1
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Wong A, Hoffman RS, Walsh SJ, Roberts DM, Gosselin S, Bunchman TE, Kebede S, Lavergne V, Ghannoum M. Extracorporeal treatment for calcium channel blocker poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila) 2021; 59:361-375. [PMID: 33555964 DOI: 10.1080/15563650.2020.1870123] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Calcium channel blockers (CCBs) are commonly used to treat conditions such as arterial hypertension and supraventricular dysrhythmias. Poisoning from these drugs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in the management of CCB poisoning. METHODS We conducted systematic reviews of the literature, screened studies, extracted data, summarized findings, and formulated recommendations following published EXTRIP methods. RESULTS A total of 83 publications (6 in vitro and 1 animal experiments, 55 case reports or case series, 19 pharmacokinetic studies, 1 cohort study and 1 systematic review) met inclusion criteria regarding the effect of ECTR. Toxicokinetic or pharmacokinetic data were available on 210 patients (including 32 for amlodipine, 20 for diltiazem, and 52 for verapamil). Regardless of the ECTR used, amlodipine, bepridil, diltiazem, felodipine, isradipine, mibefradil, nifedipine, nisoldipine, and verapamil were considered not dialyzable, with variable levels of evidence, while no dialyzability grading was possible for nicardipine and nitrendipine. Data were available for clinical analysis on 78 CCB poisoned patients (including 32 patients for amlodipine, 16 for diltiazem, and 23 for verapamil). Standard care (including high dose insulin euglycemic therapy) was not systematically administered. Clinical data did not suggest an improvement in outcomes with ECTR. Consequently, the EXTRIP workgroup recommends against using ECTR in addition to standard care for patients severely poisoned with either amlodipine, diltiazem or verapamil (strong recommendations, very low quality of the evidence (1D)). There were insufficient clinical data to draft recommendation for other CCBs, although the workgroup acknowledged the low dialyzability from, and lack of biological plausibility for, ECTR. CONCLUSIONS Both dialyzability and clinical data do not support a clinical benefit from ECTRs for CCB poisoning. The EXTRIP workgroup recommends against using extracorporeal methods to enhance the elimination of amlodipine, diltiazem, and verapamil in patients with severe poisoning.
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Affiliation(s)
- Anselm Wong
- Austin Toxicology Unit and Emergency Department, Victorian Poisons Information Centre, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Steven J Walsh
- Department of Emergency Medicine, Division of Medical Toxicology, The Poison Control Center at Children's Hospital of Philadelphia, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Darren M Roberts
- Departments of Renal Medicine and Transplantation and Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,Drug Health Clinical Services, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Sophie Gosselin
- Montérégie-Centre Emergency Department, Centre Intégré de Santé et de Services Sociaux (CISSS), Hôpital Charles-Lemoyne, Greenfield Park, QC.,Department of Emergency Medicine, McGill University, Montreal.,Centre Antipoison du Québec, Quebec, Canada
| | - Timothy E Bunchman
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - Sofia Kebede
- School of Medicine, St. Peter`s Specialized Hospital Poison Center, Addis Ababa University, Addis Ababa, Ethiopia
| | - Valery Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada
| | - Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada
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2
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Fabresse N, Larabi IA, Lamy E, Mégarbane B, Alvarez JC. Molecular adsorbent recirculating system (MARS) and continuous veno-venous hemodiafiltration (CVVHDF) for diltiazem removal: An in vitro study. Int J Artif Organs 2020; 44:489-496. [PMID: 33258721 DOI: 10.1177/0391398820975041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of the present study was to evaluate the efficacy of the molecular adsorbent recirculating system (MARS) vs continuous veno-venous hemodiafiltration (CVVHDF). Diltiazem poisoning was simulated in a central compartment consisting in a 5L dialysis solute spiked with diltiazem at two different toxic concentrations: 750 and 5000 µg/L. For CVVHDF, mean extraction coefficients (EC = (in concentration - out concentration)/in concentration) were concentration-dependent with a decrease all along the dialysis. At the end of the sessions the mean amounts remaining in the central compartment were 8% and 7% of the initial dose at 750 and 5000 µg/L, respectively. The mean cumulative amounts found in the effluent were 60% and 75% of the initial dose, respectively. The missing amounts accounted for 32% and 18% of the initial dose, respectively, corresponding to an adsorption to the dialysis membrane. In contrast, the different compartments of the MARS resulted in undetectable output concentration earlier that the end of the session. The mean concentrations of diltiazem remaining in the central compartment were <1 µg/L at the end of the sessions. Global ECs were around 50% all along the experiment at both concentrations, and the average charcoal cartridge ECs was 80% throughout the experiments.CVVHDF system in the developed model was efficient for diltiazem removal, mainly by diffusion, convection and to a lesser extent by adsorption to the dialysis membrane. In MARS system, resin cartridge and hemodialysis components are ineffective, charcoal cartridge is responsible for almost all drug removal.
