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Osman AF, Prasad RM, Marein S, O'Brien C. Multi-organ dysfunction as a presentation of calcium channel blocker intoxication. BMJ Case Rep 2022; 15:15/1/e245711. [PMID: 35039350 PMCID: PMC8768057 DOI: 10.1136/bcr-2021-245711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
SummaryWe report the case of a 73-year-old woman who intentionally ingested 400 mg of amlodipine in a suicidal attempt who initially presented with hypotension which persisted despite aggressive therapy with fluid resuscitation, multiple pressor support, high-dose insulin therapy and calcium infusion. Her haemodynamic instability evolved to include bradycardia requiring atropine and transcutaneous pacing. Eventually she required salvage therapy with intravenous lipid emulsion (ILE) therapy . Despite all aggressive therapy, she developed multi-organ failure resulting in death. The literature on high-dose insulin euglycaemic therapy (HIET) and ILE therapy shows mixed results with some showing significant improvement in haemodynamic status. In our case, it had no significant positive impact on the outcome.
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Affiliation(s)
| | | | - Shawn Marein
- Department of Pulmonary & Critical care, Sparrow Health System, Lansing, Michigan, USA
| | - Corey O'Brien
- Department of Pulmonary & Critical care, Sparrow Health System, Lansing, Michigan, USA
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Pellegrini JR, Munshi R, Tiwana MS, Abraham T, Tahir H, Sayedy N, Iqbal J. "Feeling the Blues": A Case of Calcium Channel Blocker Overdose Managed With Methylene Blue. Cureus 2021; 13:e19114. [PMID: 34868762 PMCID: PMC8627593 DOI: 10.7759/cureus.19114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
Amlodipine is a dihydropyridine calcium channel blocker (CCB) commonly used to treat hypertension. In the United States, approximately 9,500 cases of CCB intoxication due to deliberate or inadvertent overdose were reported to poison centers in 2002. We present a case of a patient who presented with CCB overdose complicated by acute respiratory distress syndrome (ARDS) and recalcitrant shock all of which resolved with methylene blue therapy. We present a case of a 56-year-old African American woman who presented to the emergency department (ED) after intentional ingestion of large amounts of multiple pills likely consisting of cyclobenzaprine, amlodipine, losartan, and ibuprofen following an argument with her boyfriend. Treatment included insulin drip, 10% dextrose, and norepinephrine drip which was titrated up. First insulin drip and 10% dextrose were titrated up; however, vasopressor-resistant hypotension persisted, and the decision was made to administer methylene blue. Over 9,500 cases of CCB toxicity were reported to poison centers in the US in 2002. Although no definitive treatment is outlined, first-line therapy consists of IV calcium, high-dose insulin, and vasopressor support with either norepinephrine or epinephrine. Traditionally, methylene blue is used for methemoglobinemia and in cardiothoracic ICUs for post coronary artery bypass vasoplegia. It acts by selectively inhibiting nitric oxide-activated cyclic guanylate cyclase leading to decreased vasodilation of arteriolar smooth muscles improving vascular tone and systemic vascular resistance. In severe amlodipine overdose, experimental models demonstrate methylene blue improves HR and mean arterial pressure (MAP), improving survival rate. With few adverse side effects (green-tinged discoloration of urine, saliva, tears, and bodily fluids), methylene blue should be explored and implemented in the treatment of CCB overdose with refractory hypotension and ARDS.
