eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Calcium Channel Blocker: Follow-up

Author: Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Contributor Information and Disclosures

Updated: May 14, 2009

Follow-up

Further Inpatient Care

  • The need to hospitalize patients who have mild calcium channel blocker (CCB) ingestions is debated.
    • Most physicians believe that adults who have potentially severe calcium channel blocker toxicity and toddlers who have ingested as little as one sustained-release calcium channel blocker tablet should be observed in the hospital for 24 hours for arrhythmias and hypotension.
    • Some groups of physicians and toxicologists are beginning to debate this practice. They state that when a few tablets are ingested, poison centers may reasonably recommend observation at home rather than refer patients for prolonged (24-h) in-hospital monitoring if the child is asymptomatic. This argument places the burden on the physician to prove that these ingestions are safe enough to be treated at home.
  • Obtain a psychiatric evaluation for all suicidal patients after they have been medically stabilized.

Further Outpatient Care

  • Most poison control centers recommend discharge and home monitoring of the patient if they are asymptomatic after 6-12 hours of ED observation, as long as they did not ingest a sustained-release calcium channel blocker preparation.
  • Patients who have exhibited suicidal ideations should have a psychiatric consultation before discharge home from the ED.

Transfer

  • Some patients may present with overwhelming bradycardia and hypotension that is unresponsive to available medical management. Patients with these complications may require cardiopulmonary bypass, extracorporeal membrane oxygenation (ECMO), or an intraaortic balloon pump to maintain peripheral perfusion until the calcium channel blocker has cleared their system; transferring these patients to a facility offering such services may be reasonable.
  • Not all community hospitals offer a pediatric ICU for inpatient care of the hemodynamically unstable child. This may also be an indication to transfer the patient.

Deterrence/Prevention

  • Parents should keep all medicine out of reach of children.
  • Use childproof bottles for all medications, especially those that are potentially dangerous to youngsters.
  • All homes should have the number of the local poison control center posted on or near their telephones for use in an emergency. The number for the New York City poison control center is 212-POISONS (212-764-7667); the center offers advice to anyone who calls from anywhere in the world. The new national poison control number is 800-222-1222; calling this number connects the caller to their regional poison control center.

Complications

  • Seizure
  • Coma
  • Death
  • Anoxic encephalopathy from prolonged CNS hypoxia
  • Ileus
  • Bowel infarction or perforation from mesenteric hypotension
  • Noncardiogenic pulmonary edema
  • Aspiration pneumonia

Prognosis

Prognosis depends on the following:

  • Amount and formulation of drug ingested
  • Co-ingestions
  • Patient's age
  • Time elapsed before treatment begins
  • Underlying disease states
  • Specific treatments
  • Initial rhythm
  • Use of a pacemaker and time before it is placed

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Few medical or legal concerns are specifically associated with calcium channel blocker (CCB) toxicity.
  • However, failure to recognize co-ingestion of a substance that has an antidote or simple treatment can result in litigation if the failure contributes to a negative outcome.

Special Concerns

  • Data collection and case reporting through regional poison control centers are necessary to direct further investigations and to determine the epidemiology of substance ingestions.
  • When calling a poison control center, be prepared to give as much information as possible during the initial call.
  • Estimate amount and type of drug ingested, elapsed time since ingestion, and time treatment was started.
  • Many poison control centers make follow-up calls to learn patient outcomes; the physician can supply additional information at that time.
 


More on Toxicity, Calcium Channel Blocker

Overview: Toxicity, Calcium Channel Blocker
Differential Diagnoses & Workup: Toxicity, Calcium Channel Blocker
Treatment & Medication: Toxicity, Calcium Channel Blocker
Follow-up: Toxicity, Calcium Channel Blocker
Multimedia: Toxicity, Calcium Channel Blocker
References
Further Reading
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Further Reading

The AAPCC has released the following clinical guidelines: Calcium channel blocker ingestion: an evidence-based consensus guideline for out-of-hospital management.

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Keywords

calcium channel blocker, Ca+ 2 channel blocker, calcium channel antagonist, slow channel blocker, CCB, nifedipine, diltiazem, verapamil, congenital heart malformations, arrhythmias, hypertension, congestive heart failure, subarachnoid hemorrhage, suicide, bradycardia, hepatomegaly, hepatojugular reflux, enteric dysmotility, hyperglycemia, phenylkalkylamine, dihydropyridine, cerebral ischemia, torsades de pointes, hypokalemia, treatment, diagnosis, overdose

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Contributor Information and Disclosures

Author

Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

William T Zempsky, MD, Associate Director, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
William T Zempsky, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Merck Salary Employment

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
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