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. The two key therapies for a significant calcium channel blocker overdose are high dose insulin and vasopressors. For a more in depth discussion of intubating the hypotensive patient, see Scott Weingart’s SMACC talk “ Laryngoscope as a Murder Weapon (LAMW) Series – Hemodynamic Kills”
I would use a higher dose of paralytic than usual (rocuronium 1.6mg/kg or succinylcholine 2mg/kg). Due to poor muscle perfusion, normal doses of paralytics may be ineffective. I would use a slightly lower dose than normal, starting at 0.5mg/kg. Ketamine may be more hemodynamically stable than other induction agents (although any agent can result in hemodynamic collapse due to loss of sympathetic tone). When the time comes for the intubation, I would use RSI with ketamine as the induction agent.
However, I am constantly reassessing the patient, because I don’t want a rapid deterioration to force me to perform a crash intubation. My plan is to begin therapy for the hypotension before attempting RSI. Induction medications and the change to positive pressure ventilation exacerbate these problems. However, if there are no signs of airway obstruction on arrival, it may be ideal to delay the intubation because these patients already have significant hypotension and myocardial depression. In a critically ill patient like this, I want a controlled airway and will plan to intubate. With most toxicologic presentations following your general ABC approach to resuscitation is a good start. How should we manage this calcium channel blocker overdose? A finger stick glucose was 23mmol/L (414mg/dL for Americans). The paramedic team reports his vital signs as a heart rate of 51, blood pressure of 82/37, respiratory rate of 23, and oxygen saturation of 91%.
The patient is drowsy and mumbling incoherently. A 52 year old man is brought to your community emergency department by EMS because he ingested an entire bottle of diltiazem after a fight with his ex-wife.
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