Clinical Commander

Back to dossier
tox.calcium-channel-blocker-overdose.core.v1PRODUCTION
tox.calcium-channel-blocker-overdose.core.v1

Calcium channel blocker overdose

toxicologyacuteadultpediatric
Hard-required inputs
0 / 12
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
1
Actions
0
Advance rule
Set
Advance when

CCB exposure scenario established and formulation (IR vs SR) noted

Patient inputs (13)

Pediatric "one-pill-can-kill" — a single SR verapamil/diltiazem tablet can kill a toddler; weight drives all antidote dosing

Calcium, HIET, lipid-emulsion dosing are all weight-based (U/kg, mL/kg)

Non-DHP (verapamil/diltiazem) vs DHP (amlodipine/nifedipine); IMMEDIATE- vs SUSTAINED-RELEASE drives delayed/prolonged-toxicity expectation + WBI decision

Time since ingestion + estimated dose; SR products peak 6–18 h with pharmacobezoar — a well-appearing early patient can crash

Beta-blocker, digoxin, antihypertensive co-ingestion compounds bradycardia / shock and changes antidote sequence

HYPERGLYCEMIA is the CCB fingerprint (islet insulin-secretion blockade) — separates CCB from beta-blocker tox and correlates with severity (St-Onge 2017)

Baseline + serial during calcium therapy to avoid dangerous hypercalcemia

HIET drives intracellular K shift — q1h K, replace to keep ≥2.8–3.0 mEq/L; baseline before infusion

Sinus bradycardia, PR prolongation, high-grade AV block, junctional escape, QRS/QT changes; baseline rhythm + monitoring

Bradycardia + AV block (non-DHP) vs reflex tachycardia early then bradycardia (DHP massive); drives calcium/atropine/pacing

Hypotension severity drives calcium → fluids → HIET → vasopressor escalation

AMS reflects cerebral hypoperfusion / impending arrest; airway watch

Tissue hypoperfusion marker; trend guides escalation to mechanical support

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningrefractory_bradycardia_av_block
    Symptomatic bradycardia / high-grade or complete AV block unresponsive to atropine + calcium boluses (non-DHP phenotype) (Crit Care 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_shock_for_hiet_and_lipid
    Hypotension / cardiogenic shock not corrected by calcium boluses + IV fluids (St-Onge Crit Care Med 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningperiarrest_refractory_to_full_ladder
    Peri-arrest / shock refractory to calcium + max HIET + ≥2 vasopressors ± lipid/methylene blue (ELSO)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpediatric_one_pill_can_kill
    Pediatric ingestion — a single SR verapamil/diltiazem tablet can be lethal in a toddler (Crit Care 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresr_formulation_ingestion
    Sustained-/extended-release verapamil, diltiazem, or amlodipine ingestion (even if currently asymptomatic) (ACMT 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehyperglycemia_distinguishes_ccb
    Hyperglycemia + shock without DKA — pivots diagnosis to CCB (insulin-secretion blockade) vs beta-blocker (St-Onge Crit Care Med 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RED_FLAGSrequiredDrives severity classification
Loading…

Recommended regimen

CCB overdose — antidotal ladder (calcium → HIET core inotrope → vasopressor → lipid / methylene blue → mechanical support)
axis: ccb_overdose_antidotal_ladderstep 1 - Step 1 — IV calcium (bolus → infusion) + GI decontamination
Selected step "Step 1 — IV calcium (bolus → infusion) + GI decontamination" — Any symptomatic CCB ingestion: hypotension, bradycardia, or AV block
  • calcium gluconate
    first line
    calcium_salt
    30–60 mL of 10% (3–6 g) IV over 5–10 min; repeat q10–20 min ×3–4 PRN, then infusion 0.6–1.5 mL/kg/h of 10% titrated to ionized calcium / hemodynamics • IV • bolus then continuous infusion
    triggers: hypotension, bradycardia, av_block, peripheral_iv_only
    ACMT 2017 — first antidote; overcomes channel blockade by raising extracellular calcium gradient. Gluconate preferred when only peripheral access (less caustic on extravasation). Target ionized Ca up to ~2× normal; surveil for hypercalcemia (Crit Care 2023)
    rxcui 1908
  • calcium chloride
    first line
    calcium_salt
    10–20 mL of 10% (1–2 g) IV via CENTRAL line over 5–10 min; repeat q10–20 min PRN then infusion • IV (central) • bolus then continuous infusion
    triggers: central_line_available, severe_shock_needs_3x_calcium_per_volume
    3× elemental calcium per mL vs gluconate — preferred in severe shock when central access exists; vesicant, central line mandatory (ACMT 2017)
    rxcui 1901
  • whole-bowel irrigation (polyethylene glycol)
    add on
    gi_decontamination
    PEG-ELS 1–2 L/h (adult) / 25 mL/kg/h (peds) NG until rectal effluent clear • PO/NG • continuous until effluent clear
    triggers: sustained_release_formulation, large_ingestion_within_window, protected_airway_if_AMS
    ACMT 2017 — SR verapamil/diltiazem form pharmacobezoars; WBI limits ongoing absorption. Activated charcoal 1 g/kg if early and airway protected. Hold if ileus / unprotected airway (Crit Care 2023)