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Affiliation(s)
- Nicolas Fabresse
- MassSpecLab, Plateforme de Spectrométrie de Masse, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin, Montigny le Bretonneux, France.,Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, Garches, France
| | - Islam Amine Larabi
- MassSpecLab, Plateforme de Spectrométrie de Masse, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin, Montigny le Bretonneux, France.,Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, Garches, France
| | - Elodie Lamy
- MassSpecLab, Plateforme de Spectrométrie de Masse, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin, Montigny le Bretonneux, France
| | - Bruno Mégarbane
- Réanimation Toxicologique, Centre Hospitalier Universitaire Lariboisière, Paris, France
| | - Jean-Claude Alvarez
- MassSpecLab, Plateforme de Spectrométrie de Masse, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin, Montigny le Bretonneux, France.,Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire Raymond Poincaré, AP-HP, Garches, France
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3
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Abstract
OBJECTIVE Overdoses with cardio-depressive medications can result in toxin-induced cardiogenic shock (TICS), a life-threatening condition characterized by severe hypotension and ineffective tissue perfusion. Vasopressors are often employed in the treatment of shock to increase heart rate and blood pressure. We sought to conduct a systematic review of the literature to evaluate the effectiveness of vasopressors in improving hemodynamic function and survival in the treatment of TICS. DATA SOURCES We searched PubMed, EMBASE, TOXLINE, and International Pharmaceutical Abstracts. STUDY SELECTION We included studies evaluating the use of vasopressors in humans or animals with TICS. We limited human study types to randomized controlled trials, clinical trials, observational studies, and case reports. DATA EXTRACTION Our search yielded 913 citations and 144 of these met our inclusion criteria. 130 were human case reports and 14 were animal studies. DATA SYNTHESIS Human case report data showed vasopressors were ineffective more often than they were partially or fully effective. In the majority of animal studies, vasopressor treatment failed to improve hemodynamic parameters and resulted in decreased survival. CONCLUSIONS Human case reports and controlled animal experiments lead to different conclusions about vasopressors in TICS. Most animal studies indicate that vasopressors impair hemodynamic function and increase mortality. In contrast, human case reports suggest that vasopressors are often ineffective but not necessarily harmful.
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Affiliation(s)
- Cassandra A Skoog
- a College of Pharmacy, University of Minnesota , Minneapolis , MN , USA
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4
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Shenoy S, Lankala S, Adigopula S. Management of calcium channel blocker overdoses. J Hosp Med 2014; 9:663-8. [PMID: 25066023 DOI: 10.1002/jhm.2241] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 07/01/2014] [Accepted: 07/08/2014] [Indexed: 11/09/2022]
Abstract
Calcium channel blockers (CCBs) are some of the most commonly used medications in clinical practice to treat hypertension, angina, cardiac arrhythmias, and some cases of heart failure. Recent data show that CCBs are the most common of the cardiovascular medications noted in intentional or unintentional overdoses.(1) Novel treatment approaches in the form of glucagon, high-dose insulin therapy, and intravenous lipid emulsion therapies have been tried and have been successful. However, the evidence for these are limited to case reports and case series. We take this opportunity to review the various treatment options in the management of CCB overdoses with a special focus on high-dose insulin therapy as the emerging choice for initial therapy in severe overdoses.
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Affiliation(s)
- Sundeep Shenoy
- Division of Inpatient Medicine, University of Arizona, Tucson, Arizona
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5
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Thakrar R, Shulman R, Bellingan G, Singer M. Management of a mixed overdose of calcium channel blockers, β-blockers and statins. BMJ Case Rep 2014; 2014:bcr-2014-204732. [PMID: 24907219 DOI: 10.1136/bcr-2014-204732] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a case of extreme mixed overdose of calcium channel blockers, β-blockers and statins. The patient was successfully treated with aggressive resuscitation including cardiac pacing and multiorgan support, glucagon and high-dose insulin for toxicity related to calcium channel blockade and β-blockade, and ubiquinone for treating severe presumed statin-induced rhabdomyolysis and muscle weakness.
