This handout is for cardiogenic shock — calcium channel blocker overdose (hie-first toxicologic cs). Your care team identified this based on: intentional ccb ingestion + bradycardia + av block + hypotension — non-dhp (diltiazem / verapamil) cardiogenic phenotype; hie pathway.
Other reasons your team may use this plan: amlodipine od with vasoplegic shock refractory to norepinephrine — dhp distributive phenotype; hie + methylene blue + vasopressin pathway; ecg bradycardia + 1st/2nd/3rd-degree av block in known or suspected ccb od — non-dhp toxicity; calcium + hie + pacing planning; concurrent ccb + bb ingestion — highest-mortality synergistic toxicity; activate va-ecmo team prophylactically.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| insulin regular | 1 U/kg IV bolus → 0.5–2 U/kg/h continuous infusion (HIE; up to 10 U/kg/h reported) | IV | continuous; titrate up if persistent shock | St-Onge meta-analysis 2017 PMID 27767299 + Engebretsen PMID 21626672 — HIE > standard pressors in CCB OD; FIRST-LINE inotropic strategy in toxicologic CS; restores myocyte glucose oxidation + improves vascular tone |
| calcium gluconate | 3 g IV q5 min × max ~12 g, then titrate to ionized Ca >2.0 | IV | q5 min initial then q4–6 h titrate | CCB-SPECIFIC core therapy — direct antagonism of L-type Ca channel block; trial 3–4 doses; if no response do not exceed safety limit but pivot to HIE + MCS; calcium chloride 10% 1 g central line is alternative (3× more elemental Ca per gram) |
| intralipid 20% | 1.5 mL/kg IV bolus over 1 min → 0.25 mL/kg/min infusion × 30–60 min (max ~10 mL/kg total) | IV | bolus may repeat × 2 q5 min then continuous | Levine 2014 PMID 25498415 — lipid sink for lipophilic agents (amlodipine log P ~3.0; verapamil also lipophilic; diltiazem intermediate; nifedipine less); rescue in shock or arrest |
| glucagon | 5–10 mg IV bolus → 5–10 mg/h infusion (trial only if response) | IV | continuous if responsive | AACT 2017 PMID 29022414 — LESS effective in CCB than BB OD (no β-blockade defect; cAMP pathway not the primary issue); trial dose; pre-treat with anti-emetic; persist only if clear response |
| norepinephrine | 0.05–0.5 µg/kg/min IV titrate MAP ≥65 | IV | continuous | SOAP-II PMID 20200382 — first-line vasopressor in CS; in DHP (amlodipine) vasoplegia, often inadequate alone — combine with vasopressin + methylene blue + HIE |
| vasopressin | 0.04 U/min IV continuous | IV | continuous | V1 pathway intact in vasoplegic shock; spares α-receptor; useful in DHP-induced vasoplegia analogous to septic shock add-on (VASST PMID 18305265) |
| methylene blue | 1–2 mg/kg IV bolus over 5 min; may repeat × 1 if partial response | IV | bolus; rarely infusion | Inhibits NO-cGMP vasodilation pathway; case-series + small-RCT evidence in distributive vasoplegic shock; reasonable rescue in refractory amlodipine OD; AVOID with serotonergic drugs (serotonin syndrome risk) |
| isoproterenol | 2–10 µg/min IV titrate to HR 60–80 | IV | continuous | β-1 chronotropic bridge during pacing capture-failure; less commonly needed in CCB OD vs BB OD because β-pathway intact and pacing capture often acceptable |
| atropine | 0.5–1 mg IV q3–5 min × max 3 mg | IV | q3–5 min | AHA 2020 ACLS bradycardia algorithm; usually inadequate in severe CCB OD; transient bridge to calcium / HIE / pacing |
| potassium chloride | 20–40 mEq IV/PO; target K ≥4.0 | IV/PO | PRN during HIE — hourly replacement common | Insulin shifts K intracellularly during HIE — replace aggressively to ≥4.0 to prevent arrhythmia |
| magnesium sulfate | 2 g IV bolus then PRN | IV | PRN | Replace to ≥2.0; arrhythmia prophylaxis during HIE |
| activated charcoal | 1 g/kg PO/NG if airway protected, ingestion <1 h (<2 h for sustained-release) | PO/NG | one-time | GI decontamination per AACT/EAPCCT — limited evidence; AVOID if ileus / obtundation without intubation |
| whole bowel irrigation with polyethylene glycol | PEG-electrolyte solution 1.5–2 L/h via NG until rectal effluent clear | NG | continuous until clear | AACT/EAPCCT — recommended for sustained-release CCB ingestion; AVOID if ileus / bowel obstruction / unprotected airway |
Plan: CCB overdose with CS — HIE-first toxicologic pillars (insulin-euglycemia + high-dose calcium + lipid emulsion + methylene blue for vasoplegia); pressors as adjuncts; VA-ECMO if refractory
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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)
Guideline: AACT 2017 BB+CCB Toxicity Expert Consensus (PMID 29022414); St-Onge 2017 meta-analysis CCB OD (PMID 27767299); Engebretsen 2011 HIE in BB/CCB OD (PMID 21626672); SCAI 2022 CS staging (Naidu PMID 35718438); ACMT HIE position statement; AHA 2020 ACLS