ed playbook — drug actions (6)

  1. 1. calcium gluconate (or chloride if central)
    Gluconate 30–60 mL 10% IV over 5–10 min, repeat q10–20 min ×3–4; chloride 10–20 mL 10% central • IV • bolus then infusion
    trigger: Hypotension / bradycardia / AV block
    First antidote — raise extracellular calcium gradient (ACMT 2017)
  2. 2. HIET (regular insulin)
    1 U/kg IV bolus then 0.5–1 U/kg/h, titrate to 10 U/kg/h • IV • bolus then infusion
    trigger: Shock not rapidly corrected by calcium + fluids — start EARLY
    Core inotrope, not last resort (St-Onge Crit Care Med 2017)
  3. 3. dextrose + potassium
    D50 25–50 g PRN then D10–25 infusion; KCl to keep K ≥2.8–3.0 • IV • titrated, q30min glucose / q1h K
    trigger: HIET running
    Prevent HIET hypoglycemia / intracellular hypokalemia (Crit Care 2023)
  4. 4. norepinephrine ± epinephrine
    NE 0.05–0.5 mcg/kg/min titrate to MAP ≥65; add epi for mixed shock • IV (central) • continuous
    trigger: MAP <65 despite calcium + HIET
    Phenotype-guided pressor (Crit Care 2023)
  5. 5. atropine (adjunct)
    0.5–1 mg IV q3–5 min, max 3 mg • IV • PRN bradycardia
    trigger: Symptomatic bradycardia
    Often ineffective — do not delay calcium/HIET/pacing (ACMT 2017)
  6. 6. IV lipid emulsion 20% (rescue)
    1.5 mL/kg bolus, repeat ×1–2 for arrest, then 0.25 mL/kg/min • IV • bolus then infusion
    trigger: Peri-arrest / refractory lipophilic CCB
    Refractory rescue (AACT/ACMT lipid workgroup)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Reported / suspected verapamil, diltiazem, amlodipine, nifedipine ingestion (ACMT 2017); Bradycardia + hypotension in a patient on or with access to a CCB (Crit Care 2023); Hyperglycemia + shock without diabetic ketoacidosis — CCB until proven otherwise (St-Onge Crit Care Med 2017).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Calcium channel blocker overdose** (tox.calcium-channel-blocker-overdose.core.v1).
Phenotype framing: 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)
Scope: Establish acute CCB exposure (intentional, accidental pediatric, therapeutic error); classify the engine as a cardiotoxic-shock toxidrome with delayed-peak SR risk (ACMT 2017)

No severity triggers fired against current inputs.

Plan

Regimen axis: **CCB overdose — antidotal ladder (calcium → HIET core inotrope → vasopressor → lipid / methylene blue → mechanical support)** — step "Step 1 — IV calcium (bolus → infusion) + GI decontamination".
1. calcium gluconate 30–60 mL of 10% (3–6 g) IV over 5–10 min; repeat q10–20 min ×3–4 PRN, then infusion 0.6–1.5 mL/kg/h of 10% titrated to ionized calcium / hemodynamics IV bolus then continuous infusion (calcium_salt, first line) — ACMT 2017 — first antidote; overcomes channel blockade by raising extracellular calcium gradient. Gluconate preferred when only peripheral access (less caustic on extravasation). Target ionized Ca up to ~2× normal; surveil for hypercalcemia (Crit Care 2023)
2. calcium chloride 10–20 mL of 10% (1–2 g) IV via CENTRAL line over 5–10 min; repeat q10–20 min PRN then infusion IV (central) bolus then continuous infusion (calcium_salt, first line) — 3× elemental calcium per mL vs gluconate — preferred in severe shock when central access exists; vesicant, central line mandatory (ACMT 2017)
3. whole-bowel irrigation (polyethylene glycol) PEG-ELS 1–2 L/h (adult) / 25 mL/kg/h (peds) NG until rectal effluent clear PO/NG continuous until effluent clear (gi_decontamination, add on) — ACMT 2017 — SR verapamil/diltiazem form pharmacobezoars; WBI limits ongoing absorption. Activated charcoal 1 g/kg if early and airway protected. Hold if ileus / unprotected airway (Crit Care 2023)

