Dig/CCB/BB Overdose

[MediMike]

Alright. What's everyone's go to for CCB/BB OD/BRASH syndrome? Have had a couple patients recently who have been refractory to everything I've thrown at them to include methylene blue

Calcium, NE, epi, vaso, high dose insulin (currently at 5u/kg/hr)...patient also had a high dig level and got 3 vials of Digibind that we had to pry from pharmacy's hands.

It's been a little demoralizing, refractory vasoplegia is a PITA.

[EMEDPA]

I assume you tried glucagon at some point for its inotropic potential. Guessing you tried that before epi, etc

next option is dialysis, right? 

[JEFTU]

Intralipid rescue therapy?

Have you consulted your toxicology service?

[LT_Oneal_PAC]

5 hours ago, MediMike said:

Alright. What's everyone's go to for CCB/BB OD/BRASH syndrome? Have had a couple patients recently who have been refractory to everything I've thrown at them to include methylene blue

Calcium, NE, epi, vaso, high dose insulin (currently at 5u/kg/hr)...patient also had a high dig level and got 3 vials of Digibind that we had to pry from pharmacy's hands.

It's been a little demoralizing, refractory vasoplegia is a PITA.

Agree with what others said. Doing the right things. Did you give 1 unit/kg insulin boils or just straight to the drip? 5-10 mg glucagon bolus, followed by 5-10mg/hr along with some droperidol or something because they will become a fountain of vomit. Start intralipid therapy. Only thing I’ll add is with the epi/norepi drips, doses will need to be significantly higher. Titrate to life, as my old attending would say.

[MediMike]

Have you had any good experience with glucagon outside of an ipecac emulator? I've yet to have personal anecdotal or trial evidence supporting it and the puking has always turned me off to it. When I picked up this patient everyone was so focused on the dig level of 3.7 that they ignored the new prescriptions for dilt and metoprolol.

Agree with "supratherapeutic" (hate that term) dosing of the pressors. RNs always get nervous but I'll push until I stop seeing a return.

Intralipid has been a wash for us in the past as well, proven efficacy in LAST but haven't seen much success in these mixed ODs.

I know metoprolol is dialyzable but dilt isn't, we had started emergent HD and didn't clear much but the lactate.  Push dose epi saved the day during induction though, gave her a nice little bump that maintained for 30 minutes or so. 

Checked on her this morning from home and it's looking like we may win this one, has titrated off of the epi, most of the NE and is back down to 1u/kg/hr of insulin (peaked at 5u/kg/hr...that's a lotta fluid). 

We had a mixed ARB and CCB OD a couple weeks ago that crashed and burned within 10 hours, refractory to every trick, turned down for ECMO due to a lack of support system.

All about surviving that initial phase...and making sure you've got your %$@ together in case you need ECMO!

[LT_Oneal_PAC]

8 hours ago, MediMike said:

Have you had any good experience with glucagon outside of an ipecac emulator? I've yet to have personal anecdotal or trial evidence supporting it and the puking has always turned me off to it. When I picked up this patient everyone was so focused on the dig level of 3.7 that they ignored the new prescriptions for dilt and metoprolol.

Agree with "supratherapeutic" (hate that term) dosing of the pressors. RNs always get nervous but I'll push until I stop seeing a return.

Intralipid has been a wash for us in the past as well, proven efficacy in LAST but haven't seen much success in these mixed ODs.

I know metoprolol is dialyzable but dilt isn't, we had started emergent HD and didn't clear much but the lactate.  Push dose epi saved the day during induction though, gave her a nice little bump that maintained for 30 minutes or so. 

Checked on her this morning from home and it's looking like we may win this one, has titrated off of the epi, most of the NE and is back down to 1u/kg/hr of insulin (peaked at 5u/kg/hr...that's a lotta fluid). 

We had a mixed ARB and CCB OD a couple weeks ago that crashed and burned within 10 hours, refractory to every trick, turned down for ECMO due to a lack of support system.

All about surviving that initial phase...and making sure you've got your %$@ together in case you need ECMO!

Unfortunately did not see a lot of CCB or BB overdose in residency. In fact, I think I had just one. 

honestly, I hate glucagon. I feel like it’s one of those things that people keep trying to make work for something and never does. I never use it in food impaction anymore. But these people have a high mortality, so I’m throwing the kitchen sink at them. Intralipid therapy is pretty theoretical too for this, but again, kitchen sink in the ED.

push dose pressors for the win! 
 

I didn’t know you couldn’t get ECMO for lacking a support system. Maybe there is something I’m missing, but that feels …wrong? I mean, we are putting ECMO on in the ED these days and we certainly have no idea about a support system when we do it. Not implying it’s your choice. I get it with transplants and what not. I suppose if you had a person you suspected an anoxic brain injury and wouldn’t be able to return to function, but that’s a tough call.