Pediatric Calcium Channel Blocker Toxicity Workup

  • Author: Derrick Lung, MD, MPH; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Dec 9, 2011
 

Approach Considerations

Look for hyperglycemia, hypokalemia, and a decreased serum bicarbonate level secondary to acidosis in patients with suspected calcium channel blocker toxicity. Obtain a baseline calcium level before intravenously administering calcium, unless the patient requires immediate detoxification due to severe poisoning. Other tests that can be performed include the following:

  • Arterial blood gas - Consider this test in severely affected patients; in patients with significant toxicity, arterial blood gases can be used to assess the acid-base status and respiratory function
  • Aspirin level - Determine the aspirin level of all patients who present to the ED after a suicide attempt
  • Acetaminophen level - Determine the acetaminophen level of all patients who present to the ED after a suicide attempt
  • Urine toxicology - Positive screening testing may suggest significant co-ingestants such as opiates

Determining the serum drug level of the ingested medication quickly enough to assist clinical decision-making is rarely feasible unless you have immediate access to a research laboratory.

Foley catheter placement

This may be indicated to monitor urine output in severely poisoned patients.

Imaging studies

An abdominal flat plate may be obtained if a co-ingestion with a radio-opaque tablet is also suspected.

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Electrocardiography

Electrocardiography (ECG) is neither sensitive nor specific for calcium channel blocker toxicity. Even so, ECG should be performed in all patients who present to the ED who may have ingested any cardiac medication. Toxicity from calcium channel blockers may manifest as bradycardia; tachycardia; first-, second-, or third-degree AV block; any type of bundle-branch block; and/or nonspecific ST-T wave changes.

Electrocardiography should also be evaluated for signs of tricyclic antidepressant (TCA) overdose. This results in a positive deflection in the augmented voltage unipolar right arm lead (aVR) in the terminal 40 microseconds of the complex. TCA toxicity can rapidly progress to malignant arrhythmia if left untreated.

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Contributor Information and Disclosures
Author

Derrick Lung, MD, MPH  Fellow, Medical Toxicology, University of California, San Francisco, School of Medicine; Clinical Instructor, Division of Emergency Medicine, Stanford University Medical Center

Derrick Lung, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, MMB, FACEP  Assistant Professor, Associate 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 Medical Center

Mark A Silverberg, MD, MMB, FACEP 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.

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.

Additional Contributors

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose .

References

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  16. American College of Medical Toxicology. ACMT position statement: interim guidance for the use of lipid resuscitation therapy. J Med Toxicol. Mar 2011;7(1):81-2. [Medline].

  17. Varpula T, Rapola J, Sallisalmi M, Kurola J. Treatment of serious calcium channel blocker overdose with levosimendan, a calcium sensitizer. Anesth Analg. Mar 2009;108(3):790-2. [Medline].

  18. Durward A, Guerguerian AM, Lefebvre M, Shemie SD. Massive diltiazem overdose treated with extracorporeal membrane oxygenation. Pediatr Crit Care Med. Jul 2003;4(3):372-6. [Medline].

 
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