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Affiliation(s)
- Reena Thakrar
- Department of Critical Care, University College London Hospital Foundation Trust, London, UK
| | - Rob Shulman
- Pharmacy Department, University College London Hospital Foundation Trust, London, UK
| | - Geoff Bellingan
- Department of Critical Care, University College London Hospital Foundation Trust, London, UK Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
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6
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Doğan M, Basaranoglu M, Peker E, Akbayram S, Sahin M, Uner A, Caksen H. Tarka® overdose in a young child. Hum Exp Toxicol 2010; 30:1392-8. [PMID: 21148598 DOI: 10.1177/0960327110389834] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tarka® is a combination antihypertensive medication composed of verapamil hydrochloride and trandolapril. A 3.5-year-old female was brought to our hospital due to a sleepy condition 7 hours after an accidental ingestion of six tablets of Tarka® containing 240 mg verapamil hydrochloride and 4 mg trandolapril in each tablet. Five hours after hospitalization, her condition deteriorated and arterial pressure progressively decreased despite the treatment. Finally, a temporary pacemaker was implanted, after which the vital findings began to return to normal values. The pacemaker was removed 13 hours after implantation as normal heart rhythm was observed. There are no reports of intoxication with fixed-dose combination products, especially Tarka®, in young children in the literature. Therefore, we believe that our report can provide an insight on the toxic dose of this drug in younger children. Clinicians should keep in mind that lethargy can be the first symptom of a possible clinical deterioration, even in normotensive and normorhythmic individuals.
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Affiliation(s)
- Murat Doğan
- Department of Pediatrics, Yuzuncu Yil University, School of Medicine, Van, Türkiye.
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7
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Levosimendan as treatment option in severe verapamil intoxication: a case report and review of the literature. Case Rep Med 2010; 2010. [PMID: 20814559 PMCID: PMC2931406 DOI: 10.1155/2010/546904] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 05/09/2010] [Accepted: 07/08/2010] [Indexed: 11/17/2022] Open
Abstract
Cardiovascular shock due to verapamil intoxication is often refractory to standard resuscitation methods. Recommended therapy includes prevention of further absorption of the drug, inotropic therapy, calcium gluconate, and hyperinsulinemia/euglycemia therapy. Often further measures are needed such as ventricular pacing or mechanical circulatory support. Still, mortality remains high.
Levosimendan, an inotropic agent, that enhances myofilament response to calcium, increases myocardial contraction and could therefore be beneficial in verapamil intoxication. Here, we report the case of a 60-year-old patient with clinically severe verapamil poisoning who presented with shock, bradycardia, and sopor. Standard therapy including high-dose inotropes failed to ameliorate the signs of intoxication. But additional therapy with levosimendan led to rapid improvement. Based on this observation, the literature is reviewed focusing on utilization of levosimendan in the treatment of calcium channel blocker overdose. We suggest to consider levosimendan as additional treatment option in patients with cardiovascular shock due to verapamil intoxication that are refractory to standard management.
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8
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Olson KR, Erdman AR, Woolf AD, Scharman EJ, Christianson G, Caravati EM, Wax PM, Booze LL, Manoguerra AS, Keyes DC, Chyka PA, Troutman WG. Calcium Channel Blocker Ingestion: An Evidence-Based Consensus Guideline for Out-of-Hospital Management. Clin Toxicol (Phila) 2009; 43:797-822. [PMID: 16440509 DOI: 10.1080/15563650500357404] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In 2003, U.S. poison control centers were consulted after 9650 ingestions of calcium channel blockers (CCBs), including 57 deaths. This represents more than one-third of the deaths reported to the American Association of Poison Control Centers' Toxic Exposure Surveillance System database that were associated with cardiovascular drugs and emphasizes the importance of developing a guideline for the out-of-hospital management of calcium channel blocker poisoning. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with suspected ingestions of calcium channel blockers. An evidence-based expert consensus process was used to create this guideline. This guideline applies to ingestion of calcium channel blockers alone and is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. The panel's recommendations follow. The grade of recommendation is in parentheses. 1) All patients with stated or suspected self-harm or the recipient of a potentially malicious administration of a CCB should be referred to an emergency department immediately regardless of the amount ingested (Grade D). 2) Asymptomatic patients are unlikely to develop symptoms if the interval between the ingestion and the call is greater than 6 hours for immediate-release products, 18 hours for modified-release products other than verapamil, and 24 hours for modified-release verapamil. These patients do not need referral or prolonged observation (Grade D). 3) Patients without evidence of self-harm should have further evaluation, including determination of the precise dose ingested, history of other medical conditions, and the presence of co-ingestants. Ingestion of either an amount that exceeds the usual maximum single therapeutic dose or an amount equal to or greater than the lowest reported toxic dose, whichever is lower (see Table 5), would warrant consideration of referral to an emergency department (Grade D). 4) Do not induce emesis (Grade D). 5) Consider the administration of activated charcoal orally if available and no contraindications are present. However, do not delay transportation in order to administer charcoal (Grade D). 6) For patients who merit evaluation in an emergency department, ambulance transportation is recommended because of the potential for life-threatening complications. Provide usual supportive care en route to the hospital, including intravenous fluids for hypotension. Consider use of intravenous calcium, glucagon, and epinephrine for severe hypotension during transport, if available (Grade D). 7) Depending on the specific circumstances, follow-up calls should be made to determine outcome at appropriate intervals based on the clinical judgment of the poison center staff (Grade D).
