Guideline sources The following summarized guidelines for the management of calcium channel blocker toxicity are prepared by our editorial team based on guidelines from the American Heart Association (AHA 2020), the American Heart Association (AHA/HRS/ACC 2019), and the Canadian Association of Poison Control Centres (CAPCC/ESICM/CAEP/AAPCC/SCCM/CPS/EAPCCT/ESEM/CCCS/ACMT 2017). 1 2 3 Guidelines 1. Medical management Gastric decontamination: consider administering oral activated charcoal in patients ingested a potentially toxic amount of CCB within 1 hour of presentation. C Intravenous calcium: As per AHA 2020 guidelines, consider administering IV calcium in patients with CCB overdose in refractory shock. C As per AHA 2019 guidelines, consider IV calcium to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise because of CCB overdose. C As per AAPCC 2017 guidelines: Administer IV calcium as first-line therapy in patients with symptomatic CCB poisoning. B https://web.pathway.md/diseases/rec5Aq6c0qybqr75Y 1/3 6/29/23, 3:24 AM Calcium channel blocker toxicity Pathway Administer IV calcium, even if previously administered, in addition to standard advanced cardiac life-support in patients with CCB poisoning in cardiac arrest. B High-dose insulin therapy: As per AHA 2020 guidelines, consider administering high-dose insulin with glucose in patients with CCB overdose in refractory shock. C As per AHA 2019 guidelines, consider administering high-dose insulin to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise because of CCB overdose. C As per AAPCC 2017 guidelines, administer high-dose insulin in addition to other first-line treatments in the presence of myocardial dysfunction in patients with CCB poisoning. B Show 5 more Glucagon: As per AHA 2020 guidelines, consider administering IV glucagon in patients with CCB overdose in refractory shock. C As per AHA 2019 guidelines, consider glucagon to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise because of CCB overdose. C Vasopressors: administer norepinephrine and/or epinephrine as first-line therapy in patients with CCB poisoning with shock, even if the myocardial function has not yet been assessed. Prefer norepinephrine in patients with vasodilatory shock. B Show 3 more Atropin: consider administering atropine as first-line therapy in patients with CCB poisoning with symptomatic bradycardia or conduction disturbances. C Lipid-emulsion therapy: consider administering IV lipid-emulsion therapy in patients with CCB poisoning refractory to first-line treatments. C Show 3 more 2. Therapeutic procedures Temporary cardiac pacing: Consider inserting a pacemaker in the presence of unstable bradycardia or high-grade AV block without significant alteration in cardiac inotropism in patients with CCB poisoning refractory to first-line treatments. C Consider inserting a pacemaker as rescue therapy, if not tried previously, in the presence of unstable bradycardia or high-grade AV block without significant alteration in cardiac inotropism in patients with CCB poisoning having refractory shock or periarrest. C Extracorporeal membrane oxygenation: As per AHA 2020 guidelines, consider performing ECMO in patients with CCB overdose in shock refractory to pharmacological therapy. C https://web.pathway.md/diseases/rec5Aq6c0qybqr75Y 2/3 6/29/23, 3:24 AM Calcium channel blocker toxicity Pathway As per AAPCC 2017 guidelines, consider performing veno-arterial ECMO, in centers where the treatment is available, in patients with CCB poisoning with cardiac arrest or caridogenic shock. C Clinical findings Medication history Vital signs CCBs Bradycardia Hypotension Cardiac exam Respiratory exam Acute cardiogenic pulmonary edema Crackles Cardiac arrest ECG findings Cardiogenic shock Jugular venous distention AV block Lab findings blood glucose Imaging findings Pulmonary edema References 1. Maude St-Onge, Kurt Anseeuw, Frank Lee Cantrell et al. Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Crit Care Med. 2017 Mar;45 3):e306-e315. Open 2. Ashish R Panchal, Jason A Bartos, Jos G Caba as et al. Part 3 Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S366 S468. Open 3. Fred M Kusumoto, Mark H Schoenfeld, Coletta Barrett et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019 Aug 20;140 8):e382-e482. Open 4. St-Onge M, Anseeuw K, Cantrell FL et al. Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Crit Care Med. 2017 Mar;45 3):e306-e315. Open https://web.pathway.md/diseases/rec5Aq6c0qybqr75Y 3/3