid diagnosis, resuscitation, and critical care management of the crashing poisoned patient in the emergency department. The topics discussed in this article include seizures and status epilepticus, respiratory failure, cardiovascular collapse and mechanical circulatory support, antidotes and drug-specific therapies, acute liver failure, and extracorporeal toxin removal.
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Affiliation(s)
- Aaron Skolnik
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
| | - Jessica Monas
- Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Martín-Macho González MM, López Hormiga DF, Huertas Fernández T. Letal poisining by calcium channel antagonists. Med Clin (Barc) 2020; 157:203-204. [PMID: 32958263 DOI: 10.1016/j.medcli.2020.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 11/25/2022]
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