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Affiliation(s)
| | - Rezwan Munshi
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Muhammad S Tiwana
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Tinu Abraham
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Hira Tahir
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Najia Sayedy
- Pulmonary and Critical Care, Nassau University Medical Center, East Meadow, USA
| | - Javed Iqbal
- Pulmonary and Critical Care, Nassau University Medical Center, East Meadow, USA
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3
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Calcium Channel Blocker Intoxication: A Critical Care Transport Perspective. Air Med J 2020; 40:69-72. [PMID: 33455631 DOI: 10.1016/j.amj.2020.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
Calcium channel blockers (CCBs) have seen an increase in rate of non-therapeutic exposure that is both accidental and intentional in nature. Patients experiencing the toxic effects of a CCB overdose are resource intensive and can quickly outstrip the capabilities of local health systems, necessitating transfer to larger tertiary or quaternary care centers. We present a case of intentional non-dihydropyridine CCB overdose and toxicity in a 20-year-old patient requiring initial stabilization at a referring critical access emergency department with continuation of treatment and support during a 60-minute rotor wing transport from the referring hospital to an academic quaternary care center. Emphasis is placed on the unique challenges in resuscitation and ongoing critical care administration during the transport phase of care. Proper stabilization of patients, planning, and consideration of potential problems associated with transport can help minimize stresses and risk of the transport, improving the outcome of extremely ill patients even under challenging circumstances.
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Bartlett JW, Walker PL. Management of Calcium Channel Blocker Toxicity in the Pediatric Patient. J Pediatr Pharmacol Ther 2019; 24:378-389. [PMID: 31598101 DOI: 10.5863/1551-6776-24.5.378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Calcium channel blockers (CCBs) are commonly prescribed cardiovascular medications used in several disease states including hypertension, coronary artery disease, and atrial fibrillation. Inadvertent exposure or intentional overdose of CCBs may result in hypotension, bradycardia, dysrhythmias, conduction disturbances, and hyperglycemia. In the most severe cases, CCB toxicity can lead to rapid cardiovascular collapse. Given the risk of significant morbidity and mortality associated with CCB toxicity, it is important that health care professionals are able to recognize and treat patients who present with a potentially toxic ingestion. Due to the paucity of literature in managing pediatric patients with severe CCB toxicity, treatment strategies for pediatric patients are mostly limited to case reports and extrapolation from expert consensus recommendations for adults. All pediatric patients with a potentially toxic CCB ingestion should be evaluated in the emergency department. Activated charcoal may be considered for asymptomatic patients presenting within an hour of ingestion. Symptomatic patients should be placed under cardiac monitoring and treatments to stabilize the patient's hemodynamics should not be delayed. Traditional first-line IV therapies include small boluses of fluids, calcium, and vasopressors. High-dose insulin has been proposed to independently increase inotropy and improve CCB-induced hypoinsulinemia and insulin resistance that results from CCB inhibition of insulin release from pancreatic β-islet cells. High-dose insulin is recommended as first-line therapy for adults and shows promising efficacy and safety in several pediatric case reports. Intravenous lipid emulsion may be considered in patients who are refractory to first-line therapies, although the data for pediatric patients are extremely limited.
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Abstract
Treating a patient of amlodipine-atenolol poisoning is nightmare for a physician. In high dose both the drugs individually cause severe bradycardia and hypotension. In combination they cause severe cardiovascular depression. Here we report a case of 66-year-old obese, hypertensive, depressed male, who presented to emergency 9 hours after consumption of 25 tablets of amlodipine-atenolol (5 mg+50 mg). On evaluation, he had refractory bradycardia, hypotension and acute kidney injury (AKI). Eventually he developed cardiac arrest. He was revived after 5 minutes of cardio-pulmonary resuscitation (CPR). He was successfully managed with gastric lavage, fluids, inotropes, atropine, isoprenaline and subsequently with calcium gluconate infusion, high-dose insulin euglycemia therapy (HIET) and lipid emulsion therapy. Glucagon infusion was also planned but it was not available. Patient hemodynamics improved and on 8th day he got the discharge. Our case exemplifies the importance of timely and aggressive management of lethal overdose of amlodipine-atenolol poisoning. How to cite this article: Tale S, Kumar M, Ghosh S, Bhalla A. A Case of Life-threatening Amlodipine and Atenolol Overdose. Indian J Crit Care Med 2019;23(6):281–283.
