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Management of calcium channel blocker overdose in the emergency department

The two key therapies for a significant calcium channel blocker overdose are high dose insulin and vasopressors. As soon as I recognize a sick calcium channel blocker overdose (or hear about it through a paramedic patch) I will have a nurse start preparing these drips. Of course, the vasopressor infusion always takes a while to get started, so I am ready to use push dose epinephrine...

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  High Dose Insulin/Euglycemia Regimen

Bolus 1 IU/kg along with 25 g dextrose. Avoid insulin bolus if glucose < 150. Avoid dextrose bolus if glucose > 400. Start 0.5 IU/kg/hr drip with IV glucose replacement as needed – aim for a blood glucose of 100-250 with accuchecks every 30 minutes. Always use central access for these infusion, in order to use higher concentration glucose and avoid volume overload. Monitor potassium closely while giving insulin.

 Calcium Channel Blocker Overdose

High dose insulin (HDI) therapy for the treatment of calcium channel blockers has been around for decades, with its first documented use in the late 1990s. Since then, its popularity has increased as more and more case reports describe its effectiveness in helping treat these overdoses.

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Calcium Channel Blocker (CCB) & Beta-Blocker (BBl) overdose

Pitfalls: Delayed initiation of high-dose insulin. Reliance on therapies that are unlikely to work (e.g., atropine, IV calcium, and glucagon). Early focus on placing a transvenous pacemaker (this wastes time, often doesn't capture the myocardium). Note that traditional algorithms for bradycardia don't work for these patients.

Calcium Channel Blocker Toxicity

Calcium channel blockers are not all born the same. Some produce severe cardiotoxic effects which in the past has caused significant mortality and others cause severe peripheral vasodilatation. Find out how identify which is which, the nuances of management and what antidote has changed our management.

EM@3AM – Calcium Channel Blocker Toxicity

HIET: insulin 1 U/kg IV bolus. Follow with an insulin infusion of 1-10 U/kg/hr + 50% glucose infusion to maintain euglycemia (requires frequent accuchecks). May increase infusion by 0.5-1 U/kg/hr every 30-60 minutes.