Maude St-Onge , MD, PhD, FRCPC , 1 , Kurt Anseeuw , MD, MSc 2 , Frank Lee Cantrell , PharmD, DABAT, FAACT 3 , Ian C. Gilchrist , MD, FCCM 4 , Philippe Hantson , MD, PhD 5 , Benoit Bailey , MD, MSc, FRCPC 6 , Valéry Lavergne , MD, MSc, FRCPC 7 , Sophie Gosselin , MD, FRCPC, FAACT 8 , William Kerns II , MD, FACMT 9 , Martin Laliberté , MD, FRCPC 10 , Eric J. Lavonas , MD, FACMT 11 , David N. Juurlink , MD, PhD, FRCPC 12 , John Muscedere , MD, FRCPC 13 , Chen-Chang Yang , MD, MPH, DrPH 14,15 , Tasnim Sinuff , MD, PhD, FRCPC 16 , Michael Rieder , MD, PhD, FRCPC 17 , Bruno Mégarbane , MD, PhD 18
17 February 2017
Supplemental Digital Content is available in the text.
Following the Appraisal of Guidelines for Research & Evaluation II instrument, initial voting statements were constructed based on summaries outlining the evidence, risks, and benefits.
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).