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Affiliation(s)
- Sudheer Tale
- Department of Internal medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mohan Kumar
- Department of Internal medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Soumitra Ghosh
- Department of Internal medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Barriers and Facilitators of Intensivists' Adherence to Hyperinsulinemia-Euglycemia Therapy in the Treatment of Calcium Channel Blocker Poisoning. J Med Toxicol 2018; 14:283-294. [PMID: 30047044 DOI: 10.1007/s13181-018-0676-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/06/2018] [Accepted: 07/09/2018] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Adherence to poison center (PC) recommendations for the management of calcium channel blocker (CCB) poisoning is inconsistent. This study aimed to identify behaviors that determine adherence to hyperinsulinemia-euglycemia therapy (HIET) for CCB poisoning. METHODS Semistructured interviews were conducted involving a convenience sample of 18 intensivists. Interview responses were analyzed using the theoretical domains framework (TDF) to identify relevant domains influencing physician adherence to HIET. Two independent reviewers performed qualitative content analysis of the interview transcripts to identify beliefs influencing decisions to initiate HIET. Initially, beliefs were classified and frequencies reported as being likely to facilitate, likely to decrease, or unlikely to affect adherence. Subsequently, beliefs were linked to a domain within the TDF. Based on the potential impact on physician behavior and frequency of reported behavior, we selected the most relevant domains likely to influence physician adherence to HIET for CCB poisoning. RESULTS Positive beliefs were identified in the following domains: "behavioral regulation" (e.g., algorithm for adjustment of perfusions), "belief about capabilities" (e.g., confidence about being able to manage HIET), "belief about consequences" (e.g., fear of clinical deterioration), and "reinforcement" (e.g., clinical instability). Negative beliefs were identified in the following domains as "nature of behavior" (e.g., preference for vasopressors over HIET) and "environmental context and resources" (e.g., accessing dextrose 50% and increased nurse workload). CONCLUSION This qualitative study identified potential behavioral targets for future implementation strategies to address to improve adherence to HIET.
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Baker KA, Austin EB, Wang GS. Antidotes: Familiar Friends and New Approaches for the Treatment of Select Pediatric Toxicological Exposures. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Joseph Antony J, George Mundadan N, Sherief R, Mukker P, Ignatius T J. AMLODIPINE OVERDOSE - A TRICKY CASE SCENARIO. JOURNAL OF EVOLUTION OF MEDICAL AND DENTAL SCIENCES 2017; 6:1464-1465. [DOI: 10.14260/jemds/2017/320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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9
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Jellinek-Cohen SP, Tolento A, Howland MA. Before and After Study of Pharmacists' and Students' Knowledge of Two Novel Antidotes: High-Dose Insulin Euglycemia and Intravenous Fatty Acid Emulsion 20. Hosp Pharm 2015; 50:586-94. [PMID: 26448670 DOI: 10.1310/hpj5007-586] [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: 11/11/2022]
Abstract
PURPOSE To assess pharmacists' and students' knowledge of high-dose insulin euglycemia (HIE) and intravenous fatty acid emulsion 20% (IFE) and to see whether it improved after an educational intervention. METHODS A survey to assess the knowledge about the use of HIE and IFE as antidotes was e-mailed to practicing pharmacists, pharmacy residents, and students prior to and following an educational intervention. Fact sheets on the antidotes were developed in conjunction with the New York City Poison Control Center and were used as the educational intervention in this study. The impact of exposure to the intervention was measured by comparing the number of correct responses per question on the pre- and posttests and the mean pre- and posttest scores using chi-square and t tests, respectively. RESULTS Most respondents felt either not at all or only somewhat comfortable with managing a toxicologic emergency. There was a statistically significant difference in mean scores on the pretest and posttest (2.9 vs 5.45; P = .001) and for the number of participants giving correct responses for each question before and after education: 52.4% of respondents answered "I don't know" to the questions prior to education versus 21.2% after education (P < .001). Fewer respondents felt not at all comfortable managing a toxicologic emergency after the educational intervention (42.4 vs 50.3%; P < .001). CONCLUSION Pharmacists and students reported little comfort in managing toxicological emergencies in general and have limited baseline knowledge about these agents. Educational interventions can significantly improve knowledge. Prior familiarity with these newer antidotes should reduce delays in their administration in an emergency.
