Selected Topics: Toxicology
High-Dose Insulin and Intravenous Lipid Emulsion Therapy for Cardiogenic Shock Induced by Intentional Calcium-Channel Blocker and Beta-Blocker Overdose: A Case Series

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Abstract

Background

Recently, high-dose insulin (HDI) and intravenous lipid emulsion (ILE) have emerged as treatment options for severe toxicity from calcium-channel blocker (CCB) and beta blocker (BB).

Objective

Our aim was to describe the use and effectiveness of HDI and ILE for the treatment of CCB and BB overdose.

Case Reports

We describe 2 patients presenting to the emergency department after intentional ingestions of CCBs and BBs. A 35-year-old man presented in pulseless electrical activity after ingesting amlodopine, verapamil, and metoprolol. A 59-year-old man presented with cardiogenic shock (CS) after ingesting amlodopine, simvastatin, lisinopril, and metformin. Both patients were initially treated with glucagon, calcium, and vasopressors. Shortly after arrival, HDI (1 unit/kg × 1; 1 unit/kg/h infusion) and ILE 20% (1.5 mL/kg × 1; 0.25 mL/kg/min × 60 min) were initiated. This led to hemodynamic improvement and resolution of shock. At the time of hospital discharge, both patients had achieved full neurologic recovery.

Conclusions

HDI effectively reverses CS induced by CCBs and BBs due to its inotropic effects, uptake of glucose into cardiac muscle, and peripheral vasodilatation. ILE is theorized to sequester agents dependent on lipid solubility from the plasma, preventing further toxicity. To our knowledge, these are the first two successful cases reported using the combination of HDI and ILE for reversing CS induced by intentional ingestions of CCBs and BBs.

Introduction

Beta-blocker (BB) and calcium-channel blocker (CCB) overdoses, which are often the result of intentional ingestion, patient error, or drug interactions, are associated with significant morbidity and mortality (1). CCBs function at the L-type calcium channels on cardiac and smooth muscle cells (2). At toxic levels, excessive blockade results in cardiac dysfunction and peripheral vasodilatation (2). BBs competitively bind to beta-adrenergic receptors, resulting in bradycardia and hypotension (3). Depending on lipid solubility, some BBs cause serious central nervous system manifestations, such as seizures, respiratory depression, and coma (3).

Traditional treatment of CCB and BB overdose involves supportive care, intravenous fluids, epinephrine, atropine, glucagon, and calcium. In more extreme cases, extracorporeal membrane bypass has been utilized; however, many of these therapies are ineffective in severe overdoses 4, 5.

Recently, high-dose insulin (HDI) and intravenous lipid emulsion (ILE) have emerged as treatment options for severe CCB and BB toxicities 6, 7. In this case series, we present 2 patients successfully treated with a combination of HDI and ILE therapies, resulting in a rapid reversal of shock and full neurologic recovery.

Section snippets

Case Reports

The first patient was a 35-year-old man with a medical history of hypertension (HTN) and diabetes mellitis (DM) type 1 on insulin pump therapy, who was found down for an unknown amount of time with empty prescription bottles of metoprolol, amlodipine, and verapamil. Upon arrival at the emergency department (ED), he was in bradycardic arrest (20 beats/min) without a measurable blood pressure (BP). He was given atropine 1 mg, glucagon 1 mg, and calcium gluconate 2 g, along with infusions of

Discussion

These cases illustrate positive outcomes with the use of combined HDI and ILE therapy to treat CS caused by CCB and BB overdose. Both cases demonstrate the benefit of ILE therapy for an amlodipine overdose. We have not seen ILE referenced in the literature for the treatment of an amlodipine overdose. There is only one other case report illustrating the effectiveness of using a combination of HDI and ILE for the treatment of cardiac arrest secondary to BB overdose. This case report describes the

Conclusions

We believe this case series to be the first to demonstrate the effectiveness of a combination of HDI and ILE therapies for the treatment of CS induced by CCB and BB overdoses. Despite presenting to the ED critically ill, both patients survived to hospital discharge with complete neurologic recovery. These cases demonstrate the potential effectiveness of ILE therapy for metoprolol and amlodipine. We would consider HDI and ILE as therapy for any patient who has CS induced by an overdose of BB or

Acknowledgments

We would like to thank the Medical Intensive Care Unit nursing staff at The Wexner Medical Center at The Ohio State University for their tremendous work to ensure optimal patient care.

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