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


  • 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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  • 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.