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

      , MD, PhD, FRCPC , 1 , , MD, MSc 2 , , PharmD, DABAT, FAACT 3 , , MD, FCCM 4 , , MD, PhD 5 , , MD, MSc, FRCPC 6 , , MD, MSc, FRCPC 7 , , MD, FRCPC, FAACT 8 , , MD, FACMT 9 , , MD, FRCPC 10 , , MD, FACMT 11 , , MD, PhD, FRCPC 12 , , MD, FRCPC 13 , , MD, MPH, DrPH 14,15 , , MD, PhD, FRCPC 16 , , MD, PhD, FRCPC 17 , , MD, PhD 18

      Critical Care Medicine

      Lippincott Williams & Wilkins

      antidotes, calcium channel blockers, cardiotoxicity, drug overdose, therapy, toxicity

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          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).


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

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          Most cited references 77

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          AGREE II: advancing guideline development, reporting and evaluation in health care.

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            2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care: Endorsed by the American Heart Assocation, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention.

            Although historically the intra-aortic balloon pump has been the only mechanical circulatory support device available to clinicians, a number of new devices have become commercially available and have entered clinical practice. These include axial flow pumps, such as Impella(®); left atrial to femoral artery bypass pumps, specifically the TandemHeart; and new devices for institution of extracorporeal membrane oxygenation. These devices differ significantly in their hemodynamic effects, insertion, monitoring, and clinical applicability. This document reviews the physiologic impact on the circulation of these devices and their use in specific clinical situations. These situations include patients undergoing high-risk percutaneous coronary intervention, those presenting with cardiogenic shock, and acute decompensated heart failure. Specialized uses for right-sided support and in pediatric populations are discussed and the clinical utility of mechanical circulatory support devices is reviewed, as are the American College of Cardiology/American Heart Association clinical practice guidelines.
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              Emergency feasibility in medical intensive care unit of extracorporeal life support for refractory cardiac arrest.

              To report the feasibility, complications, and outcomes of emergency extracorporeal life support (ECLS) in refractory cardiac arrests in medical intensive care unit (ICU). Prospective cohort study in the medical ICU in a university hospital in collaboration with the cardiosurgical team of a neighboring hospital. Seventeen patients (poisonings: 12/17) admitted over a 2-year period for cardiac arrest unresponsive to cardiopulmonary resuscitation (CPR) and advanced cardiac life support, without return of spontaneous circulation. ECLS femoral implantation under continuous cardiac massage, using a centrifugal pump connected to a hollow-fiber membrane oxygenator. Stable ECLS was achieved in 14 of 17 patients. Early complications included massive transfusions (n=8) and the need for surgical revision at the cannulation site for bleeding (n=1). Four patients (24%) survived at medical ICU discharge. Deaths resulted from multiorgan failure (n=8), thoracic bleeding(n=2), severe sepsis (n=2), and brain death (n=1). Massive hemorrhagic pulmonary edema during CPR (n=5) and major capillary leak syndrome (n=6) were observed. Three cardiotoxic-poisoned patients (18%, CPR duration: 30, 100, and 180 min) were alive at 1-year follow-up without sequelae. Two of these patients survived despite elevated plasma lactate concentrations before cannulation (39.0 and 20.0 mmol/l). ECLS was associated with a significantly lower ICU mortality rate than that expected from the Simplified Acute Physiology Score II (91.9%) and lower than the maximum Sequential Organ Failure Assessment score (>90%). Emergency ECLS is feasible in medical ICU and should be considered as a resuscitative tool for selected patients suffering from refractory cardiac arrest.

                Author and article information

                Crit Care Med
                Crit. Care Med
                Critical Care Medicine
                Lippincott Williams & Wilkins
                March 2017
                17 February 2017
                : 45
                : 3
                : e306-e315
                [1 ]Centre antipoison du Québec, CHU de Quebec Research Center, Population Health and Optimal Health Practices, Department of Family Medicine and Emergency medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Ville de Québec, Quebec, Canada.
                [2 ]Department of Emergency Medicine, ZNA Stuivenberg, Antwerp, Belgium
                [3 ]School of Pharmacy, University of California, San Francisco, San Francisco, CA.
                [4 ]Heart and Vascular Institute, Penn State Hershey Medical Center, Hershey, PA.
                [5 ]Department of Intensive Care, Cliniques St-Luc, Université Catholique de Louvain, Leuven, Belgium.
                [6 ]Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada.
                [7 ]Department of Medical Biology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada.
                [8 ]Centre antipoison du Québec, Department of Medicine, McGill University, Department of Emergency Medicine, McGill University Health Centre, Montreal, QC, Canada.
                [9 ]Division of Medical Toxicology, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
                [10 ]Quebec Poison Centre, Department of Emergency Medicine, McGill University Health Centre, Montreal, QC, Canada.
                [11 ]Department of Emergency Medicine, Denver Health and Hospital Authority, University of Colorado, Boulder, CO.
                [12 ]Ontario Poison Centre, Sunnybrook Health Sciences Centre, Departments of Medicine and Pediatrics, University of Toronto, Toronto, ON, Canada.
                [13 ]Kingston General Hospital, Queens’ University, Kingston, ON, Canada.
                [14 ]Institute of Environmental & Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
                [15 ]Division of Clinical Toxicology & Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
                [16 ]Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
                [17 ]Department of Paediatrics, Physiology and Pharmacology and Medicine, Western University, London, ON, Canada.
                [18 ]Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM U1144, Paris-Diderot University, Paris, France.
                Author notes
                For information regarding this article, E-mail: maude.st-onge@ 123456fmed.ulaval.ca
                Copyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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