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Affiliation(s)
- Kent R Olson
- American Association of Poison Control Centers, 3201 New Mexico Ave., NW, Suite 330, Washington, DC 20016, USA
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9
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Roberts DM, Roberts JA, Boots RJ, Mason R, Lipman J. Lessons learnt in the pharmacokinetic analysis of the effect of haemoperfusion for acute overdose with sustained-release diltiazem. Anaesthesia 2008; 63:714-8. [PMID: 18582256 DOI: 10.1111/j.1365-2044.2008.05477.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The effect of charcoal haemoperfusion on the pharmacokinetics of diltiazem is described in a patient with severe clinical toxicity following acute overdose. The patient presented within 3 h following acute ingestion of multiple medications including sustained-release diltiazem. Routine resuscitation and supportive care were administered, but hypotension did not resolve despite intravenous fluids and infusions of calcium, adrenaline, noradrenaline and vasopressin. Multiple-doses of activated charcoal, haemodialysis and charcoal haemoperfusion were prescribed to expedite the elimination of diltiazem. The maximum diltiazem concentration (577 microg.l(-1)) was recorded 7 h post ingestion which was followed by an erratic and prolonged elimination phase. The maximum clearance of diltiazem due to haemoperfusion was calculated to be 19.4 and 15.1 ml.min(-1) at different times, equating to removal of approximately 1.5 mg diltiazem during 4 h of haemoperfusion. Haemoperfusion did not appear to remove sufficient diltiazem to recommend its routine use in the treatment of patients with acute diltiazem overdose.
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Affiliation(s)
- D M Roberts
- Burns, Trauma and Critical Care Research Centre, University of Queensland, Butterfield Street, Herston, Australia.
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10
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Syring RS, Costello MF, Poppenga RH. Temporary transvenous cardiac pacing in a dog with diltiazem intoxication. J Vet Emerg Crit Care (San Antonio) 2008. [DOI: 10.1111/j.1476-4431.2007.00269.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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11
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Patel NP, Pugh ME, Goldberg S, Eiger G. Hyperinsulinemic Euglycemia Therapy for Verapamil Poisoning: A Review. Am J Crit Care 2007. [DOI: 10.4037/ajcc2007.16.5.498] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Treatment of patients with verapamil overdose remains challenging. Traditional decontamination and supportive measures with intravenous calcium and vasopressors are the mainstays in initial care. Recently, the successful use of rescue hyperinsulinemic euglycemia therapy has been described in multiple cases. Treatment resulted in improved hemodynamic parameters and increased metabolic efficiency in patients with a low-output, myocardial shock state. Information on clinical use of hyperinsulinemic euglycemia therapy in humans is limited to case reports and small case series; no controlled clinical trials have been done. Hyperinsulinemic euglycemia therapy should be considered for patients with calcium channel blocker overdose who do not respond to initial supportive therapy.