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Affiliation(s)
- Samantha P Jellinek-Cohen
- Assistant Clinical Professor, St. John's University, College of Pharmacy and Health Sciences , Jamaica, New York ; Emergency Medicine Clinical Pharmacy Specialist, Mount Sinai Beth Israel , New York, New York
| | - Amanda Tolento
- Critical Care Clinical Pharmacy Specialist, St. Francis Hospital-The Heart Center , Roslyn, New York
| | - Mary Ann Howland
- Clinical Professor of Pharmacy, St. John's University, College of Pharmacy and Health Sciences , Jamaica, New York ; Adjunct Professor of Emergency Medicine, New York University School of Medicine , New York, New York ; Senior Consultant in Residence, New York City Poison Center, Bellevue Hospital Center and New York University Langone Medical Center , New York, New York
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Naha K, Suryanarayana J, Aziz RA, Shastry BA. Amlodipine poisoning revisited: Acidosis, acute kidney injury and acute respiratory distress syndrome. Indian J Crit Care Med 2014; 18:467-9. [PMID: 25097362 PMCID: PMC4118515 DOI: 10.4103/0972-5229.136078] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We report the case of an 18-year-old girl presenting with shock following ingestion of 85 mg of amlodipine and 850 mg of atenolol with suicidal intent. Subsequently, the patient developed severe metabolic acidosis, acute kidney injury, and acute respiratory distress syndrome, which were managed conservatively. The patient ultimately made a full recovery. Given the popularity of amlodipine and atenolol as antihypertensive drugs in this part of the world, it is likely that more such cases will be encountered in the future. Physicians should be aware of the severe complications that can develop with amlodipine overdose.
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Affiliation(s)
- Kushal Naha
- Department of Medicine, Kasturba Hospital, Manipal, Karnataka, India
| | - J Suryanarayana
- Department of Medicine, Kasturba Hospital, Manipal, Karnataka, India
| | - Riffat Abdul Aziz
- Department of Medicine, Kasturba Hospital, Manipal, Karnataka, India
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11
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Place des inotropes en réanimation. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0860-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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12
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Critical Care Management ofVerapamil and Diltiazem Overdose With a Focus on Vasopressors: A 25-Year Experience at a Single Center. Ann Emerg Med 2013; 62:252-8. [DOI: 10.1016/j.annemergmed.2013.03.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 03/04/2013] [Accepted: 03/12/2013] [Indexed: 11/21/2022]
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Maton BL, Simmonds EE, Lee JA, Alwood AJ. The use of high-dose insulin therapy and intravenous lipid emulsion to treat severe, refractory diltiazem toxicosis in a dog. J Vet Emerg Crit Care (San Antonio) 2013; 23:321-7. [PMID: 23656275 DOI: 10.1111/vec.12053] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 03/28/2013] [Indexed: 11/29/2022]
Affiliation(s)
| | - Erin E. Simmonds
- Guardian Veterinary Centre; 5620 99; th; Street; Edmonton; AB; T6E 1V2; Canada
| | - Justine A. Lee
- Pet Poison Helpline; 3600 American Boulevard West, Suite 770; Bloomington; MN; 55431
| | - Amy J. Alwood
- VCA Boston Road Animal Hospital; 1235 Boston Road; Springfield; MA; 01119
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Olson KR. What is the best treatment for acute calcium channel blocker overdose? Ann Emerg Med 2013; 62:259-61. [PMID: 23567061 DOI: 10.1016/j.annemergmed.2013.03.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 03/13/2013] [Accepted: 03/21/2013] [Indexed: 11/29/2022]
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A survival case in a severe amlodipine intoxication. Case Rep Cardiol 2013; 2013:842606. [PMID: 24826296 PMCID: PMC4007782 DOI: 10.1155/2013/842606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 03/03/2013] [Indexed: 11/17/2022] Open
Abstract
Calcium channel blockers (CCBs) are prescribed in a wide variety of cardiovascular conditions. Nevertheless, they remain a major cause of cardiovascular drug overdose that often leads to a lethal outcome. We report the case of an intoxication with amlodipine, which caused severe hypotension, in a young woman. The patient was initially treated with fluids, calcium gluconate, and Dobutamine without effect. She then received hyperinsulinemia euglycemia therapy. A rise in blood pressure (BP) was observed two hours after insulin was started. The next day, the insulin infusion was stopped and seven days later the patient was discharged from the hospital after psychiatric consultation. The positive inotropic effect of insulin therapy in our patient supports previous findings that suggest its use as a first-line therapy in the management of CCBs overdose.
