UMEM Educational Pearls

Title: Experts consensus recommendation for CCB poisoning 2016

Keywords: CCB poisoning (PubMed Search)

Posted: 10/13/2016 by Hong Kim, MD
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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)