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A6919 - Lipid Emulsion Therapy and High Dose Insulin in Management of Calcium Channel Blocker Toxicity
Author Block: N. Mesiha1, M. Gugnani2, S. Tieku3; 1Pulmonary, Capital Health Regional Medical Center, Trenton, NJ, United States, 2Pulmonary and Critical Care, Capital Health Regional Medical Center, Trenton, NJ, United States, 3Pulmonary and Critical Care, Capital Health Regional Medical Center, Pennington, NJ, United States.
Introduction Beta-blockers and calcium channel blockers(CCB)and are among the most frequently ingested cardiovascular drugs in self-poisoning causing significant mortality. Presentation varies from mild hypotension and bradycardia to profound shock with refractory bradyarrhythmias. We report one case of refractory shock due to overdose by CCB and beta blocker. Case report A 43- year-old woman with history of personality disorder and suicide attempts was brought to ED for drug overdose.The patient ingested 20 tabs of amlodipine and 20 tabs of carvedilol. Patient was initially lethargic with heart rate 36/min and profoundly hypotensive at 57/24. Lactic acid 7.2 mmol/L, troponins x2 were negative, and ABG showed compensated severe metabolic acidosis. ECG showed sinus bradycardia. After multiple doses of IV calcium, 6 liters of crystalloid, 3 doses of atropine, repeated doses of glucagon, and dopamine infusion, the bradycardia improved to HR 62/min but patient remained hypotensive without significant improvement of mentation. Patient was intubated for refractory shock. Follow up lactic acid was 6.5. Vasopressors were changed to epinephrine and dobutamine, and glucagon infusion was started but she remained unimproved after 6 hours of aggressive management. After initiation of high dose insulin with dextrose infusion and lipid-emulsion therapy, blood pressure started to rise and requirements for vasopressors decreased. Perfusion improved dramatically with good urine output and normalization of lactic acid after 12 hours. Epinephrine was tapered off and after that dobutamine. Patient was successfully extubated on day 3 of admission, transferred safely to the telemetry floor where her blood pressure and heart rate remained stable until hospital discharge. Discussion First line therapy of CCB overdose is fluids and IV calcium. For bradycardia due to CCB and Beta blocker overdose, atropine is the drug of choice. If patients are still symptomatic, vasopressors and IV glucagon are the next step, followed by high dose regular insulin for its positive inotropic effect with a bolus of 1 U/kg followed by 1 U/kg/h and close monitoring of glucose and potassium level. Intravenouslipid emulsion has been considered as a management modality for reversal of toxicity caused by overdose of any lipophilic drug including: beta blockers, calcium channel blockers, anesthetic agents, parasiticides, herbicides and several varieties of psychotropic agents.It works by creating an intravascular lipid phase, that drives the offending drug from target tissues. We postulate from our case that intravenous high dose insulin and lipid emulsion should be considered in management of refractory shock due to CCB and/or beta-blocker ingestion.