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Affiliation(s)
- J Devasahayam
- Department of Internal Medicine, St Mary’s Health Center, St Louis, MO 63117, USA
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17
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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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18
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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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Abstract
Clinicians are frequently confronted with toxicological emergencies and challenged with the task of correctly identifying the possible agents involved and providing appropriate treatments. In this review article, we describe the epidemiology of overdoses, provide a practical approach to the recognition and diagnosis of classic toxidromes, and discuss the initial management strategies that should be considered in all overdoses. In addition, we evaluate some of the most common agents involved in poisonings and present their respective treatments. Recognition of toxidromes with knowledge of indications for antidotes and their limitations for treating overdoses is crucial for the acute care of poisoned patients.
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Affiliation(s)
- Simon W Lam
- Cleveland Clinic, Department of Pharmacy, Cleveland, OH 44195, USA.
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20
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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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Abstract
Calcium channel blockers continue to be used for the management of a wide variety of adult and pediatric conditions including hypertension, angina pectoris, atrial arrhythmias, Raynaud phenomenon, and migraine headaches. With increased use comes increased potential for misuse and abuse. This article serves as a review of calcium channel blocker physiology with emphasis on presentation and management of the pediatric patient with calcium channel blocker toxicity.
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Madden KM, Tedder G, Lockhart C, Meneilly GS. Euglycemic hyperinsulinemia alters the response to orthostatic stress in older adults with type 2 diabetes. Diabetes Care 2008; 31:2203-8. [PMID: 18716048 PMCID: PMC2571046 DOI: 10.2337/dc08-1058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Insulin has opposing influences on blood pressure by simultaneously increasing adrenergic activity and vasodilatating peripheral blood vessels. In this study, we sought to determine whether hyperinsulinemia affects tilt table responses in older adults with type 2 diabetes not complicated by orthostatic hypotension. RESEARCH DESIGN AND METHODS Twenty-two older adults (mean age 71.7 +/- 1.1) with diet-controlled or oral hypoglycemic drug-controlled type 2 diabetes were recruited. All subjects with orthostatic hypotension, diabetic nephropathy, and sensory neuropathy were excluded. Subjects underwent euglycemic-hyperinsulinemic clamp and placebo "sham clamp" sessions. Sequential euglycemic-hyperinsulinemic clamps were performed for 2 h at 40 mU x m(-2) x min(-1) (low dose) and 2 h at 80 mU x m(-2) x min(-1) (high dose), and each was followed by a head-up tilt table test at 70 degrees C for 10 min. RESULTS There were no incidents of presyncope during the sham clamp, whereas there were four presyncopal events during both the low-dose and high-dose tilts. Although the low-dose clamp showed no difference in the response between sessions (two-way ANOVA), subjects demonstrated a significantly larger decrease in mean arterial pressure (P = 0.005) and diastolic blood pressure (P = 0.08) during the high-dose tilt. Doppler measures of middle cerebral artery velocity were no different between the two sessions at either dose. CONCLUSIONS The vasodilatory response to insulin can unmask orthostatic intolerance in older adults with type 2 diabetes, resulting in presyncopal symptoms. This could contribute to orthostatic hypotension in combination with other factors such as hyperthermia, hypovolemia, and adverse effects from medications.
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Affiliation(s)
- Kenneth M Madden
- Department of Medicine, Division of Geriatric Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
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Abstract
Amlodipine overdose is only scarcely reported from India. We report two cases of near fatal Amlodipine overdose managed in our ICU with fluid, vasopressors, calcium infusion and Glucagon. Literature is reviewed and other treatment modalities discussed.
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Affiliation(s)
- Supradip Ghosh
- Fortis-Escorts Hospital, Neelam Bata Road, Faridabad, Haryana-121 001, India.
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24
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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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