Case reportTreatment of calcium channel blocker intoxication with insulin infusion: case report and literature review
Introduction
Calcium channel blocker (CCB) overdose is a reasonably well-known cause of death [1]. Cardiogenic shock and different types of arrhythmia, both usually difficult to control, precede this final event. CCBs suppress cardiac function. Bradycardia and hypotension are common and other cardiovascular effects include intraventricular conduction delays, ventricular dysrhythmias and congestive heart failure. Other effects are respiratory depression, gastrointestinal upset, central nervous system depression, with or without seizure and coma, hyperglycemia and lactic acidosis in hypotensive patients [3]. Conventional therapy, consisting of intravenous fluids, calcium, dopamine, dobutamine, norepinephrine and glucagon often fails to improve the haemodynamic function in intoxicated patients [1], [2].
New therapeutic measures have been advocated recently to treat the most severe cases that do not respond to conventional treatment. Recent recommendations for treatment of intoxication with CCB include induction of hyperinsulinaemia and euglycaemia as adjunctive therapy [2].
Section snippets
Case report
A 75-year-old woman with a prior medical history of arterial hypertension, chronic atrial fibrillation and psychiatric disturbance with previous suicide attempts, was found at home with a decreased level of consciousness. The Emergency Medical System was activated by the patient's family and on arrival, found the patient was confused, disoriented, with an arterial pressure 120/70 mmHg and an electrocardiogram revealing periods of bradycardia and ventricular extrasystoles. Several pharmaceutical
Review of the literature
We present a case of CCB intoxication with severe associated shock. Although this patient had taken many different medications, only diltiazem has been associated with haemodynamic instability.
CCB inhibits the entry of extracellular calcium into the cardiac cells through voltage-dependent L-type calcium channel inhibition [3], [4]. Calcium is the primary intracellular stimulus for cardiac and smooth muscle contraction and for intracardiac electric conduction. During CCB-induced shock, the
Conclusions
The first line recommended therapy for CCB poisoning or toxicity is the use of inotropic agents, calcium chloride and glucagon in refractory shock. The case we report is an example of severe intoxication with diltiazem, with unresponsiveness to the international treatment guidelines. Unlike other cases described in the literature, the patient received all recommended therapies before insulin infusion was initiated [1], [2]. So, hyperinsulinaemia–euglycaemia therapy must be considered in
References (6)
- et al.
Treatment of calcium-channel-blocker intoxication with insulin infusion
N. Engl. J. Med.
(2001) - et al.
Insulin–glucose as adjunctive therapy for severe calcium channel antagonism poisoning
J. Toxicol. Clin. Toxicol.
(1999) - et al.
Calcium channel-blocking drugs
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2010, ResuscitationCitation Excerpt :Evidence is limited to extrapolations from nonfatal case reports of severe cardiovascular toxicity. In 16 human case series (n = 28) high-dose insulin (bolus 0.5–2 U kg−1 followed by 0.5 U kg−1 h−1 infusion) given with glucose supplementation and electrolyte monitoring appeared effective (as measured by improved haemodynamic stability [25/28] and survival [26/28]) in the setting of severe cardiovascular toxicity associated with calcium channel blockers (LOE 5).553–568 There is insufficient clinical evidence to suggest any change to cardiac arrest resuscitation treatment algorithms for patients with cardiac arrest caused by calcium channel blockers.
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