Setting playbook (ed) — Recognize CCB toxidrome (bradycardia/hypotension + hyperglycemia), start calcium + early HIET, decontaminate SR, escalate pressors, and mobilize ICU/ECMO before collapse (ACMT 2017)
4. calcium gluconate (or chloride if central) Gluconate 30–60 mL 10% IV over 5–10 min, repeat q10–20 min ×3–4; chloride 10–20 mL 10% central IV bolus then infusion — Hypotension / bradycardia / AV block (First antidote — raise extracellular calcium gradient (ACMT 2017))
5. HIET (regular insulin) 1 U/kg IV bolus then 0.5–1 U/kg/h, titrate to 10 U/kg/h IV bolus then infusion — Shock not rapidly corrected by calcium + fluids — start EARLY (Core inotrope, not last resort (St-Onge Crit Care Med 2017))
6. dextrose + potassium D50 25–50 g PRN then D10–25 infusion; KCl to keep K ≥2.8–3.0 IV titrated, q30min glucose / q1h K — HIET running (Prevent HIET hypoglycemia / intracellular hypokalemia (Crit Care 2023))
7. norepinephrine ± epinephrine NE 0.05–0.5 mcg/kg/min titrate to MAP ≥65; add epi for mixed shock IV (central) continuous — MAP <65 despite calcium + HIET (Phenotype-guided pressor (Crit Care 2023))
8. atropine (adjunct) 0.5–1 mg IV q3–5 min, max 3 mg IV PRN bradycardia — Symptomatic bradycardia (Often ineffective — do not delay calcium/HIET/pacing (ACMT 2017))
9. IV lipid emulsion 20% (rescue) 1.5 mL/kg bolus, repeat ×1–2 for arrest, then 0.25 mL/kg/min IV bolus then infusion — Peri-arrest / refractory lipophilic CCB (Refractory rescue (AACT/ACMT lipid workgroup))

Non-pharmacologic actions:
- Whole-bowel irrigation for SR ingestion (PEG-ELS NG) once airway protected (ACMT 2017)
- Activated charcoal 1 g/kg if early presentation + airway protected (Crit Care 2023)
- Two large-bore IVs + early central line for calcium chloride / pressors (ACMT 2017)
- Continuous cardiac + arterial monitoring; transcutaneous pacing pads on (Crit Care 2023)
- Notify ICU + ECMO-capable centre EARLY for SR / refractory shock (ELSO)

AVOID / contraindication checks:
- Calcium chloride central line only — vesicant tissue necrosis on extravasation (ACMT 2017)
- Do not delay HIET as a last resort — start early as a core inotrope (St Onge Crit Care Med 2017)
- HIET requires q30min glucose and q1h potassium — hypoglycemia and intracellular hypokalemia (Crit Care 2023)
- Atropine frequently ineffective in CCB AV block — do not delay calcium/HIET/pacing waiting for it (ACMT 2017)
- Methylene blue avoid in G6PD deficiency and with serotonergic agents — serotonin syndrome / hemolysis (Crit Care 2023)
- Lipid emulsion may cause fat overload and interfere with lab assays — reserve for refractory/peri arrest (AACT/ACMT lipid workgroup)
- Surveil ionized calcium during calcium infusion — avoid dangerous hypercalcemia (Crit Care 2023)
- Engage ECMO capable centre early for refractory shock — do not wait for arrest (ELSO)

