Maude St-Onge, Kurt Anseeuw, Frank Lee Cantrell, Ian C. Gilchrist, Philippe Hantson, Benoit Bailey, Valéry Lavergne, Sophie Gosselin, William Kerns II, Martin Laliberté, Eric J. Lavonas, David N. Juurlink, John Muscedere, Chen-Chang Yang, Tasnim Sinuff, Michael Rieder, Bruno Mégarbane
To provide a management approach for adults with calcium channel blocker poisoning.
DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION:
Following the Appraisal of Guidelines for Research & Evaluation II instrument, initial voting statements were constructed based on summaries outlining the evidence, risks, and benefits.
We recommend 1) for asymptomatic patients, observation and consideration of decontamination following a potentially toxic calcium channel blocker ingestion (1D); 2) as first-line therapies (prioritized based on desired effect), IV calcium (1D), high-dose insulin therapy (1D-2D), and norepinephrine and/or epinephrine (1D). We also suggest dobutamine or epinephrine in the presence of cardiogenic shock (2D) and atropine in the presence of symptomatic bradycardia or conduction disturbance (2D); 3) in patients refractory to the first-line treatments, we suggest incremental doses of high-dose insulin therapy if myocardial dysfunction is present (2D), IV lipid-emulsion therapy (2D), and using a pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block without significant alteration in cardiac inotropism (2D); 4) in patients with refractory shock or who are periarrest, we recommend incremental doses of high-dose insulin (1D) and IV lipid-emulsion therapy (1D) if not already tried. We suggest venoarterial extracorporeal membrane oxygenation, if available, when refractory shock has a significant cardiogenic component (2D), and using pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block in the absence of myocardial dysfunction (2D) if not already tried; 5) in patients with cardiac arrest, we recommend IV calcium in addition to the standard advanced cardiac life-support (1D), lipid-emulsion therapy (1D), and we suggest venoarterial extracorporeal membrane oxygenation if available (2D).
We offer recommendations for the stepwise management of calcium channel blocker toxicity. For all interventions, the level of evidence was very low.