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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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Beavers JR, Stollings JL, Rice TW. Hyponatremia induced by hyperinsulinemia-euglycemia therapy. Am J Health Syst Pharm 2019; 74:1062-1066. [PMID: 28687552 DOI: 10.2146/ajhp160262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE A case of symptomatic hyponatremia induced by hyperinsulinemia-euglycemia (HIE) therapy is reported. SUMMARY A 59-year-old, 81.65-kg woman with hypertension, major depressive disorder, and anxiety arrived at a tertiary medical center 1.5 hours after an intentional overdose of oral amlodipine 200 mg, metoprolol tartrate 2,000 mg, and isosorbide mononitrate 1,200 mg. Upon arrival, her pulse was 63 beats/min and blood pressure was 106/56 mm Hg. The patient's blood pressure was refractory to fluids, calcium gluconate, and norepinephrine, resulting in initiation of HIE therapy. She had recurrent episodes of hypoglycemia, which required increases of the dextrose infusion and resulted in the patient receiving a total of 6.9 L of dextrose with free water. Seventeen hours into the hospitalization, the patient became obtunded due to hyponatremia (serum sodium concentration, 121 mmol/L). HIE therapy was discontinued, an infusion of 5% dextrose injection with sodium bicarbonate added was started, and a bolus of 3% sodium chloride was administered. Nine hours after the presentation of hyponatremia, the patient's serum sodium concentration normalized (137 mmol/L), and her symptoms resolved. The patient's blood pressure, pulse, and mental status continued to improve, and the patient was transferred out of the medical intensive care unit 41 hours after her arrival at the hospital. CONCLUSION A woman who overdosed on amlodipine, metoprolol tartrate, and isosorbide mononitrate was treated with HIE therapy and developed symptomatic hyponatremia. Hyponatremia resolved after administration of dextrose with sodium bicarbonate infusion and 3% sodium chloride infusion and cessation of HIE therapy.
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Affiliation(s)
- Jennifer R Beavers
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Todd W Rice
- Division of Allergy/Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
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Bijsmans ES, Doig M, Jepson RE, Syme HM, Elliott J, Pelligand L. Factors Influencing the Relationship Between the Dose of Amlodipine Required for Blood Pressure Control and Change in Blood Pressure in Hypertensive Cats. J Vet Intern Med 2018; 30:1630-1636. [PMID: 27717190 PMCID: PMC5032874 DOI: 10.1111/jvim.14562] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 07/02/2016] [Accepted: 07/18/2016] [Indexed: 11/30/2022] Open
Abstract
Background Hypertension is a common problem in elderly cats. In most cats, systolic blood pressure (SBP) of <160 mmHg is achieved in response to amlodipine besylate at either 0.625 or 1.25 mg q24h. The individual cat factors determining dose requirement dose have not been explored. Aims To determine whether individual cat factors influence the dose of amlodipine required to achieve adequate blood pressure control and to determine whether factors other than the prescribed dose of drug alter the achieved plasma amlodipine concentrations. Methods Fifty‐nine hypertensive cats that required 0.625 mg (A) and 41 cats that required 1.25 mg (B) amlodipine to reach a target SBP of <160 mmHg were identified, and plasma amlodipine concentrations were determined. Comparisons were made between groups, and multivariable linear regression models were performed to investigate predictors of antihypertensive response. Results Cats that required a greater dose of amlodipine had significantly higher SBP at diagnosis of hypertension (A: (median [25th, 75th percentile]) 182 [175,192] mmHg; B: 207 [194,217] mmHg, P < .001), but comparable blood pressure was achieved after treatment. Plasma amlodipine concentrations were directly related to the dose of amlodipine administered. At diagnosis, cats in group B had significantly lower plasma potassium concentration (A: 4.1 [3.8,4.5]; B: 3.8 [3.6,4.2] mEq/L, P < .01). Weight did not differ between groups. The decrease in SBP was directly and independently associated with the SBP at diagnosis and the plasma amlodipine concentration. Conclusions and Clinical Importance Cats with higher blood pressure at diagnosis might require a greater dose of amlodipine to control their blood pressure adequately. Differences in amlodipine pharmacokinetics between cats do not seem to play a role in the antihypertensive response.