Monitoring

Regimen monitoring:
- continuous telemetry + arterial line (Crit Care 2023)
- glucose q30min during HIET titration (St-Onge Crit Care Med 2017)
- potassium q1h during HIET — replace to keep K ≥2.8–3.0 mEq/L (Crit Care 2023)
- ionized calcium q1–2h during calcium infusion — avoid hypercalcemia (ACMT 2017)
- lactate clearance q2–4h as perfusion marker (Crit Care 2023)
- MAP / cardiac output (echo or invasive) to phenotype pump vs vasoplegia (ELSO)
- prolonged ≥24 h monitoring for SR pharmacobezoar delayed peak (ACMT 2017)
- delayed hypoglycemia surveillance for hours after HIET discontinuation (St-Onge 2017)

Setting (ed) monitoring:
- HR/rhythm + MAP continuous (ACMT 2017)
- Glucose q30min during HIET (St-Onge Crit Care Med 2017)
- Potassium q1h during HIET (Crit Care 2023)
- Ionized calcium q1–2h during calcium infusion (ACMT 2017)
- Lactate q2–4h (Crit Care 2023)

Follow-up plan: 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)
- Close-out criterion: Antidotes safely weaned, psych/social disposition complete, prevention education delivered

Monitoring phase: 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)

Disposition

Current setting: ed — Recognize CCB toxidrome (bradycardia/hypotension + hyperglycemia), start calcium + early HIET, decontaminate SR, escalate pressors, and mobilize ICU/ECMO before collapse (ACMT 2017)

Disposition criteria:
- ICU: any antidote requirement, any SR product, any symptomatic ingestion, any AV block (Crit Care 2023)
- Monitored ward only if asymptomatic IR ingestion with normal serial vitals/ECG + observation window cleared (ACMT 2017)
- Transfer to ECMO-capable centre for refractory cardiogenic shock (ELSO)
- Psychiatry + safety planning before discharge if intentional (AACT/ACMT)

Escalation triggers (move to higher acuity):
- Refractory hypotension on calcium + HIET → add vasopressors + ICU now (Crit Care 2023)
- High-grade AV block / pre-arrest → pacing + ICU + tox consult (ACMT 2017)
- SR product ingestion → admit/observe ≥24 h even if currently well (pharmacobezoar) (ACMT 2017)
- Peri-arrest / shock refractory to full ladder → IV lipid + ECMO-centre transfer (ELSO)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Symptomatic bradycardia / high-grade or complete AV block unresponsive to atropine + calcium boluses (non-DHP phenotype) (Crit Care 2023)
- [LIFE_THREATENING] Hypotension / cardiogenic shock not corrected by calcium boluses + IV fluids (St-Onge Crit Care Med 2017)
- [LIFE_THREATENING] Peri-arrest / shock refractory to calcium + max HIET + ≥2 vasopressors ± lipid/methylene blue (ELSO)

Citations

- ACMT 2017 Position Statement: Interim Guidance for the Use of High-Dose Insulin and Lipid Emulsion in CCB/BB Poisoning + St-Onge et al. Crit Care Med 2017 (Experts Consensus / systematic review on CCB-poisoning management) + AACT/ACMT Lipid Emulsion Workgroup + 2023 Critical Care narrative review of CCB/BB toxicity + ELSO ECPR guidance [PMID:27749343](https://pubmed.ncbi.nlm.nih.gov/27749343/)
- Cited evidence (PMID 28169558) [PMID:28169558](https://pubmed.ncbi.nlm.nih.gov/28169558/)
- Cited evidence (PMID 26059743) [PMID:26059743](https://pubmed.ncbi.nlm.nih.gov/26059743/)
- Cited evidence (PMID 37170354) [PMID:37170354](https://pubmed.ncbi.nlm.nih.gov/37170354/)
- Cited evidence (PMID 25998059) [PMID:25998059](https://pubmed.ncbi.nlm.nih.gov/25998059/)

Last reconciled with current guidelines: 2026-05-16.
References
  • ACMT 2017 Position Statement: Interim Guidance for the Use of High-Dose Insulin and Lipid Emulsion in CCB/BB Poisoning + St-Onge et al. Crit Care Med 2017 (Experts Consensus / systematic review on CCB-poisoning management) + AACT/ACMT Lipid Emulsion Workgroup + 2023 Critical Care narrative review of CCB/BB toxicity + ELSO ECPR guidance — PMID:27749343
  • Cited evidence (PMID 28169558) — PMID:28169558
  • Cited evidence (PMID 26059743) — PMID:26059743
  • Cited evidence (PMID 37170354) — PMID:37170354
  • Cited evidence (PMID 25998059) — PMID:25998059