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Affiliation(s)
- Nirav P. Patel
- Nirav P. Patel is a fellow in the Division of Pulmonary, Allergy, and Critical Care Medicine and the Center for Sleep and Respiratory Neurobiology, and Meredith E. Pugh is chief resident in the Department of Medicine, at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Meredith E. Pugh
- Nirav P. Patel is a fellow in the Division of Pulmonary, Allergy, and Critical Care Medicine and the Center for Sleep and Respiratory Neurobiology, and Meredith E. Pugh is chief resident in the Department of Medicine, at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven Goldberg
- Steven Goldberg, director of the medical intensive care unit, and Glenn Eiger, associate chairman for the department of medicine, are both members of the Division of Pulmonary and Critical Care Medicine, Albert Einstein Medical Center, in Philadelphia
| | - Glenn Eiger
- Steven Goldberg, director of the medical intensive care unit, and Glenn Eiger, associate chairman for the department of medicine, are both members of the Division of Pulmonary and Critical Care Medicine, Albert Einstein Medical Center, in Philadelphia
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12
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Kerns W. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am 2007; 25:309-31; abstract viii. [PMID: 17482022 DOI: 10.1016/j.emc.2007.02.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
State-of-the-art therapy for beta-adrenergic receptor blocker and calcium channel antagonist toxicity is reviewed in the light of new insights into drug-induced shock. A brief discussion of pathophysiology, including cardiac, hemodynamic, and metabolic effects of cardiac drug toxicity, provides a foundation for understanding the basis of therapy. The major focus of this review is a critical evaluation of antidotal use of calcium, glucagon, catecholamines, insulin-euglycemia, and other novel therapies based on investigational studies and cumulative clinical experience.
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Affiliation(s)
- William Kerns
- Division of Toxicology, Department of Emergency Medicine, Carolinas Medical Center, Medical Education Building, Charlotte, NC 28203, USA.
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13
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Harris NS. Case records of the Massachusetts General Hospital. Case 24-2006. A 40-year-old woman with hypotension after an overdose of amlodipine. N Engl J Med 2006; 355:602-11. [PMID: 16899781 DOI: 10.1056/nejmcpc069016] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- N Stuart Harris
- Department of Emergency Medicine, Massachusetts General Hospital, and Harvard Medical School, USA
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14
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DeWitt CR, Waksman JC. Pharmacology, Pathophysiology and Management of Calcium Channel Blocker and ??-Blocker Toxicity. ACTA ACUST UNITED AC 2004; 23:223-38. [PMID: 15898828 DOI: 10.2165/00139709-200423040-00003] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Calcium channel blockers (CCB) and beta-blockers (BB) account for approximately 40% of cardiovascular drug exposures reported to the American Association of Poison Centers. However, these drugs represent >65% of deaths from cardiovascular medications. Yet, caring for patients poisoned with these medications can be extremely difficult. Severely poisoned patients may have profound bradycardia and hypotension that is refractory to standard medications used for circulatory support.Calcium plays a pivotal role in cardiovascular function. The flow of calcium across cell membranes is necessary for cardiac automaticity, conduction and contraction, as well as maintenance of vascular tone. Through differing mechanisms, CCB and BB interfere with calcium fluxes across cell membranes. CCB directly block calcium flow through L-type calcium channels found in the heart, vasculature and pancreas, whereas BB decrease calcium flow by modifying the channels via second messenger systems. Interruption of calcium fluxes leads to decreased intracellular calcium producing cardiovascular dysfunction that, in the most severe situations, results in cardiovascular collapse.Although, CCB and BB have different mechanisms of action, their physiological and toxic effects are similar. However, differences exist between these drug classes and between drugs in each class. Diltiazem and especially verapamil tend to produce the most hypotension, bradycardia, conduction disturbances and deaths of the CCB. Nifedipine and other dihydropyridines are generally less lethal and tend to produce sinus tachycardia instead of bradycardia with fewer conduction disturbances.BB have a wider array of properties influencing their toxicity compared with CCB. BB possessing membrane stabilising activity are associated with the largest proportion of fatalities from BB overdose. Sotalol overdoses, in addition to bradycardia and hypotension, can cause torsade de pointes. Although BB and CCB poisoning can present in a similar fashion with hypotension and bradycardia, CCB toxicity is often associated with significant hyperglycaemia and acidosis because of complex metabolic derangements related to these medications. Despite differences, treatment of poisoning is nearly identical for BB and CCB, with some additional considerations given to specific BB. Initial management of critically ill patients consists of supporting airway, breathing and circulation. However, maintenance of adequate circulation in poisoned patients often requires a multitude of simultaneous therapies including intravenous fluids, vasopressors, calcium, glucagon, phosphodiesterase inhibitors, high-dose insulin, a relatively new therapy, and mechanical devices. This article provides a detailed review of the pharmacology, pathophysiology, clinical presentation and treatment strategies for CCB and BB overdoses.