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Affiliation(s)
- E S Bijsmans
- Department of Comparative Biomedical Sciences, Royal Veterinary College, University of London, London, UK.
| | - M Doig
- ABS Laboratories Ltd, Welwyn Garden City, Hertfordshire, UK
| | - R E Jepson
- Department of Clinical Science and Services, Royal Veterinary College, University of London, Hatfield, Hertfordshire, UK
| | - H M Syme
- Department of Clinical Science and Services, Royal Veterinary College, University of London, Hatfield, Hertfordshire, UK
| | - J Elliott
- Department of Comparative Biomedical Sciences, Royal Veterinary College, University of London, London, UK
| | - L Pelligand
- Department of Clinical Science and Services, Royal Veterinary College, University of London, Hatfield, Hertfordshire, UK
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Bartlett D. β-Blocker and Calcium Channel Blocker Poisoning: High-Dose Insulin/Glucose Therapy. Crit Care Nurse 2018; 36:45-50. [PMID: 27037338 DOI: 10.4037/ccn2016370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Overdoses of β-blockers and calcium channel blockers can produce significant morbidity and mortality, and conventional therapies often do not work as treatments for these poisonings. High-dose insulin/glucose therapy has been successful in reversing the cardiotoxic effects of these drugs in cases where the standard therapies have failed, and it appears to be relatively safe. Many successes have been well documented, but the clinical experience consists of case reports, the mechanisms of action are not completely understood, and guidelines for use of the therapy are empirically derived and not standardized. Regardless of these limitations, high-dose insulin/glucose therapy can be effective, it is often recommended by clinical toxicologists and poison control centers, and critical care nurses should be familiar with when and how the therapy is used.
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Affiliation(s)
- Dana Bartlett
- Dana Bartlett is an information specialist at the Connecticut Poison Control Center, Farmington, Connecticut.
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Reuter-Rice KE, Peterson BM. Conventional and Unconventional Lifesaving Therapies in an Adolescent With Amlodipine Ingestion. Crit Care Nurse 2018; 36:64-9. [PMID: 27481803 DOI: 10.4037/ccn2016524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Amlodipine, a dihydropyridine calcium channel blocker, is commonly prescribed for the treatment of hypertension. Ingestion of an overdose leads to severe hypotension; if the hypotension is not treated, death may be imminent. Conventional and unconventional interventions were used to treat an adolescent who ingested a life-threatening dose of amlodipine. Severe hypotension resistant to conventional treatment with intralipids and hyperinsulinemia-euglycemia therapy led to the use of plasmapheresis and a pneumatic antishock garment as lifesaving measures. Plasmapheresis has been described in only one other case of severe amlodipine overdose, and the use of a pneumatic antishock garment has never been described in the management of a calcium channel blocker overdose. Because short-term use of a pneumatic antishock garment has associated risks, the critical care nurse's anticipation of side effects and promotion of safe use of the garment were instrumental in the patient's care and outcome. (Critical Care Nurse 2016; 36[4]:64-69).
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Affiliation(s)
- Karin E Reuter-Rice
- Karin E. Reuter-Rice is an associate professor and a Robert Wood Johnson Foundation scholar, School of Nursing and School of Medicine, Department of Pediatrics, Duke University, Durham, North Carolina. She is also a pediatric nurse practitioner in critical care at Duke University Health System and formerly at Rady Children's Hospital, San Diego, California.Bradley M. Peterson is a senior consultant to the pediatric intensive care unit, Rady Children's Hospital.
| | - Bradley M Peterson
- Karin E. Reuter-Rice is an associate professor and a Robert Wood Johnson Foundation scholar, School of Nursing and School of Medicine, Department of Pediatrics, Duke University, Durham, North Carolina. She is also a pediatric nurse practitioner in critical care at Duke University Health System and formerly at Rady Children's Hospital, San Diego, California.Bradley M. Peterson is a senior consultant to the pediatric intensive care unit, Rady Children's Hospital
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Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, Brattebø G, Brugger H, Dunning J, Hunyadi-Antičević S, Koster RW, Lockey DJ, Lott C, Paal P, Perkins GD, Sandroni C, Thies KC, Zideman DA, Nolan JP, Böttiger BW, Georgiou M, Handley AJ, Lindner T, Midwinter MJ, Monsieurs KG, Wetsch WA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95:148-201. [PMID: 26477412 DOI: 10.1016/j.resuscitation.2015.07.017] [Citation(s) in RCA: 527] [Impact Index Per Article: 58.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic.
