Which medical procedures are indicated in the treatment of calcium channel blocker (CCB) toxicity?

Updated: Jan 04, 2021
  • Author: B Zane Horowitz, MD, FACMT; Chief Editor: Michael A Miller, MD  more...
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A transvenous pacemaker may be placed if the transthoracic cutaneous pacer fails to capture in the face of symptomatic bradycardia. Pacing may decrease the need for pressors in a patient who may not tolerate a positive cardiac inotrope because of cardiac ischemia, although this likely is not a concern for pediatric patients. Cardiac pacing is typically required for 12-48 hours.

Consider temporary placement of an intra-aortic balloon pump for hypotension that is refractory to all other medical treatments. Cardiopulmonary bypass can be a last resort to support the blood pressure long enough for the body to clear the ingested toxin. [72, 73]

Extracorporeal membrane oxygenation (ECMO) has also been attempted in patients who have hypotension refractory to all pharmacologic therapies. One case reported by Durward described a massive diltiazem ingestion (12 g Cardura CD) that resulted in prolonged cardiac standstill. [74] However, after 48 hours of ECMO and 15 days in the critical care unit, the patient made a very good recovery and was discharged home "fit and well," showing "no evidence of neurologic dysfunction."

Plasma exchange [75] and continuous renal replacement techniques with hemodiafiltration [76] have each been used in cases of severe poisoning resistant to aggressive medical treatments, such as patients failing glucagon and norepinephrine infusions. [72, 73, 75, 76] These cannot be recommended at this time for CCB toxicity.

Although CCBs are highly protein bound, some physicians believe that hemodialysis or charcoal hemoperfusion may be used as a last resort in severely toxic patients who have no other hope. In a case report of overdose with sustained-release diltiazem, however, charcoal hemoperfusion showed little efficacy. [77]

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