ʻO ka Beta-Blocker a me ka Calcium Channel Blocker Overdose: Slow Heart Rate and Shock Triage¶

ʻO nā Beta-blockers a me ka calcium channel blockers (CCBs) kekahi o nā lāʻau lapaʻau maʻamau i kuhikuhi pinepine ʻia ma ka honua holoʻokoʻa, hoʻohana ʻia i kēlā me kēia lā e nā miliona o nā pākeke e mālama i ke koko kiʻekiʻe, angina, puʻuwai puʻuwai, naʻau arrhythmias, migraines, a me nā haʻalulu. Eia nō naʻe, i ka overdose koʻikoʻi, a i ʻole ke ʻai ʻana o kahi keiki liʻiliʻi i hoʻokahi a ʻelua paha mau papa hoʻokuʻu hoʻokuʻu ʻia, ʻo kēia mau papa lāʻau lapaʻau ʻelua no ka hapa nui o nā lāʻau ʻawaʻawa maʻi cardiovascular i hōʻike ʻia i nā kikowaena hoʻomalu o ka honua. Inā manaʻo ʻoe ua lawe kekahi i ka overdose o ke kahe koko a i ʻole ka puʻuwai puʻuwai, a i ʻole ua kau ke keiki i hoʻokahi papa hoʻokahi i loko o ko lākou waha, e kelepona i kāu helu pilikia kūloko (911 ma ʻAmelika Hui Pū ʻIa a me Kanada, 112 ma waena o ka European Union, 999 i United Kingdom) ma o kā mākou helu pilikia papa kuhikuhi koke. No ka mea hiki ke hoʻomohala koke ka hāʻule ʻana o ka maʻi cardiovascular koʻikoʻi a i ʻole he mau hola ma hope o ka lohi asymptomatic hoʻopunipuni. ʻona kōkua mua, ka ʻike ʻana i ka haʻalulu lapaʻau, a ka hoʻōla ʻana o ka puʻuwai puʻuwai (CPR) oiai e kali ana i na kanaka lapaau.

He aha ka mea e hoʻopunipuni ai ka beta-blocker a me ka calcium channel blocker i ka hui pū ʻana o ka hemodynamic wikiwiki me nā papa hoʻokuʻu koke a me ka manawa lōʻihi o 6 a 24 mau hola me ka hoʻokuʻu lōʻihi (ER, XL, SR, CD, a i ʻole LA). Hiki i ka mea maʻi ke ale i ka verapamil hoʻokuʻu lōʻihi, diltiazem, amlodipine, metoprolol, a propranolol paha ke hele i loko o kahi keʻena pilikia e kamaʻilio maʻamau me ka puʻuwai maʻamau a me ke kahe koko maʻamau, e paheʻe wale i loko o ka refractory bradycardia (piʻi ka puʻuwai pōʻino), poloka puʻuwai piha, nā hola vasoplegic hohonu ma hope o ka hopu ʻana a i ʻole 12 mau hola ma hope o ka hopu ʻana i ka maʻi cardtic. hoʻoheheʻe ʻia ka uhi ʻana i ka ʻōpū o lalo. Hoʻopili kēia alakaʻi i nā hana ma mua o ka haukapila, ka make ʻana o ka pediatric single-pill, pehea e hoʻokaʻawale ai i ka beta-blocker mai ka calcium channel blocker toxicity me ka hoʻohana ʻana i ka glucose koko a me nā hōʻailona electrocardiogram, ka hoʻomaʻamaʻa mua ʻana o ka ʻōpū, a me nā kaʻina hoʻopakele o ka hale mālama kino me ka high-dose insulin euglycemic therapy (HIET), intravenous a me ka hoʻopakele lipid, emulcagon.