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, Southampton University Hospital NHS Trust, Southampton, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | | | - Guttorm Brattebø
- Bergen Emergency Medical Services, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Hermann Brugger
- EURAC Institute of Mountain Emergency Medicine, Bozen, Italy
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Rudolph W Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - David J Lockey
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; School of Clinical Sciences, University of Bristol, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet, Mainz, Germany
| | - Peter Paal
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, UK; Department of Anaesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | | | - David A Zideman
- Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
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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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10
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Rizvi I, Ahmad A, Gupta A, Zaman S. Life-threatening calcium channel blocker overdose and its management. BMJ Case Rep 2012; 2012:bcr.01.2012.5643. [PMID: 22669854 DOI: 10.1136/bcr.01.2012.5643] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A young woman presented to the emergency department with complaints of nausea, vomiting, pain in the abdomen and difficulty in breathing after ingestion of 56 tablets of amlodipine 5 mg each (total 280 mg of amlodipine). She was managed using hyperinsulinaemia/euglycaemia therapy and other measures like calcium gluconate, glucagon and vasopressors. She was discharged from hospital in a stable condition after 5 days.
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Affiliation(s)
- Imran Rizvi
- Department of General Medicine, J N Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India.
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Toxic bradycardias in the critically ill poisoned patient. Emerg Med Int 2012; 2012:852051. [PMID: 22545217 PMCID: PMC3321542 DOI: 10.1155/2012/852051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 11/15/2011] [Accepted: 01/18/2012] [Indexed: 11/17/2022] Open
Abstract
Cardiovascular drugs are a common cause of poisoning, and toxic bradycardias can be refractory to standard ACLS protocols. It is important to consider appropriate antidotes and adjunctive therapies in the care of the poisoned patient in order to maximize outcomes. While rigorous studies are lacking in regards to treatment of toxic bradycardias, there are small studies and case reports to help guide clinicians' choices in caring for the poisoned patient. Antidotes, pressor support, and extracorporeal therapy are some of the treatment options for the care of these patients. It is important to make informed therapeutic decisions with an understanding of the available evidence, and consultation with a toxicologist and/or regional Poison Control Center should be considered early in the course of treatment.
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Management of calcium channel antagonist overdose with hyperinsulinemia-euglycemia therapy: case series and review of the literature. Case Rep Crit Care 2012; 2012:927040. [PMID: 24826345 PMCID: PMC4010055 DOI: 10.1155/2012/927040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 01/17/2012] [Indexed: 01/21/2023] Open
Abstract
Calcium channel antagonists (CCAs) are commonly involved in drug overdoses. Standard approaches to the management of CCA overdoses, including fluid resuscitation, gut decontamination, administration of calcium, glucagon, and atropine, as well as supportive care, are often ineffective. We report on two patients who improved after addition of hyperinsulinemia-euglycemia (HIE) therapy. We conclude with a literature review on hyperinsulinemia-euglycemia therapy with an exploration of the physiology behind its potential use.
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Kute VB, Shah PR, Goplani KR, Gumber MR, Vanikar AV, Trivedi HL. Successful treatment of refractory hypotension, noncardiogenic pulmonary edema and acute kidney injury after an overdose of amlodipine. Indian J Crit Care Med 2011; 15:182-4. [PMID: 22013313 PMCID: PMC3190472 DOI: 10.4103/0972-5229.84901] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Treatment of patients with amlodipine overdose remains challenging. We describe a case of successful treatment of refractory hypotension, noncardiogenic pulmonary edema and acute kidney injury after an intoxication with 250 mg of amlodipine. Marked improvement in all hemodynamic parameters was noted with combination of fluids, inotropes, low-dose calcium, low dose insulin, mechanical ventilation and hemodialysis. All available information on overdose of amlodipine is limited to case reports and series. Prospective trial on the use of these agents is required to define its role as the first-line treatment in amlodipine, a calcium channel blockers overdose.
