BETA AND CALCIUM CHANNEL BLOCKER TOXICITY AND POISONING

Question 1

Approach to the Critically Ill Beta and Calcium Channel Blocker Toxicity and Poisoning

Answer 1

Monitor
Oxygen
Vitals
IV Access
ECG / Airway Equipment

AIRWAY / BREATHING
CNS Depression requiring airway protection is infrequent

Peri- and Post-intubation cardiac arrest is common

Optimize hemodynamics:
IVF resuscitation
Ketamine at 1/2 dose
Vasoactive infusion before and after intubation

CIRCULATION
Hypotension: 10-20 mL/kg IV crystalloid bolus PRN

POCUS:
heart (ejection fraction and wall motion)
vena cava (size and collapsibility)
lungs (pulmonary edema)

CCB TOXICITY:

Atropine 0.5 - 1 mg q 3-5 min (max 3 doses)

Calcium Gluconate 3-6 g IV q10-20 min

Calcium Chloride 1-2 g IV q 10-20 min

Vasoplegic Shock: Norepinephrine 0.05 - 0.3 mcg / kg / min

Cardiogenic Shock:
Epinephrine 0.05 - 2 mcg / kg / min

Myocardial Dysfunction:
Insulin Regular Monotherapy 1-20 units/kg IV bolus, followed by 1-2 units/kg/h infusion

AND

10% dextrose in water 3-5 mL/kg at 1.5-2x maintenance

BETA BLOCKER TOXICITY

Atropine 0.5 - 1 mg q 3-5 min (max 3 doses)

Glucagon:
3-10 mg IV bolus follwed by 3-5 mg / h infusion

Vasoplegic Shock: Norepinephrine 0.05 - 0.3 mcg / kg / min

Cardiogenic Shock:
Epinephrine 0.05 - 2 mcg / kg / min

Isoprotenerol:
20-60 mcg IV bolus followed by 1-20 mcg / min infusion

Myocardial Dysfunction:
Insulin Regular Monotherapy 1-20 units/kg IV bolus, followed by 1-2 units/kg/h infusion

AND

10% dextrose in water 3-5 mL/kg at 1.5-2x maintenance

DISABILITY
CNS Depression is infrequent

Question 2

History & Physical

Answer 2

Hypotension
Bradydysrhythmia
Shock
Death

Things to Ask:

What was taken

When was it taken (TIME)

How much was taken (DOSE AND NUMBER OF TABLETS)

Type of preparation (IMMEDIATE OR SUSTAINED RELEASE)

How it was taken (ROUTE)

What else was taken (CO-INGESTIONS?)

Why was it taken (INTENTIONAL VS ACCIDENTAL)

COLLATERAL INFORMATION: medication containers, EMS

ONSET OF SYMPTOMS

Look For:
Bradycardia > 50%
Hypotension > 50%
CNS Depression (less common)

Question 3

Investigations

Answer 3

Accucheck (part of inital assessment)

Hyperglycemia is common in CCB

Hypoglycemia is common in BB

CBC
lytes - hypokalemia may appear in CCB
creatinine
LFT
INR / PTT
Serum Osolarity
Osmolar gap
VBG
Lactate

Quantitave drug levels: (acetaminophen, salicylates, ethanol)

Urine Tox Screen
Pregnancy test
ECG
CXR (aspiration and pulmonary edema)

Question 4

Beta Blocker Toxicity Management

Answer 4

BETA BLOCKER TOXICITY

Atropine 0.5 - 1 mg q 3-5 min (max 3 doses)

Glucagon:
3-10 mg IV bolus follwed by 3-5 mg / h infusion

Vasoplegic Shock: Norepinephrine 0.05 - 0.3 mcg / kg / min

Cardiogenic Shock:
Epinephrine 0.05 - 2 mcg / kg / min

Isoprotenerol:
20-60 mcg IV bolus followed by 1-20 mcg / min infusion

Myocardial Dysfunction:
Insulin Regular Monotherapy 1-20 units/kg IV bolus, followed by 1-2 units/kg/h infusion

AND

10% dextrose in water 3-5 mL/kg at 1.5-2x maintenance

Question 5

Calcium Channel Blocker Toxicity

Answer 5

Atropine 0.5 - 1 mg q 3-5 min (max 3 doses)

Calcium Gluconate 3-6 g IV q10-20 min

Calcium Chloride 1-2 g IV q 10-20 min

Vasoplegic Shock: Norepinephrine 0.05 - 0.3 mcg / kg / min

Cardiogenic Shock:
Epinephrine 0.05 - 2 mcg / kg / min

Myocardial Dysfunction:
Insulin Regular Monotherapy 1-20 units/kg IV bolus, followed by 1-2 units/kg/h infusion

AND

10% dextrose in water 3-5 mL/kg at 1.5-2x maintenance