From the Guidelines
The treatment of calcium channel blocker (CCB) overdose requires prompt, aggressive intervention with a multi-modal approach, prioritizing high-dose insulin euglycemia therapy and vasopressors like norepinephrine, as recommended by the most recent guidelines 1.
Initial Management
The initial management of CCB overdose includes gastrointestinal decontamination with activated charcoal if the patient presents within 1-2 hours of ingestion. Hemodynamic support is crucial, starting with IV fluids for hypotension.
Hemodynamic Support
Hemodynamic support is crucial, starting with IV fluids for hypotension, followed by vasopressors like norepinephrine or vasopressin if needed. High-dose insulin euglycemia therapy is particularly effective, starting with regular insulin bolus of 1 unit/kg followed by infusion at 0.5-1 unit/kg/hour, along with dextrose to maintain normoglycemia 1.
Additional Therapies
Other therapies that may be beneficial include:
- High-dose calcium administration, typically given as calcium gluconate 30-60 mL of 10% solution or calcium chloride 10-20 mL of 10% solution, repeated every 15-20 minutes until hemodynamic improvement occurs 1
- Glucagon can be administered as a 5-10 mg IV bolus followed by 1-5 mg/hour infusion 1
- For severe cases unresponsive to conventional therapy, lipid emulsion therapy (1.5 mL/kg bolus of 20% lipid emulsion followed by 0.25 mL/kg/minute infusion) may be beneficial, although its effectiveness is debated 1
- Methylene blue (1-2 mg/kg IV) can help with vasodilatory shock 1
- In life-threatening cases, extracorporeal membrane oxygenation may be necessary 1
Key Considerations
The choice of vasopressors, such as norepinephrine, is crucial, and high-dose insulin euglycemia therapy has been shown to improve inotropy in patients with severe cardiogenic shock from CCB poisoning 1. The use of VA-ECMO for patients with refractory cardiogenic shock after CCB overdose is described in case series, with reported survival rates as high as 77% 1.
From the Research
Treatment Options for Calcium Channel Blocker Overdose
The treatment for calcium channel blocker (CCB) overdose includes various approaches, such as:
- Administration of calcium salts, which can be given in bolus doses or as a continuous infusion 2
- High-dose insulin therapy, which has been used effectively to increase cardiac inotropy and survival 3, 4, 2, 5
- Glucagon, which is a specific antidote for CCB overdose 3, 2
- Intravenous lipid emulsion therapies, which have been successful in treating CCB overdoses 3, 4
- Levosimendan, a calcium sensitizer, which has been considered in severe CCB poisoning 6
- Supportive care, including the use of phosphodiesterase inhibitors, adrenergic agents, cardiac pacing, balloon pump, or extracorporeal bypass 2, 5
Management of Severe CCB Overdose
In cases of severe CCB overdose, advanced hemodynamic monitoring may be necessary to guide treatment 4. Additionally, careful evaluation of asymptomatic patients, including an electrocardiogram and a period of observation, is indicated 2. Patients ingesting a nonsustained-release product should be observed in a monitored setting for 12 hours, while those who ingest a sustained-release preparation should be observed for no less than 24 hours 2.
Specific Treatment Approaches
Specific treatment approaches may vary depending on the severity of toxicity and the specific agents involved. For example, beta-blocker and CCB overdoses may require different treatment approaches 5. In general, the goal of treatment is to support cardiac function and maintain adequate blood pressure, while also addressing any underlying electrolyte imbalances or other complications.