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Affiliation(s)
- Vivek B Kute
- Department of Nephrology and Transplantation Medicine, IKDRC-ITS, Ahmedabad, India
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Engebretsen KM, Kaczmarek KM, Morgan J, Holger JS. High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning. Clin Toxicol (Phila) 2011; 49:277-83. [DOI: 10.3109/15563650.2011.582471] [Citation(s) in RCA: 156] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJLM, Brugger H, Deakin CD, Dunning J, Georgiou M, Handley AJ, Lockey DJ, Paal P, Sandroni C, Thies KC, Zideman DA, Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2011; 81:1400-33. [PMID: 20956045 DOI: 10.1016/j.resuscitation.2010.08.015] [Citation(s) in RCA: 361] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
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Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e93-e174. [PMID: 20956032 DOI: 10.1016/j.resuscitation.2010.08.027] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S829-61. [PMID: 20956228 DOI: 10.1161/circulationaha.110.971069] [Citation(s) in RCA: 388] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Soar J, Perkins G, Abbas G, Alfonzo A, Barelli A, Bierens J, Brugger H, Deakin C, Dunning J, Georgiou M, Handley A, Lockey D, Paal P, Sandroni C, Thies KC, Zideman D, Nolan J. Kreislaufstillstand unter besonderen Umständen: Elektrolytstörungen, Vergiftungen, Ertrinken, Unterkühlung, Hitzekrankheit, Asthma, Anaphylaxie, Herzchirurgie, Trauma, Schwangerschaft, Stromunfall. Notf Rett Med 2010. [DOI: 10.1007/s10049-010-1374-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP, Adrie C, Alhelail M, Battu P, Behringer W, Berkow L, Bernstein RA, Bhayani SS, Bigham B, Boyd J, Brenner B, Bruder E, Brugger H, Cash IL, Castrén M, Cocchi M, Comadira G, Crewdson K, Czekajlo MS, Davies SR, Dhindsa H, Diercks D, Dine CJ, Dioszeghy C, Donnino M, Dunning J, El Sanadi N, Farley H, Fenici P, Feeser VR, Foster JA, Friberg H, Fries M, Garcia-Vega FJ, Geocadin RG, Georgiou M, Ghuman J, Givens M, Graham C, Greer DM, Halperin HR, Hanson A, Holzer M, Hunt EA, Ishikawa M, Ioannides M, Jeejeebhoy FM, Jennings PA, Kano H, Kern KB, Kette F, Kudenchuk PJ, Kupas D, La Torre G, Larabee TM, Leary M, Litell J, Little CM, Lobel D, Mader TJ, McCarthy JJ, McCrory MC, Menegazzi JJ, Meurer WJ, Middleton PM, Mottram AR, Navarese EP, Nguyen T, Ong M, Padkin A, Ferreira de Paiva E, Passman RS, Pellis T, Picard JJ, Prout R, Pytte M, Reid RD, Rittenberger J, Ross W, Rubertsson S, Rundgren M, Russo SG, Sakamoto T, Sandroni C, Sanna T, Sato T, Sattur S, Scapigliati A, Schilling R, Seppelt I, Severyn FA, Shepherd G, Shih RD, Skrifvars M, Soar J, Tada K, Tararan S, Torbey M, Weinstock J, Wenzel V, Wiese CH, Wu D, Zelop CM, Zideman D, Zimmerman JL. Part 8: Advanced Life Support. Circulation 2010; 122:S345-421. [DOI: 10.1161/circulationaha.110.971051] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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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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Smith SW, Ferguson KL, Hoffman RS, Nelson LS, Greller HA. Prolonged severe hypotension following combined amlodipine and valsartan ingestion. Clin Toxicol (Phila) 2009; 46:470-4. [DOI: 10.1080/15563650701779695] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ezidiegwu C, Spektor Z, Nasr MR, Kelly KC, Rosales LG. A Case Report on the Role of Plasma Exchange in the Management of a Massive Amlodipine Besylate Intoxication. Ther Apher Dial 2008; 12:180-4. [DOI: 10.1111/j.1744-9987.2008.00567.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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Patel NP, Pugh ME, Goldberg S, Eiger G. Hyperinsulinemic Euglycemia Therapy for Verapamil Poisoning: Case Report. Am J Crit Care 2007. [DOI: 10.4037/ajcc2007.16.5.520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A 49-year-old woman was brought to the emergency department because of an intentional overdose of sustained-release verapamil along with captopril and glyburide. The estimated interval between ingestion and the time she was found was several hours. Initial findings were blood pressure 72/39 mm Hg, heart rate 32/min, and a score of 9 on the Glasgow Coma Scale. She was intubated and given intravenous fluid and vasopressor support. Decontamination with activated charcoal was instituted. Administration of dopamine and norepinephrine, atropine, sodium bicarbonate, and calcium chloride did not yield significant clinical improvement. Hyperinsulinemic euglycemia therapy was started: a bolus of regular insulin then infusions of insulin and 10% dextrose. After 24 hours of therapy, the bradycardia resolved and the patient’s hemodynamic condition stabilized with normalization of cardiac indices. On day 5 the patient was transferred to the medical unit, and on day 8 she was discharged to psychiatric care.
