Table 2 Fatal cases
From: Outcomes following calcium channel blocker exposures reported to a poison information center
Gender and age | Comorbidity | Anamnestic drug exposure (doses noted if known) | Interval to presentation and death post intake | Clinical presentation at hospital Time from intake to admission if known) and symptoms (GCS, temperature, hemodynamic, renal, other | Paraclinical parameters Arterial blood gas (pH, base excess, lactate) blood samples (e.g. glucose, calcium,) and ECGs | Treatment Gastrointestinal decontamination (e.g. gastric emptying, activated charcoal). Inotropes, vasopressors and vasoactive therapy (e.g. isoprenaline, norepinephrine). Other interventions (e.g. dialysis, calcium, glucagon) |
|---|---|---|---|---|---|---|
Female, 82 y | Morbus Meniere. Cardiovascular disease. Several previous suicidal attempts. | Verapamil 24,000 mg (as extended release tablets 240 mg) Escitalopram 280 mg | 3 days | 12 h after intake: Somnolent. BP 80/35 mmHg, HR 35 increasing to 50. Anuria. Muscle twitches and cramps in the extremities. | ABG: pH 7.33, BE −10.8, lactate 1,6–3,2 mmol/l. P-glucose 9.1 mmol/l, P-calcium (ion)1.17 mmol/l Increasing creatinine ECG: Initially AV nodal rhythm, atrial fibrillation with LBBB | Gastric aspiration (without lavage) without any tablets retrieved. Activated charcoal - single dose. Atropine, Isoprenaline, norepinephrine (up to 0.56 μg/kg/minute), epinephrine (up to 0.4 μg/kg/minute). Levosimendan. Other: Plasmapheresis and CRRT, temporary pacemaker (bradycardia), non-invasive ventilation due to carbon dioxide retention |
Male, 49 y | Anxiety Periodic Depression, Epilepsy. | Verapamil (as extended release tablets 240 mg) Quetiapine Codeine Acetaminophen Tramadol Topiramate | 2 h | Within 12 h after intake: GCS 3. Temperature 32,5 °C. Seizure in ambulance, BP low, cold and pale. Low urine production. | ABG: pH 6.88, lactate 11.3 mmol/L. ECG: ST-depression V2-V6 turning into first bradycardia, then PEA and finally cardiac arrest. | Gastric aspiration (without lavage) with small amounts of tablets retrieved. Activated charcoal - single dose. Endotracheal intubation Atropine, epinephrine, norepinephrine, phenylephrine, Other: Sodium bicarbonate, calcium, dobutamine, naloxone After PEA: Glucagon, amiodarone, infusion with insulin-glucose (high dose). |
Female 76 y | Obesity. COPD. Arterial hypertension. Anxiety disorder, Several previous suicidal attempts. | Verapamil Acetaminophen ozaxepam | 12 h | Time unknown. Admission status: GCS 9. Temperature 32,7 °C. BP 80/50 mmHg, HR 40 initially increases to 65. AKI. Myoglobin 1167 μg/L. | ABG: pH 7.2, BE 3, lactate 2.4 mmol/L P-glucose 16,1 mmol/L ECG: Bradycardia, 3rd degree AV-block, asystole turning into cardiac arrest. | (GID not performed) Atropine, isoprenaline, norepinephrine (up to 0.7 μg/kilo/minute), epinephrine (0.4 μg/kilo/minute). Other: Flumazenil, N-acetylcysteine, calcium, dopamine, sodium bicarbonate, naloxone. |
Female 63 y | Unknown. | Amlodipine 425 mg, Metoprolol 4250 mg Enalapril | 2 days | 6 h after intake: Comatose. MAP 50, HR 44 (SR), cold. Anuria. | ABG: pH 7.1, BE-19.8, lactate 17 mmol/L. ECG: Atrioventricular Junctional Rhythm (25–40 bpm) | Gastric aspiration (without lavage) with unknown result. Activated charcoal - single dose. Endotracheal intubation, controlled ventilation with high oxygen demand. Atropine, norepinephrine, epinephrine, isoprenaline. Levosimendan, Other: temporary pacemaker, calcium infusion, glucagon, intravenous lipid emulsion. Dialysis. |
Female, 61 y | COPD. Depression. Multiple previous suicide attempts. | Verapamil 6000 mg Ramipril 150 mg Ibuprofen 20 g Zolpidem 200 mg | 2 | Time unknown. Admission status: Unconscious. Reacts to pain. Mumbles. Temperature 34,2 °C. BP 60/ 35, HR 36, cold, pale and sweaty. Anuria. | ABG: pH 7.26, BE − 6,8, lactate 11.1 mmol/L ECG: Wide QRS-complexes. | Activated charcoal - single dose. Endotracheal intubation. Atropine isoprenaline, noradrenaline, adrenaline, dopamine, ephedrine. Other: temporary pacemaker, calcium, glucagon, Calcium (bolus and infusion), glucagon, insulin, flumazenil. Dialysis. After temperature increases to 39 °C: Tazobactam/piperacillin, ciprofloxacin, metronidazole. |
Male, 83 y | Paranoid psychosis Cerebral infarction Dementia Arterial hypertension. Aortic valve insufficiency. | Felodipine (as 5 mg tablets) Acetaminophen 10 g Baclofen Quinine 4 g, Acetylsalicylic acid (as 75 mg tablets) | 8 days | Time unknown. Admission status: Somnolence. BP 111/45, HR 77 Urine production. | ABG: pH 7.24, BE 8 P-creatinine: 207 mmol/L P-calcium (ion): 0,96 ECG: 1st degree AV block, Right bundle branch block (pre-existing) ( | (GID nor performed). adrenalin, noradrenalin Endotracheal intubation. Other: calcium, sodium bicarbonate, N-acetylcysteine. Furosemide, labetalol. Symptomatic treatment (morphine, diazepam) |
Male, 30 y | Depression Hypertension | Amlodipine (as 10 mg tablets) Acetylsalicylic acid (as 75 mg tablets) Ramipril | 12 h | Time unknown. Admission status: Awake and fully aware of the situation. Nausea and sweaty – otherwise as usual. | P-salicylate 0.4 mmol/L ECG: Normal No further test - patient leaves the hospital. | Activated charcoal - single dose. Patient leaves the hospital before any other treatment is started. The patient dies 12 h later of carbon monoxide poisoning. |