12-phase flow (11)

1. 1FRAME
   Recognize CCB OD as toxicologic CS — Ca-channel blockade defeats standard pressors; HIE + calcium + lipid emulsion + methylene blue (DHP) are pillars; standard NE / vasopressin alone often inadequate
   inputs: ecg, sbp
   advance: CCB OD with shock physiology confirmed
2. 2ENTRY
   Activate poison control (1-800-222-1222) + medical toxicology + CS team; secure airway if AMS; IV access × 2 large-bore + arterial line + central line if shock; identify agent + dose + time of ingestion + sustained-release formulation
   inputs: sbp, hr, agent_dose_time_of_ingestion
   advance: Tox + CS team activated + airway secured + access in place
3. 3CONTEXT
   Specific agent (amlodipine = long t½ vasoplegia; verapamil = highest mortality; diltiazem intermediate; sustained-release formulations delayed peak), dose in mg/kg, time of ingestion, co-ingestants (BB synergistic), psych history, prior cardiac disease
   inputs: weight, temperature, creatinine, co_ingestion_screen
   advance: Agent + co-ingestants + dosing weight documented
4. 4RED_FLAGS
   Amlodipine vasoplegia refractory to NE (DHP distributive phenotype — methylene blue + vasopressin); diltiazem AV block requiring pacing (non-DHP cardiogenic phenotype); HIE failure → ECMO triggers (lactate not clearing, SBP unsupportable); suicide risk + repeated OD (psych safety planning)
   inputs: sbp, hr, glucose
   actions: cardiogenic_shock, wide_complex_tach
   advance: Acute hemodynamic + electrical derangements managed + co-ingestion screened
5. 5INITIAL_WORKUP
   ECG (bradycardia, AV block — usually narrow QRS); STAT echo (cardiogenic vs distributive phenotype distinction — drives MCS strategy); BMP + Mg + ionized Ca + glucose + lactate + ABG; troponin (rule out ischemic mimic); APAP + salicylate level (universal coingestant screen); EtOH; tox screen; serum / urine drug screen; serum drug level if assay available (rare)
   inputs: ecg, echo, glucose, potassium, calcium_ionized, lactate, troponin
   actions: cardiogenic_shock, wide_complex_tach, panel.cardiac, panel.renal
   advance: Baseline labs + ECG + echo + co-ingestion labs documented
6. 6BRANCHING_WORKUP
   GI decontamination — activated charcoal 1 g/kg PO if airway protected + ingestion <1 h (or <2 h for sustained-release); WHOLE-BOWEL IRRIGATION especially important for sustained-release CCB (verapamil-SR, diltiazem CD) — polyethylene glycol 1.5–2 L/h until rectal effluent clear; hemodialysis generally NOT effective (most CCBs high Vd + protein-bound); CRRT for AKI from sustained shock
   inputs: ecg
   advance: Decontamination decision + dialysis triage documented
7. 7RISK_STRATIFICATION
   SCAI 2022 stage; SOFA / CardShock score; agent-specific risk (verapamil = highest mortality; amlodipine = vasoplegia challenge); refractoriness to first-line (HIE + calcium) → MCS / VA-ECMO triage; vasoplegia phenotype → methylene blue trial
   inputs: sbp, lactate
   advance: SCAI stage + agent-specific severity + MCS triage assigned
8. 8TREATMENT
   PILLAR THERAPY: HIE — regular insulin 1 U/kg IV bolus → 0.5–2 U/kg/h infusion + D10W titrate to euglycemia 100–250 (St-Onge meta PMID 27767299); CALCIUM gluconate 3 g IV q5 min × max ~12 g (or CaCl2 10% 1 g via central line — 3× more elemental Ca per gram) — CCB-specific antagonism; trial GLUCAGON 5–10 mg IV (less effective than for BB OD); LIPID EMULSION 20% 1.5 mL/kg bolus → 0.25 mL/kg/min infusion for amlodipine / verapamil (lipophilic). PRESSORS: norepinephrine titrate MAP ≥65 (combine with HIE); add vasopressin 0.04 U/min for vasoplegia; consider METHYLENE BLUE 1–2 mg/kg IV bolus for refractory amlodipine vasoplegia (NO-cGMP pathway). PACING: transvenous if symptomatic brady refractory (capture acceptable in CCB OD). MCS: VA-ECMO if refractory CS despite all of above (SCAI D/E)
   inputs: sbp, lactate, glucose, calcium_ionized, weight
   actions: cardiogenic_shock
   advance: HIE + calcium + lipid (if lipophilic) + pressors + methylene blue (if vasoplegic) + MCS plan all in place
9. 9DISPOSITION
   CICU at MCS-capable center; transfer if MCS not available locally; Toxicology + Cardiology + Psych comanagement; psychiatric admission post-medical clearance for intentional OD
   advance: CICU bed assigned + tox + psych comanagement + MCS pathway documented
10. 10MONITORING
    Continuous telemetry; A-line; central line; serial ECG q4–6 h (track conduction); glucose q1h during HIE (D10W titration; target 100–250); K hourly (insulin shifts intracellularly — replace aggressively to ≥4.0); ionized Ca q4–6 h (target >2.0; avoid >3.0 toxicity); Mg q4–6 h; lactate q2–4 h until clearing; UOP hourly; serial echo q12–24 h to track inotropic recovery + distinguish persistent cardiogenic vs distributive phenotype
    inputs: glucose, potassium, calcium_ionized, lactate
    actions: panel.cardiac, panel.renal
    advance: Monitoring cadence + HIE + calcium titration loop established
11. 11FOLLOWUP
    Psychiatric inpatient admission post-medical clearance for intentional OD (mandatory safety planning); Toxicology + Cardiology follow-up at 1–4 wks; outpatient SSRI / mood stabilizer review with psychiatry; medic-alert documentation for severe CCB-sensitivity if therapeutic re-introduction needed; family education on lethal-means counseling (esp removal of long-acting CCBs from home)
    advance: Psych admission + safety plan + outpatient cardiology + toxicology follow-up scheduled