Development of ventricular fibrillation after intravenous calcium chloride administration in a patient with supraventricular tachycardia

Chemical cardioversion of supraventricular tachycardia with calcium gluconate

BACKGROUND

Approximately 0.05% of Emergency Department visits in the United States are related to supraventricular tachycardia (SVT). The majority of patients convert with an atrioventricular nodal blocking medication.

CASE REPORT

We report a case of SVT that converted after administration of calcium gluconate after failing conversion with adenosine.

CONCLUSION

Conversion to normal sinus rhythm resulted after administration of i.v. calcium in our patient. Additional investigations would be helpful in determining the causal vs. temporal association of conversion of SVT with calcium administration.

Deep Tendon Reflexes, Magnesium, and Calcium: Assessments and Implications

The perinatal nurse, in collaboration with physicians, can use deep tendon reflexes as a powerful tool in determining the need to start, adjust, or stop magnesium infusion. Toxicity can be detected using physical manifestations as a guide. Clinical signs may be a better indicator than serum levels of tissue levels of magnesium. Whether magnesium is given to prevent seizures or for tocolysis, patients in both situations are at risk for developing toxicity and must be assessed regularly to ensure patient safety.

Pharmacology, Pathophysiology and Management of Calcium Channel Blocker and ??-Blocker Toxicity

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.

The use of calcium salts in the prevention and management of verapamil-induced hypotension

OBJECTIVE

To review the available literature on the use of intravenous calcium salts for the prevention of hypotension associated with intravenous verapamil.

METHODS

A MEDLINE search (1966-June 1999) identified pertinent articles; references from these articles were identified to serve as additional resources.

DISCUSSION

Verapamil is effective in inhibiting atrioventricular nodal conduction, thereby controlling ventricular rate in patients with atrial fibrillation/flutter and terminating paroxysmal supraventricular tachycardia. However, hypotension may be caused by the negative inotropic and vasodilating effects of verapamil. In vitro and animal data suggest that calcium pretreatment may minimize the effects of verapamil on cardiac output and blood pressure. Case reports suggest that intravenous calcium may be useful for both prevention and reversal of the hemodynamic effects of verapamil. A number of small clinical trials have been performed, suggesting that calcium administered prior to intravenous verapamil results in a decreased incidence of hypotension. The most common adverse effect of intravenous calcium is flushing.

CONCLUSIONS

Calcium pretreatment prior to intravenous calcium-channel blocker administration should be considered in patients in whom further reductions in blood pressure may precipitate hypoperfusion or worsen underlying cardiovascular status. A dose of calcium gluconate 1 g (ionized calcium 90 mg) administered over three minutes is recommended for preventing or lessening the hypotensive effect of verapamil without affecting the antiarrhythmic effects of verapamil.