From the Guidelines
The initial management for a calcium channel blocker overdose should prioritize administering vasopressors for hypotension and high-dose insulin therapy, as recommended by the 2023 American Heart Association guidelines 1.
Key Interventions
- Provide supportive care including airway management, intravenous access, and cardiac monitoring.
- Administer activated charcoal (1 g/kg) if the patient presents within 1-2 hours of ingestion and has a protected airway.
- Give intravenous calcium as a first-line antidote - calcium chloride 10% (10-20 mL) or calcium gluconate 10% (30-60 mL), which can be repeated every 15-20 minutes for 3-4 doses based on clinical response, although its use is considered reasonable but not strongly recommended 1.
- Start high-dose insulin therapy with an insulin bolus of 1 unit/kg followed by an infusion at 0.5-1 unit/kg/hour, along with dextrose to maintain euglycemia, as it is recommended for hypotension due to CCB poisoning 1.
- Administer intravenous fluids for hypotension, and if blood pressure remains low, initiate vasopressors (norepinephrine or epinephrine), which are recommended for hypotension from CCB poisoning 1.
Additional Considerations
- For severe cases unresponsive to these measures, consider extracorporeal life support techniques such as VA-ECMO for cardiogenic shock due to CCB poisoning that is refractory to pharmacological interventions, as it may be reasonable 1.
- The routine use of intravenous lipid emulsion (ILE) therapy for CCB poisoning is not recommended, according to the 2023 American Heart Association guidelines 1.
Prioritization of Care
The management of calcium channel blocker overdose prioritizes interventions that address hypotension and cardiac dysfunction, with a focus on vasopressors and high-dose insulin therapy as first-line treatments, based on the most recent guidelines from 2023 1.
From the FDA Drug Label
10 OVERDOSAGE Overdosage of Calcium Gluconate Injection may result in hypercalcemia. Symptoms of hypercalcemia typically develop when the total serum calcium concentration is ≥12 mg/dL. Neurologic symptoms include depression, weakness, fatigue, and confusion at lower levels, with patients experiencing hallucinations, disorientation, hypotonicity, seizures, and coma. Effects on the kidney include diminished ability to concentrate urine and diuresis. If overdose of Calcium Gluconate Injection occurs immediately discontinue administration and provide supportive treatments to restore intravascular volume as well as promote calcium excretion in the urine if necessary.
The initial management for a calcium channel blocker overdose is not directly addressed in the provided drug label, as it discusses the overdose of Calcium Gluconate Injection, which is used to treat conditions caused by low calcium levels.
- Discontinuation of the offending agent is a general principle in overdose management.
- Supportive care may be necessary to manage symptoms and prevent further complications. 2
From the Research
Initial Management of Calcium Channel Blocker Overdose
The initial management of calcium channel blocker overdose involves supportive care measures, including:
- Administration of glucagon, calcium, catecholamines, phosphodiesterase inhibitors, and insulin 3
- High-dose insulin therapy as an emerging choice for initial therapy in severe overdoses 4
- Gut decontamination with charcoal, or whole bowel irrigation or multiple-dose charcoal in the setting of extended-release products 5
- Supportive care, including the use of phosphodiesterase inhibitors, adrenergic agents, cardiac pacing, balloon pump, or extracorporeal bypass if antidotal therapy is not effective 5
Specific Treatment Options
Specific treatment options for calcium channel blocker overdose include:
- Administration of calcium salts, which may be given in bolus doses or as a continuous infusion 5
- Insulin administration to increase cardiac inotropy and survival, with glucose administration to maintain euglycaemia 5
- Vasopressors and high-dose insulin euglycaemia treatment 6
- Advanced treatments, such as extracorporeal membrane oxygenation (ECMO), may be indicated depending on the severity of toxicity and specific agents involved 6
Patient Evaluation and Monitoring
Patients with calcium channel blocker overdose should be carefully evaluated, including: