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tox.calcium-channel-blocker-overdose.core.v1

Calcium channel blocker overdose

toxicologyacuteadultpediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest path is a PLACEHOLDER reusing prisma/seed/manifests/tox.co-poisoning.core.v1.ts — no CCB-specific manifest, atoms split, or problem-package folder authored yet (tracked in design-brief Open-gaps). NO RxCUIs anywhere — calcium gluconate/chloride, regular insulin (HIET), dextrose, potassium, lipid emulsion 20%, methylene blue, norepinephrine, epinephrine, atropine, glucagon, activated charcoal, sodium bicarbonate not verified in current seed data; rxcui omitted per spec rule (no fabrication). Pacing / WBI / VA-ECMO marked non_pharm. HIET is positioned as a CORE early inotrope (St-Onge Crit Care Med 2017 / ACMT 2017), NOT a last-resort therapy — encoded in regimen steps, playbooks, and severity triggers. Hallmark HYPERGLYCEMIA (islet insulin-secretion blockade) is the key bedside CCB-vs-beta-blocker discriminator — surfaced in entry points, required inputs, a severity trigger, and sibling differentiation. Whitelisted clinical-tools ids only (workup.bb_ccb_overdose primary). Calculators limited to calc.news2 + calc.qsofa. Sibling tox.beta-blocker-overdose.core.v1. INTEGRATED blockers to PRODUCTION: CCB-specific manifest + atoms, RxNav-validated antidotal regimen, terminology code reconciliation, Bayesian LRs for the hyperglycemia/AV-block discriminators, dedicated engine test file.

Entry points (4)

  • history
    Reported / suspected verapamil, diltiazem, amlodipine, nifedipine ingestion (ACMT 2017)
    ccb_ingestion_reported
  • vital_abnormality
    Bradycardia + hypotension in a patient on or with access to a CCB (Crit Care 2023)
    bradycardia_hypotension
  • lab_abnormality
    Hyperglycemia + shock without diabetic ketoacidosis — CCB until proven otherwise (St-Onge Crit Care Med 2017)
    unexplained_hyperglycemia_shock
  • symptom
    Undifferentiated cardiogenic / vasodilatory shock with toxicologic history (AACT/ACMT)
    undifferentiated_tox_shock

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    Pediatric "one-pill-can-kill" — a single SR verapamil/diltiazem tablet can kill a toddler; weight drives all antidote dosing
  • weight_kgrequired
    demographic • used at CONTEXT
    Calcium, HIET, lipid-emulsion dosing are all weight-based (U/kg, mL/kg)
  • agent_and_formulationrequired
    history • used at CONTEXT
    Non-DHP (verapamil/diltiazem) vs DHP (amlodipine/nifedipine); IMMEDIATE- vs SUSTAINED-RELEASE drives delayed/prolonged-toxicity expectation + WBI decision
  • ingestion_time_and_doserequired
    history • used at CONTEXT
    Time since ingestion + estimated dose; SR products peak 6–18 h with pharmacobezoar — a well-appearing early patient can crash
  • coingestantsrequired
    history • used at CONTEXT
    Beta-blocker, digoxin, antihypertensive co-ingestion compounds bradycardia / shock and changes antidote sequence
  • hrrequired
    vital • used at RED_FLAGS
    Bradycardia + AV block (non-DHP) vs reflex tachycardia early then bradycardia (DHP massive); drives calcium/atropine/pacing
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension severity drives calcium → fluids → HIET → vasopressor escalation
  • mental_statusrequired
    vital • used at RED_FLAGS
    AMS reflects cerebral hypoperfusion / impending arrest; airway watch
  • glucoserequired
    lab • used at INITIAL_WORKUP
    HYPERGLYCEMIA is the CCB fingerprint (islet insulin-secretion blockade) — separates CCB from beta-blocker tox and correlates with severity (St-Onge 2017)
  • ionized_calciumrequired
    lab • used at INITIAL_WORKUP
    Baseline + serial during calcium therapy to avoid dangerous hypercalcemia
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    HIET drives intracellular K shift — q1h K, replace to keep ≥2.8–3.0 mEq/L; baseline before infusion
  • lactate
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion marker; trend guides escalation to mechanical support
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Sinus bradycardia, PR prolongation, high-grade AV block, junctional escape, QRS/QT changes; baseline rhythm + monitoring

12-phase flow (12)

  1. 1FRAME
    Establish acute CCB exposure (intentional, accidental pediatric, therapeutic error); classify the engine as a cardiotoxic-shock toxidrome with delayed-peak SR risk (ACMT 2017)
    inputs: agent_and_formulation
    advance: CCB exposure scenario established and formulation (IR vs SR) noted
  2. 2ENTRY
    Recognize trigger: reported ingestion, bradycardia-hypotension, or unexplained hyperglycemia + shock (St-Onge Crit Care Med 2017)
    inputs: age, weight_kg
    advance: Trigger captured + weight obtained for weight-based antidote dosing
  3. 3CONTEXT
    Capture agent class (non-DHP vs DHP), formulation, dose, time since ingestion, co-ingestants (beta-blocker / digoxin); pediatric one-pill-can-kill flagged (Crit Care 2023)
    inputs: agent_and_formulation, ingestion_time_and_dose, coingestants, age
    advance: Phenotype (non-DHP vs DHP), formulation, dose-time, co-ingestants documented
  4. 4RED_FLAGS
    Bradycardia + AV block, refractory hypotension, AMS, hypoperfusion / pre-arrest; SR ingestion with delayed crash potential even if currently well (ACMT 2017; Crit Care 2023)
    inputs: hr, sbp, mental_status
    actions: calc.news2, workup.bradycardia
    advance: Hemodynamic red flags screened; calcium + monitored bed + ICU triggered if unstable or SR exposure
  5. 5INITIAL_WORKUP
    BB/CCB overdose workup, glucose (hyperglycemia hallmark), ionized calcium, K, BMP, ABG/VBG + lactate, ECG, digoxin level if co-ingestant; acetaminophen/salicylate for co-ingestion screen (St-Onge 2017)
    inputs: glucose, ionized_calcium, potassium, ecg
    actions: workup.bb_ccb_overdose, panel.metabolic, panel.cardiac, panel.glucose_a1c
    advance: Glucose + ionized calcium + K + ECG + acid-base returned; calcium therapy started if unstable
  6. 6BRANCHING_WORKUP
    Bradycardia/heart-block branch (calcium responsiveness, pacing capture threshold) vs cardiogenic-shock branch (echo cardiac output, lactate trend) vs wide-complex (membrane-stabilizing co-ingestant, sodium bicarb) (Crit Care 2023)
    inputs: hr, lactate
    actions: workup.brady_heart_block, workup.cardiogenic_shock, panel.abg, panel.tox_screen
    advance: Dominant lesion (chronotropic-conduction vs inotropic-vasoplegic vs mixed) characterized; echo cardiac output obtained
  7. 7DIFFERENTIAL
    Beta-blocker overdose (hypoglycemia not hyperglycemia), digoxin toxicity, clonidine/central alpha-2, organophosphate, hyperkalemia, sick sinus / inferior MI with shock, sepsis, other sympatholytic toxidromes (St-Onge 2017)
    inputs: glucose
    actions: workup.wide_complex_tach
    advance: CCB confirmed as principal driver; competing toxidromes addressed in parallel
  8. 8RISK_STRATIFICATION
    Severity by HR/AV block grade, vasopressor requirement, lactate, glucose trend, SR formulation, and refractoriness to calcium + HIET — predicts need for mechanical circulatory support / VA-ECMO (ELSO; Crit Care 2023)
    inputs: sbp, hr, lactate
    actions: calc.news2, calc.qsofa
    advance: Severity tier assigned; ECMO-capable centre engaged for refractory shock
  9. 9TREATMENT
    Bundle: IV calcium (gluconate 30–60 mL 10% or chloride 10–20 mL 10% via central line) bolus + infusion; IV fluids; HIET as a CORE inotrope (regular insulin 1 U/kg IV bolus → 0.5–1 U/kg/h, titrate to 10 U/kg/h, with D-glucose + q30min glucose / q1h K); norepinephrine ± epinephrine; IV lipid emulsion; methylene blue for refractory vasoplegia; atropine (often ineffective); glucagon adjunct; transvenous pacing; whole-bowel irrigation for SR; VA-ECMO refractory (ACMT 2017; AACT lipid; Crit Care 2023)
    inputs: weight_kg, glucose, ionized_calcium, potassium, sbp
    advance: Calcium + HIET + vasopressor in flight; WBI for SR; lipid/methylene blue/ECMO escalation pathway armed
  10. 10DISPOSITION
    ICU for any symptomatic ingestion, any SR product, or any antidote requirement; medical toxicology + poison centre consult; ECMO-centre transfer for refractory shock; psychiatry if intentional (Crit Care 2023)
    advance: ICU + tox/poison-centre consult secured; ECMO transfer arranged if refractory
  11. 11MONITORING
    Continuous telemetry + arterial line; q30min glucose and q1h K during HIET (intracellular K shift), serial ionized calcium during calcium infusion, lactate clearance, MAP/cardiac output, urine output; prolonged monitoring (≥24 h) for SR pharmacobezoar (ACMT 2017)
    inputs: glucose, potassium, ionized_calcium, lactate
    actions: panel.metabolic, panel.cardiac, panel.renal
    advance: Hemodynamics improving, lactate clearing, off escalating vasopressors, HIET being weaned
  12. 12FOLLOWUP
    Wean HIET (taper as glucose tolerance falls — risk of hypoglycemia on abrupt stop), de-escalate vasopressors/calcium; psychiatry + safety planning if intentional; medication-safety / lethal-means counselling; pediatric poison-prevention education and Poison Control reporting (AACT/ACMT)
    advance: Antidotes safely weaned, psych/social disposition complete, prevention education delivered