Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults

Abstract

Objective: To provide a management approach for adults with calcium channel blocker poisoning.

Data sources, study selection, and data extraction: Following the Appraisal of Guidelines for Research & Evaluation II instrument, initial voting statements were constructed based on summaries outlining the evidence, risks, and benefits.

Data synthesis: We recommend 1) for asymptomatic patients, observation and consideration of decontamination following a potentially toxic calcium channel blocker ingestion (1D); 2) as first-line therapies (prioritized based on desired effect), IV calcium (1D), high-dose insulin therapy (1D-2D), and norepinephrine and/or epinephrine (1D). We also suggest dobutamine or epinephrine in the presence of cardiogenic shock (2D) and atropine in the presence of symptomatic bradycardia or conduction disturbance (2D); 3) in patients refractory to the first-line treatments, we suggest incremental doses of high-dose insulin therapy if myocardial dysfunction is present (2D), IV lipid-emulsion therapy (2D), and using a pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block without significant alteration in cardiac inotropism (2D); 4) in patients with refractory shock or who are periarrest, we recommend incremental doses of high-dose insulin (1D) and IV lipid-emulsion therapy (1D) if not already tried. We suggest venoarterial extracorporeal membrane oxygenation, if available, when refractory shock has a significant cardiogenic component (2D), and using pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block in the absence of myocardial dysfunction (2D) if not already tried; 5) in patients with cardiac arrest, we recommend IV calcium in addition to the standard advanced cardiac life-support (1D), lipid-emulsion therapy (1D), and we suggest venoarterial extracorporeal membrane oxygenation if available (2D).

Conclusion: We offer recommendations for the stepwise management of calcium channel blocker toxicity. For all interventions, the level of evidence was very low.

Figure 1.

Analytical framework for calcium channel blocker (CCB) poisoning treatment guidelines. Key questions (KQ): 1) Is there direct evidence that one (or more than one) intervention reduces mortality (critical outcome), improves functional outcomes, reduces hospital length of stay (LOS) or reduces ICU LOS (important outcomes)? 2) Does the patient clinical presentation or type of ingestion influence the intervention(s) provided and the outcomes? 3) Does one (or more than one) intervention decrease CCB serum concentration, improve hemodynamics, or reduce the duration of vasopressor use? 4) Are the intermediate outcomes reliably associated with reduced mortality or improved functional outcomes? 5) Does one (or more than one) intervention result in adverse effects or demonstrate a lack of cost-effectiveness?

Figure 2.

Voting process for recommendations.

Figure 3.

Progression of care for key recommendations. ACLS = advanced cardiac life-support, CCB = calcium channel blocker, ECLS = Extracorporeal Life Support, VA-ECMO = venoarterial extracorporeal membrane oxygenation.