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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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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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Greene SL, Gawarammana I, Wood DM, Jones AL, Dargan PI. Relative safety of hyperinsulinaemia/euglycaemia therapy in the management of calcium channel blocker overdose: a prospective observational study. Intensive Care Med 2007; 33:2019-24. [PMID: 17622512 DOI: 10.1007/s00134-007-0768-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Accepted: 06/08/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine the clinical safety of hyperinsulinaemia/euglycaemia therapy (HIET) in calcium channel blocker (CCB) poisoning. DESIGN A prospective observational study examining biochemical and clinical outcomes of a HIET protocol administered under local poisons centre guidance. SETTING Critical care settings. PATIENTS Seven patients with significant CCB toxicity [systolic blood pressure (BP) <90 mmHg] treated with HIET. INTERVENTIONS HIET was commenced after correction of any pre-existing hypoglycaemia ([blood glucose]<65 mg/dl) or hypokalaemia ([K+]<3.5mmol/l). A quantity of 50 ml of 50% intravenous dextrose was followed by a loading dose (1 unit/kg) of intravenous short-acting insulin and an insulin maintenance infusion (0.5-2.0 units/kg/h). Euglycaemia was maintained using 5-10% dextrose infusions. Potassium was maintained within low normal range (3.8-4.0 mmol/l). MEASUREMENTS AND RESULTS Six patients survived. All patients received fluids, calcium, and conventional inotropes. Three patients (who all ingested diltiazem) received an insulin-loading dose; all experienced a significant sustained rise in systolic BP (>10 mmHg) during the first hour of HIET. Systolic BP did not increase significantly in four patients who did not receive insulin loading. Single episodes of non-clinically significant biochemical hypoglycaemia and hypokalaemia were recorded in one and two patients respectively. Hypoglycaemia was not recorded in any patient administered HIET during the 24[Symbol: see text]h following CCB ingestion. CONCLUSIONS HIET used to treat CCB-induced cardiovascular toxicity is a safe intervention when administered in a critical care setting. Maximal HIET efficacy may be obtained when HIET is administered in conjunction with conventional therapy relatively early in the course of severe CCB poisoning when insulin resistance is high.
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Affiliation(s)
- Shaun L Greene
- Medical Toxicology Unit, Guy's and St. Thomas Poisons Unit, Guy's and St. Thomas' NHS Foundation Trust, Avonley Rd, New Cross, SE14 5ER London, UK.
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Verbrugge LB, van Wezel HB. Pathophysiology of Verapamil Overdose: New Insights in the Role of Insulin. J Cardiothorac Vasc Anesth 2007; 21:406-9. [PMID: 17544895 DOI: 10.1053/j.jvca.2007.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2006] [Indexed: 01/23/2023]
Affiliation(s)
- Lisette B Verbrugge
- Department of Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands.
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Abstract
A case of severe amlodipine overdose with only mild symptoms is described. Plasma concentrations of amlodipine were measured in serial samples by gas chromatography. There was no concomitant overdose. The present case is compared with previous reported cases of amlodipine overdose where patients all developed severe symptoms. We conclude that amlodipine overdose does not always cause severe symptoms.
