Posted: July 4th, 2024

Complications and Management of Sustained-Release Diltiazem Overdose

Complications and Management of Sustained-Release Diltiazem Overdose

Diltiazem overdose presents significant challenges in emergency medicine due to its potential for severe cardiovascular complications. This paper examines the complications associated with sustained-release diltiazem overdose and discusses appropriate management strategies, including gastrointestinal decontamination and supportive care.

Complications of Sustained-Release Diltiazem Overdose

Sustained-release diltiazem overdose can lead to several serious complications, primarily affecting the cardiovascular system. The most significant complications include:

1. Hypotension: Severe and prolonged hypotension may occur due to the vasodilatory effects of diltiazem, potentially leading to organ hypoperfusion and shock (Arroyo and Kao, 2021).

2. Bradycardia: Excessive slowing of the heart rate can result from diltiazem’s action on the sinoatrial and atrioventricular nodes, potentially progressing to complete heart block (St-Onge et al., 2020).

3. Cardiac conduction abnormalities: Various conduction disturbances may develop, including atrioventricular blocks and bundle branch blocks (Patel et al., 2019).

4. Cardiogenic shock: The combination of hypotension and depressed myocardial contractility can lead to cardiogenic shock, a life-threatening condition (Arroyo and Kao, 2021).

5. Hyperglycemia: Calcium channel blockers can impair insulin release, resulting in elevated blood glucose levels (St-Onge et al., 2020).

Gastrointestinal Decontamination

In cases of sustained-release diltiazem overdose, gastrointestinal decontamination plays a crucial role in limiting drug absorption. The following approaches may be considered:

1. Activated charcoal: Administration of activated charcoal within 1-2 hours of ingestion can effectively adsorb the drug and reduce systemic absorption. Multiple doses of activated charcoal may be beneficial due to the sustained-release formulation (Patel et al., 2019).

2. Whole bowel irrigation: This technique may be employed to expedite the elimination of sustained-release tablets from the gastrointestinal tract, potentially reducing the duration and severity of toxicity (St-Onge et al., 2020).

3. Gastric lavage: While controversial, gastric lavage may be considered in cases of large ingestions presenting within one hour, provided there are no contraindications (Arroyo and Kao, 2021).

Management Strategies

The management of sustained-release diltiazem overdose requires a multifaceted approach, focusing on supportive care and specific interventions to address cardiovascular complications:

1. Fluid resuscitation: Intravenous fluid administration is crucial to address hypotension and maintain adequate organ perfusion (Patel et al., 2019).

2. Vasopressors: In cases of refractory hypotension, vasopressors such as norepinephrine or epinephrine may be necessary to maintain blood pressure (St-Onge et al., 2020).

3. Calcium administration: High-dose intravenous calcium, either as calcium gluconate or calcium chloride, can help counteract the cardiovascular effects of diltiazem by increasing intracellular calcium (Arroyo and Kao, 2021).

4. High-dose insulin therapy: The combination of high-dose insulin and glucose has shown efficacy in managing calcium channel blocker toxicity by improving myocardial contractility and peripheral vascular resistance (Patel et al., 2019).

5. Glucagon: Intravenous glucagon may be administered to increase cardiac output and heart rate through its positive inotropic and chronotropic effects (St-Onge et al., 2020).

6. Lipid emulsion therapy: Intravenous lipid emulsion has been reported as a potential rescue therapy in severe cases of calcium channel blocker toxicity (Arroyo and Kao, 2021).

7. Extracorporeal life support: In cases of refractory shock or severe cardiac dysfunction, extracorporeal membrane oxygenation (ECMO) may be considered as a temporary supportive measure (Patel et al., 2019).

8. Cardiac pacing: Temporary transvenous pacing may be necessary for patients with severe bradycardia or high-degree atrioventricular blocks (St-Onge et al., 2020).

Conclusion

Sustained-release diltiazem overdose presents significant challenges in emergency medicine due to its potential for severe cardiovascular complications. Prompt recognition of the toxicity, appropriate gastrointestinal decontamination, and implementation of targeted management strategies are essential for optimizing patient outcomes. A multidisciplinary approach involving emergency physicians, toxicologists, and critical care specialists is often necessary to provide comprehensive care for these complex cases.

References

Arroyo, A.M. and Kao, L., 2021. Calcium Channel Blocker Toxicity. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.

Patel, N., Patel, N.J., Arora, S., Patel, S., Patel, S., Patel, N., Tripathi, B., Deshmukh, A., Badheka, A.O., Atti, V. and Manvar, S., 2019. Trends in management and outcomes of acute poisoning from calcium channel blockers: A nationwide analysis. Journal of the American Heart Association, 8(24), p.e012373.

St-Onge, M., Dubé, P.A., Gosselin, S., Guimont, C., Godwin, J., Archambault, P.M., Chauny, J.M., Frenette, A.J., Darveau, M., Le Sage, N. and Poitras, J., 2020. Treatment for calcium channel blocker poisoning: a systematic review. Clinical Toxicology, 58(2), pp.108-120.

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History: A 47-year-old female presents to your emergency department 30 minutes
after a suicide attempt in which she ingested 2000 mg of sustainedrelease diltiazem. She insists there were no other ingested medications.
The patient has experienced no vomiting.
PMH: None.
Physical Examination:
T: 99.4°F HR: 90 bpm RR: 17 breaths per minute BP: 120/70 mm Hg
General: Alert and oriented.
HEENT: Examination is normal.
Pulmonary: Clear to auscultation.
CV: Regular rate and rhythm without murmur.
Abdomen: Soft and nontender.
Neurologic: GCS 15. Cranial nerves II-XII intact.
Skin: Pale with a normal capillary refill.
QUESTIONS CASE STUDY #14
1. What are the complications which may be associated with this type of overdose?
2. What type of gastrointestinal decontamination, if any, is indicated?
3. What management strategies should be used?

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