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15
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Satar S, Acikalin A, Akpinar O. Unusual electrocardiographic changes with propranolol and diltiazem overdosage: a case report. Am J Ther 2003; 10:299-302. [PMID: 12845395 DOI: 10.1097/00045391-200307000-00011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The therapeutic efficacy and safety of beta-adrenoreceptor-blocking drugs has been well established in patients with angina pectoris, cardiac arrhythmias, and hypertension and reducing the risk of mortality and nonfatal reinfarction on survival of acute myocardial infarction. The calcium antagonists are used for the treatment of patients with angina pectoris, long-term systemic hypertension, and the management of hypertensive emergencies and also for a multitude of other cardiovascular and noncardiovascular conditions. Because adverse cardiovascular effects can occur, however, patients being considered for combination treatment with propranolol and diltiazem must be selected carefully and observed closely. In this article, we present a suicidal case of drug overdose with propranolol and diltiazem with unusual electrocardiographic changes.
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Affiliation(s)
- Salim Satar
- Emergency Department, Faculty of Medicine, Cukurova University, Adana, Turkey.
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16
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Durward A, Guerguerian AM, Lefebvre M, Shemie SD. Massive diltiazem overdose treated with extracorporeal membrane oxygenation. Pediatr Crit Care Med 2003; 4:372-6. [PMID: 12831424 DOI: 10.1097/01.pcc.0000074273.50306.f5] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To describe a case of massive diltiazem overdose with a good outcome achieved after early and aggressive supportive therapy. DESIGN Case report. SETTING Pediatric Critical Care Unit. PATIENT Sixteen-year-old adolescent girl. MEASUREMENTS AND MAIN RESULTS A 16-yr-old adolescent girl presented to the emergency department 6 hrs after the intentional ingestion of 40 300-mg sustained-release diltiazem tablets (12 g of Cardura CD). She was hypotensive and required a glucagon and epinephrine infusion despite initial fluid resuscitation with saline and intravenous calcium (1 g). Multiple asystolic cardiac arrests ensued which became increasingly refractory to high-dose epinephrine. Hemodynamic support was achieved with a 48-hr period of extracorporeal membrane oxygenation for atrial standstill. Severe multiorgan dysfunction ensued (cardiac, neurologic, renal, hepatic, gastrointestinal, hematologic, and metabolic). Plasma diltiazem and its metabolites were measured and its half-life was reported between 28 and 48 hrs. A sustained decline in plasma diltiazem levels and its metabolites was not observed after two periods of charcoal hemoperfusion. Recovery of organ function occurred with sinus rhythm noted on the ninth day. The patient made a full recovery and was discharged from the critical care unit after 15 days. CONCLUSIONS Although massive calcium channel blocker overdose can produce profound and prolonged cardiac or multiorgan dysfunction, its toxic effects may be reversible. Supportive therapy, particularly of the cardiovascular system, is the most important goal.
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Affiliation(s)
- Andrew Durward
- Pediatric Critical Care Unit, Hospital for Sick Children, Toronto, Canada
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Snook CP, Sigvaldason K, Kristinsson J. Severe atenolol and diltiazem overdose. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2001; 38:661-5. [PMID: 11185975 DOI: 10.1081/clt-100102018] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CASE REPORT A case of combined, massive overdose of both atenolol and diltiazem in an adult male is reported. Cardiac arrest ensued which was responsive to cardiopulmonary resuscitation. Bradycardia, hypotension, and oliguria followed which were resistant to intravenous pacing and multiple pharmacologic interventions, including intravenous fluids, calcium, dopamine, dobutamine, epinephrine, prenalterol, and glucagon. Adequate mean arterial pressure and urine output were restored only after addition of phenylephrine to therapy with multiple agents and transvenous pacing. The patient survived until discharge after a hospital course complicated by nontransmural myocardial infarct on hospital day 4 and pneumonia. Laboratory testing subsequently revealed high serum levels of both atenolol and diltiazem. The atenolol level of 35 microg/mL in this patient is the highest reported associated with survival. CONCLUSION This case illustrates severe cardiovascular toxicity after overdose of both atenolol and diltiazem. Oliguria, which has previously been reported in severe atenolol overdose, was successfully treated without hemodialysis by the addition of phenylephrine to aggressive therapy with pacing, inotropic, and pressor support.
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Affiliation(s)
- C P Snook
- Department of Emergency Medicine, Iceland Poison Information Centre, Reykjavik Hospital.
