Show Introduction
- Welcome to PICU Doc On Call, a podcast dedicated to current and aspiring intensivists.
- Hosted by Dr. Pradip Kamat and Dr. Rahul Damania
Case Presentation
- A 14-year-old female with a history of depression and oppositional defiant disorder presents with dizziness, slurring speech, and is pale appearance.
- The mother noticed symptoms of dizziness, stumbling, and sleepiness.
- The patient had a prior suicide attempt.
- Vital signs: HR 50 bpm, BP 75/40, GCS 10.
- The initial workup reveals hyperglycemia, and she is stabilized and admitted to the PICU.
Key Aspects of Ingestion Work-up
- History and physical exam are crucial.
- Stratify acute or chronic ingestions.
- Consider baseline medications and coingestants.
- Perform initial screening examination to identify immediate measures for stabilization.
Diagnostic Studies
- Pulse oximetry, continuous cardiac monitoring, ECG, capillary glucose measurement.
- Serum acetaminophen, ASA levels
- Consider extended toxicology screen.
Differentiating CCB vs. Beta-Blocker Overdose
- ECG findings: PR interval prolongation and Bradydysrhythmia suggest CCB poisoning.
- Hyperglycemia in non-diabetic patients may indicate CCB overdose
Approach to CCB Overdose
- Initial resuscitation and stabilization
- ABC approach
- Consult Poison Control Center
- Empiric use of glucagon, IV fluids, and vasopressors
- Consideration of orogastric lavage and activated charcoal
Specific Medical Therapies
- Vasopressors: norepinephrine/epinephrine infusion
- Atropine for bradycardia
- IV calcium salts to overcome cardiovascular effects
- High-dose insulin and dextrose for myocardial function
- Investigational therapies: methylene blue, lipid emulsion
Procedures
- Transvenous pacemaker placement if needed
- ECMO in refractory hypotension
Key Takeaways
- Hypotension and bradycardia indicate life-threatening toxidromes.
- Differential includes CCB, BB, digoxin, clonidine, and CNS depressants.
- Stepwise approach includes close monitoring of ABCs and specific medical therapies.
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References
- Fuhrman & Zimmerman – Textbook of Pediatric Critical Care Chapter 125 and 126.
- St-Onge M et al. Treatment for calcium channel blocker poisoning: a systematic review.
- DeRoos F. Calcium channel blockers. In: Goldfrank’s Toxicologic Emergencies, 8th edition.