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Vogt S, Mehlig A, Hunziker P, Scholer A, Jung J, González AB, Weinmann W, Marsch S. Survival of severe amlodipine intoxication due to medical intensive care. Forensic Sci Int 2006; 161:216-20. [PMID: 16872774 DOI: 10.1016/j.forsciint.2006.02.051] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2005] [Revised: 02/03/2006] [Accepted: 02/03/2006] [Indexed: 10/24/2022]
Abstract
We report the case of attempted suicide with amlodipine, chlorthalidone and mefenamic acid and subsequent medical intensive care measures which resulted in total recovery of a 42-year-old male. After admission to the medical intensive care unit the intoxicated patient was deeply hypotensive and needed fluid replacement, dobutamine and norepinephrine. Additionally insulin and calcium gluconate were given. Since hypotension persisted and the patient developed oliguria, terlipressin was applied and finally showed an effect on blood pressure and on urinary output. A volume overload of 7 L in the first 24 h resulted in a pulmonary edema. The patient was started on non-invasive ventilation with continuous positive airway pressure (CPAP) and frusemide was added to the therapy with good success. Quantitative determination of amlodipine in plasma samples was performed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). The highest amlodipine concentrations was measured in the plasma sample collected approximately 8 h after ingestion of the drug, and was 393 microg/L. Four days later, it was possible to stop the treatment with catecholamines, at that time the amlodipine plasma concentration had declined to 132 microg/L, still tenfold higher than therapeutic (5-18 microg/L). Elimination half-life of amlodipine is approximately 55 h. After 6 days in the intensive care unit the patient was transferred to psychiatric treatment. Intensive care management and plasma levels in this intoxication case are compared to data from literature on other cases.
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Affiliation(s)
- Susanne Vogt
- Institute of Forensic Medicine, University Hospital, Freiburg, Germany
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Lheureux PER, Zahir S, Gris M, Derrey AS, Penaloza A. Bench-to-bedside review: hyperinsulinaemia/euglycaemia therapy in the management of overdose of calcium-channel blockers. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:212. [PMID: 16732893 PMCID: PMC1550937 DOI: 10.1186/cc4938] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Hyperinsulinaemia/euglycaemia therapy (HIET) consists of the infusion of high-dose regular insulin (usually 0.5 to 1 IU/kg per hour) combined with glucose to maintain euglycaemia. HIET has been proposed as an adjunctive approach in the management of overdose of calcium-channel blockers (CCBs). Indeed, experimental data and clinical experience, although limited, suggest that it could be superior to conventional pharmacological treatments including calcium salts, adrenaline (epinephrine) or glucagon. This paper reviews the patho-physiological principles underlying HIET. Insulin administration seems to allow the switch of the cell metabolism from fatty acids to carbohydrates that is required in stress conditions, especially in the myocardium and vascular smooth muscle, resulting in an improvement in cardiac contractility and restored peripheral resistances. Studies in experimental verapamil poisoning in dogs have shown that HIET significantly improves metabolism, haemodynamics and survival in comparison with conventional therapies. Clinical experience currently consists only of a few isolated cases or short series in which the administration of HIET substantially improved cardiovascular conditions in life-threatening CCB poisonings, allowing the progressive discontinuation of vasoactive agents. While we await further well-designed clinical trials, some rational recommendations are made about the use of HIET in severe CBB overdose. Although the mechanism of action is less well understood in this condition, some experimental data suggesting a potential benefit of HIET in β-adrenergic blocker toxicity are discussed; clinical data are currently lacking.
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Affiliation(s)
- Philippe E R Lheureux
- Acute Poisoning Unit, Department of Emergency Medicine, Erasme University Hospital, 808 route de Lennik, B 1070 Brussels, Belgium.
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Abstract
More than 50% of the toxic-exposure calls to US poison centers involve children. Although most of these exposures are nontoxic, there are several products and medications that are widely available to the pediatric population that can lead to severe toxicity or even death. With some of these medications, death or severe symptoms can occur with the ingestion of only a small amount. It is important that the clinician be familiar with presenting signs and symptoms of potentially toxic ingestions and is able to initiate a therapeutic and life-saving intervention. This article reviews some of the deadlier ingestions that children may be exposed to.
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Affiliation(s)
- Keith Henry
- Emergency Medicine Department, Saint John's Hospital, Maplewood, MN 55109-1169, USA
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Abstract
The diagnoses and subsequent treatment of poisoned patients manifesting cardiovascular compromise challenges the most experienced emergency physician. Numerous drugs and chemicals cause cardiac and vascular disorders. Despite widely varying indications for therapeutic use, many agents share a common cardiovascular pharmacologic effect if taken in overdose. Standard advanced cardiac life support protocol care of these patients may not apply and may even result in harm if followed. This chapter discusses com-mon cardiovascular toxins and groups them into their common mechanisms of toxicity. Multiple agents exist that result in human cardiovascular toxicity. The management of the toxicity of each agent should follow a rationale approach. The first step in the care of all poisoned patients focuses on good supportive care.