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18
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Satchithananda DK, Stone DL, Chauhan A, Ritchie AJ. Lesson of the week. Unrecognised accidental overdose with diltiazem. BMJ (CLINICAL RESEARCH ED.) 2000; 321:160-1. [PMID: 10894696 PMCID: PMC1236716 DOI: 10.1136/bmj.321.7254.160] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Invasive haemodynamic monitoring should be considered when hypotension fails to respond to empirical treatments
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19
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Abstract
Several cases of poisoning with diltiazem have been described in the literature, but information about the pharmacokinetics of diltiazem in overdose is sparse. The authors report pharmacokinetic and clinical observations in a patient who ingested 7.2 g of slow-release dilitiazem. Grave, persistent hypotension was the overriding clinical manifestation, but the patient eventually survived with aggressive cardiovascular support. No serious conduction abnormalities were seen. Blood samples were taken repeatedly for 2-3 days for analysis of serum diltiazem and desacetyldiltiazem and desacetyldiltiazem concentrations. The serum diltiazem concentration measured in the first sample taken (16.5 h postingestion), 3,171 ng/ml, is one of the highest concentrations reported in a patient who survived. The half-life was 13.3 h for diltiazem and 10.5 h for desacetyldiltiazem. Charcoal hemoperfusion had no apparent effect on the elimination of either compound. The relatively long half-life of diltiazem may have resulted from rate-limiting absorption and probably does not indicate saturation of diltiazem metabolism. The patient was discharged with no apparent neurological or cardiological deficits.
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Affiliation(s)
- K Luomanmäki
- Department of Medicine, Helsinki University Central Hospital, Finland
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20
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Williamson KM, Dunham GD. Plasma concentrations of diltiazem and desacetyldiltiazem in an overdose situation. Ann Pharmacother 1996; 30:608-11. [PMID: 8792947 DOI: 10.1177/106002809603000608] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To describe the elimination of diltiazem and desacetyldiltiazem in an overdose situation. CASE SUMMARY An 18-year-old woman ingested controlled delivery diltiazem 14.94 g in a suicide attempt. After arriving at the hospital unresponsive and hypotensive, her condition progressed to complete heart block, cardiogenic shock, asystole, and acute renal failure. Supportive care consisted of vasopressors, intravenous calcium, intravenous glucagon, charcoal hemoperfusion, temporary transvenous pacing, and an intraaortic balloon pump. After 12 days in the hospital, the patient recovered fully. DISCUSSION We report a large, documented overdose of diltiazem and detail the pharmacokinetic profiles of both diltiazem and its active metabolite, desacetyldiltiazem. Nonlinear elimination of diltiazem appears to occur at higher concentrations. Although the patient improved clinically following charcoal hemoperfusion, no dramatic effects on diltiazem elimination were apparent. CONCLUSIONS Survival following massive diltiazem overdose can be achieved with supportive care. Charcoal hemoperfusion had a limited effect on improving the clearance of diltiazem as evidenced by serial plasma concentrations.
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Affiliation(s)
- K M Williamson
- School of Pharmacy, University of North Carolina, Chapel Hill 27599, USA
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21
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Terlato RJ, Kopec SE, Aaron CK, Laifer LI, Becker RC. Massive Overdose of Cardizem CD. J Intensive Care Med 1996. [DOI: 10.1177/088506669601100204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Long-acting diltiazem preparations are currently frequently prescribed, and the potential for serious morbidity and mortality with an overdose can be significant. We present a case of Cardizem CD overdose in which a 22-year-old patient ingested 18.0 g, in an apparent suicide attempt. She presented within 5 hours of ingestion with a blood pressure of 80/30 mm Hg and a pulse of 80 beats/minute. Interventions included intravenous fluids, activated charcoal, atropine, calcium, dopamine, norepinephrine, glucagon, bowel irrigation with polyethylene glycol, and placement of a temporary transvenous pacemaker. Diltiazem levels were obtained, and an elimination half-life was calculated. Unique side effects of this overdose are discussed, and a treatment approach is suggested. Early and aggressive treatment is essential, and preparation for anticipated side effects should be initiated as soon as possible.
