Elsevier

Resuscitation

Volume 57, Issue 2, May 2003, Pages 211-213
Resuscitation

Case report
Treatment of calcium channel blocker intoxication with insulin infusion: case report and literature review

https://doi.org/10.1016/S0300-9572(03)00026-1Get rights and content

Abstract

We present a case report of successful treatment of shock induced by the calcium channel blocker (CCB) diltiazem. A 75-year-old woman took a combination of tablets, including diltiazem. Soon after arrival, she developed haemodynamic shock which persisted despite treatment with fluids, dopamine, dobutamine, norepinephrine (noradrenaline), calcium gluconate and glucagon. Haemodynamic stability was not achieved until an insulin infusion and glucose administration was started. We review the literature and the updated guidelines for the treatment of CCB intoxication, with particular emphasis on situations where insulin and glucose infusions can be live saving.

Sumàrio

Os autores apresentam um caso de tratamento com sucesso do choque induzido por bloqueador do canal de cálcio (BCC) diltiazem. Uma mulher de 75 anos ingeriu vários comprimidos, incluindo o diltiazem. Pouco depois de chegar ao Hospital, desenvolveu um quadro de choque que persistiu apesar do tratamento com fluidos, dopamina, dobutamina, norepinefrina, gluconato de cálcio e glucagon. Não foi possı́vel obter estabilidade hemodinâmica até ser iniciada a perfusão de insulina e a administração de glicose. Reviu-se a literatura e as recomendações para tratamento da intoxicação por BCC, com ênfase particular nas situações em que a infusão de glicose e insulina foram “life saving”.

Resumen

Presentamos el reporte de un caso de tratamiento exitoso del shock inducido por el bloqueador de canales de calcio(CCB) diltiazem. Una mujer de 75 años tomó una combinación de tabletas, incluyendo diltiazem. Poco después de su llegada, desarrolló un shock hemodinámico que persistió pese al tratamiento con fluidos, dopamina, dobutamina, norepinefrina, gluconato de calcio y glucagón. No se alcanzó estabilidad hemodinámica hasta iniciar la administración de una infusión de insulina y glucosa. Revisamos la literatura y las últimas guı́as para el tratamiento de intoxicación con bloqueadores de canales de calcio, con especial énfasis en situaciones donde las infusiones de glucosa e insulina pueden ser salvadoras.

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

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