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

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.

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 1: Silibinin in suspected amatoxin-containing mushroom poisoning.

A shortcut review was carried out to establish whether silibinin is better than conservative management at reducing liver transplantation and death after poisoning with amatoxin-containing mushrooms. Thirty-eight papers were found in Medline and 86 in EMBASE using the reported searches. Of these, five presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that the evidence is limited, but given the lack of alternative treatments in patients with suspected amatoxin-containing mushroom poisoning and the relatively few adverse effects, silibinin should be considered in some patients.

Thyroid storm caused by a chinese herb contaminated with thyroid hormones.

BACKGROUND: We report a case of thyroid storm caused by consuming a Chinese herb contaminated with thyroid hormones. CASE REPORT: A 70-year-old man presented to an emergency department after 2 days of nausea, vomiting, and weakness. Three days previously, he had started taking Cordyceps powder and "Flower Man Sang Hung" as recommended by his Chinese physician. Following admission, the patient deteriorated and was eventually diagnosed with thyroid storm complicated by rapid atrial fibrillation requiring cardioversion, intubation, and intensive care admission. The analysis of the Chinese herb "Flower Man Sang Hung" was positive for levothyroxine. The patient was extubated 11 days after admission and discharged to a rehabilitation centre after 17 days of hospitalization. The Chinese medicine physician was informed of the events. CONCLUSIONS: Herbal products can be the source of illness, medication interactions, and contamination. Awareness should be raised among Chinese medicine physicians, allopathic physicians, and their patients. Clinicians should also have a low threshold of suspicion to seek laboratory analysis of suspect substances when the cause of the clinical presentation is unclear.

L-Carnitine for the treatment of a calcium channel blocker and metformin poisoning.

INTRODUCTION: The object of the current communication is to discuss the theory and the evidence for the use of L-carnitine in calcium channel blocker and metformin poisonings. CASE REPORT: A 68-year-old male known for hypertension and type II diabetes was admitted to the critical care unit of a community hospital following an overdose of amlodipine and metformin. The patient was intubated, ventilated, and hemodynamically supported with vasopressors. Despite calcium, glucagon, high-dose insulin (HDI), and lipid emulsion for calcium channel blocker and bicarbonate for metabolic acidosis, the patient remained hemodynamically unstable. The patient was considered too unstable to initiate continuous renal replacement therapy; and without access to extracorporeal life support, the administration of L-carnitine was administered as a last resort. One hour after L-carnitine, the norepinephrine requirements started to decrease, the patient began to improve and was subsequently extubated successfully without apparent sequelae in less than 4 days. DISCUSSION: L-Carnitine combined with HDI may have helped with the calcium channel blocker (CCB) poisoning by decreasing insulin resistance, promoting intracellular glucose transport, facilitating the metabolism of free fatty acids, and increasing calcium channel sensitivity. It may have also stimulated oxidative utilization of glucose instead of converting pyruvate into lactate and contributed to decrease lactate production with metformin poisoning.

Adherence to calcium channel blocker poisoning treatment recommendations in two Canadian cities.

CONTEXT: No study has documented whether physicians call poison control centres (PCC) for calcium channel blocker (CCB) poisoning or if interventions suggested by the PCC are being applied. OBJECTIVES: This study evaluated the compliance of physicians with the Quebec Poison Control Center's (QPCC) recommendations for the treatment of CCB poisoning. It also assessed the outcomes of these patients. METHODS: This retrospective chart review was conducted with CCB-poisoned adults who were admitted to a hospital in Quebec City or Montreal between January 2004 and November 2007. Using the sequence of interventions, it was determined whether or not the PPC recommendations were adhered to. Level of care provided, morbidity and mortality were reported. The researchers also used the QPCC database to verify if the poison centre was consulted for the care of the patient. RESULTS: A total of 103 cases were identified. 42% (43/103) were classified as compliant (all PCC recommendations were followed) and 58% (60/103) non-compliant group (some or no PCC recommendations followed). The poison control centre (PCC) was contacted for 74% of the total cases (81% of cases in the compliant group and 68% in the non-compliant group). High-dose insulin euglycemia therapy (HIET) was not started when indicated or started at too low dosage in 20 cases. Glucagon was given, even if not indicated, in 14 cases and decontamination was inappropriate in at least 10 cases. For the entire sample, there was an average of 8 days of hospitalization, 47 h of intensive care, 11 h of vasopressor use, a morbidity of 50% and a mortality of 6%. Acute renal failure (35%), metabolic acidosis (25%), acute pulmonary oedema (15%), aspiration pneumonia (15%), rhabdomyolysis (8%), myocardial ischemia (7%), abnormal liver function tests (AST/ALT) (6%), cerebral anoxia (4%) and ileus (3%) were among the most frequent complications. The outcomes in the non-compliant group versus the compliant group showed a mortality of 10% versus 0% (95%CI 0.00-0.20, p-value < 0.0001), a morbidity 67% versus 26% (95%CI 0.17-0.57, p-value < 0.0001) (OR 0.21 unadjusted and 0.64 adjusted, p-value < 0.0001), a median hospital length of stay (LOS) of 5 days versus 1 da y (p-value < 0.0001) (OR of a LOS ≥ 1 day 0.23 unadjusted and 0.39 adjusted, p-value < 0.0001), a median ICU LOS of 34 h versus 0 h (p-value < 0.0001) (OR of a ICU LOS ≥ 1 day 0.16 unadjusted and 0.38 adjusted, p-value < 0.0001) and a median duration of vasopressor of 17 h versus 3 h (p-value 0.0002) (OR of a vasopressor ≥ 1 h 0.15 unadjusted and 0.29 adjusted, p-value < 0.0001). CONCLUSION: In conclusion, the majority of the physicians did not follow PCC recommendations for the treatment of CCB poisoning. Further studies are ongoing as to evaluate the barriers to protocol adherence and to develop evidence based guidelines accompanied by an effective implementation strategy.