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Affiliation(s)
- Robert J. Terlato
- Division of Cardiovascular Medicine and Department of Emergency Services, University of Massachusetts Medical School, Worcester, MA
| | - Scott E. Kopec
- Division of Cardiovascular Medicine and Department of Emergency Services, University of Massachusetts Medical School, Worcester, MA
| | - Cynthia K. Aaron
- Division of Cardiovascular Medicine and Department of Emergency Services, University of Massachusetts Medical School, Worcester, MA
| | - Lawrence I. Laifer
- Division of Cardiovascular Medicine and Department of Emergency Services, University of Massachusetts Medical School, Worcester, MA
| | - Richard C. Becker
- Division of Cardiovascular Medicine and Department of Emergency Services, University of Massachusetts Medical School, Worcester, MA
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22
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Abstract
A case of diltiazem overdose with significant hemodynamic compromise is presented. Multiple therapeutic modalities were attempted with limited results. Control was finally achieved with a combination of norepinephrine, dobutamine, and cardiac pacing. Invasive pulmonary monitoring parameters are reported and were important in the management of this patient. The management of calcium channel blocker overdose and the various available therapeutic modalities are discussed.
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Affiliation(s)
- L Proano
- Department of Emergency Medicine, Brown University School of Medicine, Rhode Island Hospital, Providence 02903, USA
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23
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Fauville JP, Hantson P, Honore P, Belpaire F, Rosseel MT, Mahieu P. Severe diltiazem poisoning with intestinal pseudo-obstruction: case report and toxicological data. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1995; 33:273-7. [PMID: 7760457 DOI: 10.3109/15563659509017999] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This case report concerns a 30-year-old man who survived a 4.2 g diltiazem overdose. He sustained vasoplegic shock with a junctional escape rhythm which required high doses of norepinephrine and epinephrine. Among other complications, ileus with paralytic intestinal pseudo-obstruction developed on day three. Cecal distention was demonstrated by abdomen computed tomodensitometry. The ileus resolved on day seven following the poisoning. Diltiazem plasma concentrations were determined during the first three days. The possible role of other medications, activated charcoal and sufentanil, is noted.
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Affiliation(s)
- J P Fauville
- Department of Intensive Care, Cliniques Universitaires St-Luc, Brussels, Belgium
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25
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26
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Patel R, Lipper B, Schwartzbard A, Nelson C, O'Connor MA, Frishman W. Toxic effects of diltiazem in a patient with chronic renal failure. J Clin Pharmacol 1994; 34:273-4. [PMID: 8021338 DOI: 10.1002/j.1552-4604.1994.tb03999.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- R Patel
- Department of Medicine and Critical Care, Albert Einstein College of Medicine, Bronx, NY
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27
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Oshida J, Goto H, Benson KT, Arakawa K. Effects of calcium chloride on verapamil- and diltiazem-pretreated isolated rat hearts. J Cardiothorac Vasc Anesth 1993; 7:717-20. [PMID: 8305663 DOI: 10.1016/1053-0770(93)90058-s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The effects of calcium chloride on cardiac responses to verapamil and diltiazem were investigated using isolated and perfused rat hearts with a Langendorff technique. Ionized calcium concentrations were increased approximately from 0.5 mM to 2.2 mM when the hearts were pretreated with 0.2 mg/L of verapamil or 0.28 mg/L of diltiazem, or were untreated with calcium blockers. Calcium significantly counteracted the negative inotropic effect produced by diltiazem and verapamil. In contrast, the negative chronotropic effects of both diltiazem and verapamil were potentiated by increasing concentrations of ionized calcium, and this potentiation was not eliminated by 1.0 mg/L of atropine. An atrioventricular block was induced by both verapamil and diltiazem when ionized calcium concentrations were lower than normal. It is suggested from this study that, although calcium chloride counteracts the negative inotropic effects of verapamil and diltiazem, abruptly increased ionized calcium may cause severe bradycardia clinically.
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Affiliation(s)
- J Oshida
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City 66160-7415
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Affiliation(s)
- D L Connolly
- Department of Medicine, Queen Elizabeth Hospital, Kings Lynn, Norfolk, United Kingdom
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29
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Abstract
Glucagon is a pancreatic polypeptide hormone that has diverse utility as both a therapeutic and diagnostic agent. Many of its pharmacologic actions are pertinent to the practice of emergency medicine. The author reviews the literature supporting each potential use of the drug and the purported physiologic mechanisms by which glucagon exerts these actions. The indications and proper dosages for glucagon in the acute care setting are summarized.
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Affiliation(s)
- C V Pollack
- Department of Emergency Medicine, Maricopa Medical Center, Phoenix, Arizona
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30
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Henderson A, Stevenson N, Hackett LP, Pond SM. Diltiazem overdose in an elderly patient: efficacy of adrenaline. Anaesth Intensive Care 1992; 20:507-10. [PMID: 1463184 DOI: 10.1177/0310057x9202000422] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- A Henderson
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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