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Affiliation(s)
- Christopher P Holstege
- Blue Ridge Poison Center, Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia, Charlottesville, 22908-0774, USA.
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Wood DM, Wright KD, Jones AL, Dargan PI. Metaraminol (Aramine) in the management of a significant amlodipine overdose. Hum Exp Toxicol 2005; 24:377-81. [PMID: 16119252 DOI: 10.1191/0960327105ht538oa] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To report a patient with a significant amlodipine self-poisoning who failed to clinically respond to conventional treatment and was managed with metaraminol (Aramine). PATIENT A 43-year old male presenting after ingestion of 560 mg amlodipine, who failed to respond clinically to treatment with fluid resuscitation, calcium salts, glucagon and norepinephrine/epinephrine inotropic support. MAIN RESULTS Following a loading bolus of 2 mg and intravenous infusion (83 microg/min) of metaraminol (Aramine) there was improvement in his blood pressure, cardiac output and urine output. CONCLUSIONS This is the first case report of the beneficial use of metaraminol (aramine) in the management of significant amlodipine poisoning unresponsive to conventional therapy.
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Affiliation(s)
- D M Wood
- Pharmacology and Clinical Pharmacology, Department of Basic Medical Sciences, St George's Hospital Medical School, Jenner Wing, Cranmer Terrace, London SW17 ORE, UK.
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35
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Rygnestad T, Moen S, Wahba A, Lien S, Ingul CB, Schrader H, Knapstad SE. Severe poisoning with sotalol and verapamil. Recovery after 4 h of normothermic CPR followed by extra corporeal heart lung assist. Acta Anaesthesiol Scand 2005; 49:1378-80. [PMID: 16146479 DOI: 10.1111/j.1399-6576.2005.00709.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In acute poisoning with beta-blocking drugs and calcium-channel blockers patients may present with serious symptoms. We present a case of life-threatening sotalol and verapamil intoxication in a 29-year-old female suffering from depression. She was admitted to our hospital a few hours after she had taken 3.6 g verapamil and 4.8 g sotalol. On being found the patient was breathing and had a palpable pulse. On admission the patient experienced a cardiovascular collapse and CPR was started. Echocardiography confirmed cardiac standstill. After 4 h of normothermic CPR, extra corporeal heart lung assist (ECHLA) was established. Vasoactive drugs could be stopped after 2 days with ECHLA, and after 5 days the patient was extubated. The patient experienced several complications (intestinal bleeding, transient nerve paralysis, and renal failure due to rhabdomyolysis) but made a complete recovery and started working 6 months after the poisoning. She was no longer depressed.
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Affiliation(s)
- T Rygnestad
- St. Olavs. Hospital, Trondheim University Hospital, Trondheim, Norway.
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Mégarbane B, Karyo S, Baud FJ. The role of insulin and glucose (hyperinsulinaemia/euglycaemia) therapy in acute calcium channel antagonist and beta-blocker poisoning. ACTA ACUST UNITED AC 2005; 23:215-22. [PMID: 15898827 DOI: 10.2165/00139709-200423040-00002] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The inotropic effect of insulin has been long established. High-dose (0.5-1 IU/kg/hour) insulin, in combination with a glucose infusion to maintain euglycaemia (hyperinsulinaemia/euglycaemia therapy), has been proposed as a treatment for calcium channel antagonist (CCA) and beta-adrenoceptor antagonist (beta-blocker) poisonings. However, the basis for its beneficial effect is poorly understood.CCAs inhibit insulin secretion, resulting in hyperglycaemia and alteration of myocardial fatty acid oxidation. Similarly, blockade of beta(2)-adrenoceptors in beta-blocker poisoning results in impaired lipolysis, glycogenolysis and insulin release. Insulin administration switches cell metabolism from fatty acids to carbohydrates and restores calcium fluxes, resulting in improvement in cardiac contractility. Experimental studies in verapamil poisoning have shown that high-dose insulin significantly improved survival compared with calcium salts, epinephrine or glucagon. In several life-threatening poisonings in humans, the administration of high-dose insulin produced cardiovascular stabilisation, decreased the catecholamine vasopressor infusion rate and improved the survival rate. In a canine model of propranolol intoxication, high-dose insulin provided a sustained increase in systemic blood pressure, cardiac performance and survival rate compared with glucagon or epinephrine. In contrast, insulin had no effect on heart rate and electrical conduction in the myocardium. In another study, high-dose insulin reversed the negative inotropic effect of propranolol to 80% of control function and normalised heart rate. High-dose insulin produced a significant decrease in the left ventricular end-diastolic pressure and a significant increase in the stroke volume and cardiac output. The vasodilator effect was explained by an enhanced cardiac output leading to withdrawal of compensatory vasoconstriction. No clinical studies have yet been performed. Although not effective in all cases, we recommend hyperinsulinaemia/euglycaemia therapy in patients with severe CCA poisoning who present with hypotension and respond poorly to fluid, calcium salts, glucagon and catecholamine infusion. However, careful monitoring of blood glucose and serum potassium concentrations is required to avoid serious adverse effects. More clinical data are needed before this therapy can be recommended in beta-blocker poisoning. There is a need for large prospective clinical trials to confirm safety and efficacy of hyperinsulinaemia/euglycaemia therapy in both CCA and beta-blocker poisoning.
