| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links). |
| Clinical features |
- Hypotension and bradycardia are common findings with significant ingestions
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- ECG may show PR prolongation or any bradydysrhythmia
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- Laboratory findings may include hyperglycemia
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- Patients with a significant CCB ingestion can deteriorate rapidly
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| Diagnostic evaluation |
- Assays for CCBs are not routinely available and do not aid management
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- Diagnosis depends on the history and clinical presentation
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- Differential diagnosis for unexplained bradycardia includes toxicity from beta blockers, clonidine, digoxin, and cholinergic medications
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- Structural cardiac disease and active myocardial ischemia may cause similar findings and must be excluded
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| Treatment |
| Stabilize airway, breathing, and circulation |
- Administer IV bolus crystalloid for hypotension (500 to 1000 mL isotonic saline); may be repeated
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- Administer atropine 1 mg IV for bradycardia; may repeat up to 3 total doses
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| For severe CCB poisoning (eg, profound hypotension refractory to crystalloid boluses and atropine), give ALL of the following (in addition to IV crystalloid and IV atropine): |
- IV calcium salt, IV glucagon, IV high-dose insulin and dextrose, vasopressor, and IV lipid emulsion
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| For patients with milder symptoms from CCB poisoning, give the following treatments in succession, but only if prior treatment(s) is ineffective: |
- IV crystalloid (for hypotension, as above), IV atropine (for bradycardia, as above), IV calcium salt, IV glucagon, IV high-dose insulin and dextrose, vasopressor, and IV lipid emulsion
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| Gastrointestinal decontamination |
- Give a single dose of activated charcoal (1 g/kg, up to 50 g maximum) to all patients who are hemodynamically stable with normal mental status
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- Give whole-bowel irrigation (2 L/hour by mouth until clear rectal effluent) for potentially life-threatening ingestion of extended-release preparation
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| Dosing regimens |
| IV calcium (hypotension and/or bradycardia) |
- Bolus therapy (select 1):
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- Calcium chloride: 10 to 20 mL of 10% solution (via central venous access if possible), or
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- Calcium gluconate: 30 to 60 mL of 10% solution
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- 0.5 meq calcium/kg per hour
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- Monitor serum calcium and ECG for evidence of hypercalcemia
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| Glucagon (bradycardia) |
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- 1 to 5 mg IV push, may repeat up to 15 mg total
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- Determine bolus amount needed to obtain response; give this "response dose" every hour as continuous infusion
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| Vasopressor support (hypotension) |
- Norepinephrine: begin 2 mcg/minute IV, titrate rapidly to systolic blood pressure 100 mmHg
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| High-dose insulin and dextrose (hypotension) |
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- Regular insulin: 1 Unit/kg IV
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- Dextrose: 25 to 50 grams IV; repeat for hypoglycemia; give potassium for hypokalemia
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- Regular insulin: start infusion at 0.5 Units/kg per hour IV; titrate upwards until hypotension corrected or maximum dose of 2 Units/kg per hour reached
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- Dextrose: 0.5 grams/kg per hour; titrate to euglycemia
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| IV lipid emulsion (20% solution) |
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- 1.5 mL/kg over 1 minute; may give 2 additional bolus doses if no response
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- 0.025 mL/kg per minute; maximum dose 12.5 mL/kg over 24 hours
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| Additional interventions |
- The following therapies may be necessary if the patient fails to improve with the interventions above or specific complications arise:
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- Transvenous cardiac pacing
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- Intra-aortic balloon pump
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- Extracorporeal membrane oxygenation
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