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US, Canadian and European critical care and toxicology societies recently published a consensus recommendation is the management of CCB poisoning.
Bottom line:
1. First line therapy remains unchanged: IV calcium, atropin, high-dose insulin (HIE) therapy, vasopressor support (norepinephrine and/or epinephrine).
2. Refractory to first line therapy: increase HIE, lipid-emulsion, transvenous pacemaker
3. Refractory shock, periarrest or cardiac arrest: Above (#1 & #2) plus ECMO if available.
Additional Information
Overall, there has not been a signficant changes to the current management of CCB poisoning. However, there is a nice flow chart of the algorithm/recommendation in the article. The authors note that the "level of evidenc was very low" for all intervention.
Briefly:
A. asymptomatic patients
- Observation up to 24 hours for potentially toxic ingestion
- GI decontamination
B. First line therapy
- IV calcium
- atropine in symptomatic bradycardia or conduction disturbance
- high-dose insulin therapy
- norepineprhine and/or epinephrine
- In the presence of cardiogenic shock: epinephrine or dobutamine
C. Refractory to first line therapy
- Incremental increase of high-dose insulin therapy (up to 10 unit/kg/hr) in presence of myocardia dysfunction
- IV lipid-emulsion therapy
- pacemaker in the presence of unstable bradycardia or high-grade AV block
D. Refratory shock or periarrest
- incremental increase of high-dose insulin therapy
- IV lipid-emulsion therapy if not administered
- pacermaker in the presence of unstable bradycardia or high-grade AV block in absence of myocardial dysfunction if not initated previously
- ECMO, if available
E. Cardiac arrest
- IV calcium
- ACLS guided resuscitation
- IV lipid-emulsion therapy
- ECMO
References
St-Onge, M et al. Experts consensus recommendations for the management of calcium channel blocker poisoning in adults. Crit Care Med 2016 (http://journals.lww.com/ccmjournal/Abstract/publishahead/Experts_Consensus_Recommendations_for_the.96757.aspx)