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Affiliation(s)
- Bruno Mégarbane
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière - Université Paris 7, Paris, France.
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Shepherd G, Klein-Schwartz W. High-Dose Insulin Therapy for Calcium-Channel Blocker Overdose. Ann Pharmacother 2005; 39:923-30. [PMID: 15811898 DOI: 10.1345/aph.1e436] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE:To evaluate the evidence for using high-dose insulin therapy with supplemental dextrose and potassium in calcium-channel blocker (CCB) overdose.DATA SOURCES:Evidence of efficacy for high-dose insulin therapy with supplemental dextrose and potassium was sought by performing a search of MEDLINE and Toxline between 1966 and July 2004 using combinations of the terms calcium-channel blocker, overdose, poisoning, antidote, and insulin. Abstracts from the North American Congress of Clinical Toxicology for the years 1996–2003 were also reviewed.STUDY SELECTION AND DATA EXTRACTION:Identified articles, including animal studies, case reports, and case series, were evaluated for this review. No clinical trials were available.DATA SYNTHESIS:Animal models of CCB overdose demonstrate that high-dose insulin with supplemental dextrose and potassium was a more effective therapy than calcium, glucagon, or catecholamines. High-dose insulin appears to enhance cardiac carbohydrate metabolism and has direct inotropic effects. Published clinical experience is limited to 13 case reports where insulin was used after other therapies were failing; 12 of these patients survived. High-dose insulin therapy was beneficial for CCB-induced hypotension, hyperglycemia, and metabolic acidosis. Bradycardia and heart block resolved in some patients, but persisted in others.CONCLUSIONS:Based on animal data and limited human experience, as well as the inadequacies of available alternatives for patients with significant poisoning, high-dose insulin therapy warrants further study and judicious use in patients with life-threatening CCB poisoning.
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Affiliation(s)
- Greene Shepherd
- College of Pharmacy, University of Georgia, Augusta, GA, USA.
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Avramchik OA, Korotkova EI, Plotnikov EV, Lukina AN, Karbainov YA. Antioxidant and electrochemical properties of calcium and lithium ascorbates. J Pharm Biomed Anal 2004; 37:1149-54. [PMID: 15862699 DOI: 10.1016/j.jpba.2004.11.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2004] [Revised: 11/09/2004] [Accepted: 11/09/2004] [Indexed: 11/19/2022]
Abstract
The calcium and lithium pharmaceutical products have been widely used in medicine, especially at diseases of the mind. Bioactivity and toxically of novel complex ascorbates of calcium and lithium were considered in this work. Study of antioxidant properties of new forms of the compounds was carried out by differential pulse voltammetry. Cyclic voltammetry was used for investigation of their electrochemical properties in order to obtain information about electron-transfer reactions. The influence of these substances on the electrochemical oxygen reduction and its kinetic was also studied. As a result, the kinetic parameters interaction between reactive oxygen species and ascorbates of calcium and lithium were evaluated.
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Affiliation(s)
- O A Avramchik
- Department of Physical and Analytical Chemistry, Tomsk Polytechnic University, Lenin 30, 634050 Tomsk, Russia
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