E hana i kēia i kēia manawa¶

1. Kele koke i nā lawelawe lapaʻau kūikawā a me ka hoʻomalu ʻana i ka lāʻau make: E kelepona iā 911 (US a me Kanada), 112 (EU), a i ʻole 999 (UK) inā ua lawe ke kanaka i ka nui o ka manaʻo, ua nīniu, hiamoe, huikau, pōkole o ka hanu, a i ʻole he puʻupuʻu lohi a haʻahaʻa ke koko, a inā ua ʻai ke keiki i hoʻokahi pil. Ma ʻAmelika Hui Pū ʻIa, hiki iā ʻoe a i ʻole kahi mea kōkua ke kāhea aku i ka Poison Control ma 1-800-222-1222 oiai e kali ana i ke kaʻa kaʻa i hiki i ke kauka lāʻau toxicologist ke hoʻomaopopo mua i ka hale mālama koʻikoʻi o ka haukapila.
2. E hōʻiliʻili i kēlā me kēia omole pila, pūʻulu blister, a me ka mea hoʻonohonoho pila i kēlā me kēia pule: E hoʻopaʻa i nā ʻōmole pololei a i ʻole nā ​​pahu pepa i hiki i nā paramedic a me nā kauka pilikia ke heluhelu i ka inoa lāʻau, ka ikaika milligram ma kēlā me kēia papa, a me ka suffix hoʻokuʻu (e like me ER, XL, SR, XT, LA, CD, a i ʻole hoʻokuʻu koke). E helu i nā lāʻau i koe inā hiki a e nānā i ka manawa o ka uaki i moni ʻia ai nā lāʻau.
3. E hoʻomoe i ke kanaka ma ke kua a pale iā ia mai ke kū ʻana i luna: ʻO nā beta-blockers a me ka calcium channel blockers e pale i ka hiki o ke kino ke hoʻopaʻa i nā kīʻaha koko a i ʻole ka wikiwiki o ka naʻau ke kū. ʻO ke kū ʻana a i ʻole ka hele ʻana i kahi kaʻa hiki ke hoʻoulu i ka syncope orthostatic hikiwawe (maule), ʻeha poʻo, a i ʻole ka hopu ʻana i ka naʻau. E hoʻopaʻa i ke kanaka me ka hoʻokiʻekiʻe iki ʻana o kona mau wāwae ma luna o ka uluna ke ʻole ʻo ia e paʻakikī e hanu mai ka wai i loko o ko lākou māmā (pulmonary edema), i laila e hoʻopaʻa ʻia ko lākou poʻo a me nā poʻohiwi ma 30 a 45 degere.
4. Mai hoʻokuke aku i ka mea maʻi i ka haukapila iā ʻoe iho: No ka mea hiki ke loaʻa ka maʻi maʻi i ka haukapila (ʻoi loa me ka propranolol), ka puʻuwai ʻekolu-degere, a me ka hopu ʻana i ka naʻau me ka ʻole o ka ʻōlelo ʻana i loko o kahi kaʻa ponoʻī e neʻe ana, e kali mau i kahi kaʻa kaʻa paramedic i hoʻolako ʻia me nā monitor cardiac, intravenous atropine, calcium, glucagon, vasopressors, a me nā cardia transcutaneous waho.
5. Mai hoʻoulu i ka luaʻi a i ʻole hāʻawi i ka meaʻai, ka waiū, a i ʻole ka wai: Mai hoʻāʻo e hana i ka mea maʻi e ʻāke a luaʻi paha. I loko o kahi beta-blocker a i ʻole calcium channel blocker overdose, hoʻoulu ʻia ke aʻalolo vagus, ka mea e hoʻokuʻu ai i ka acetylcholine ma luna o kahi sinoatrial a me atrioventricular node a hiki ke hoʻōki koke i ka puʻuwai (vagal asystole). E mālama ʻole i ka ʻōpū inā pono ke keʻena pilikia e hāʻawi i ka lanahu hoʻōla, ka hoʻoheheʻe ʻana i ka ʻōpū holoʻokoʻa, a i ʻole ke kaʻina hana wikiwiki.
6. E nānā i ka pane ʻana a me ka hanu ʻana i kēlā me kēia 60 kekona a hoʻomākaukau no CPR: E noho pololei ma ka ʻaoʻao o ke kanaka. Inā lilo lākou i mea pane ʻole a hoʻōki i ka hanu maʻamau (a i ʻole ka ʻūhā wale nō), e hoʻomaka koke i ka hoʻopaʻa ʻana i ka umauma ma ka wikiwiki o ka 100 a 120 kaomi i kēlā me kēia minuke a me ka hohonu o 5 a 6 mau kenimika (2 a 2.4 iniha) no ke kanaka makua a hiki i ka lawe ʻana o ka lāʻau lapaʻau.

Laau hoʻoholo: Beta-blocker a me ka calcium channel blocker overdose triage¶

flowchart TD
    Start["Manaʻo ʻia ʻo Beta-Blocker (BB) a i ʻole Calcium Channel Blocker (CCB)."] --> CallEMS["E kelepona iā 911 / 112 / 999 a me ka hoʻomalu ʻana i ka lāʻau make ʻĀpana i kēia manawa"]
    CallEMS --> Position["E hoʻomoe paʻa i ka maʻi (ʻaʻole e kū) a e hōʻiliʻili i nā ʻōmole pila a pau"]
    Position --> CheckVitals{"ʻAʻole pane ʻole ka maʻi a ʻaʻole hanu maʻamau?"}

    CheckVitals -->|Yes| StartCPR["Hoʻomaka koke i ka CPR Kūlana Kiʻekiʻe (100-120/min) a hoʻopili iā AED"]
    CheckVitals -->|No, Awake or Drowsy| IdentifyForm{"E nānā i ka Lepili Bomole: Hoʻokuʻu koke (IR) vs Hoʻokuʻu Hoʻonui (ER / XL / SR / CD)?"}

    IdentifyForm -->|Immediate-Release (IR) or Liquid| EarlyWindow["Hoʻomaka i loko o 30 mau minuke a 2 mau hola: kiaʻi no ka wikiwiki o ka Bradycardia, Hypotension, a i ʻole ka hopu ʻana."]
    IdentifyForm -->|Extended-Release (ER/XL/SR) or Amlodipine| DelayedWindow["Hoʻopaneʻe ka hoʻomaka ʻana a hiki i 6 a 24 mau hola: Manaʻo 24-Hour ICU / Telemetry Observation ʻOiai inā Asymptomatic"]

    EarlyWindow --> HospitalArrival["ʻO ka hōʻea ʻana o ka Halemai ED: 12-Lead ECG, Point-of-Care Blood Glucose, Serum Electrolytes, Lactate"]
    DelayedWindow --> HospitalArrival

    HospitalArrival --> GI_Decon{"Hōʻike ʻia i loko o 1-2 mau hola (IR) a i ʻole ka hoʻohana ʻana i ka Sustained-Release / Massive Pill Burden?"}
    GI_Decon -->|Yes, Airway Protected| GiveCharcoal["ʻO ka Lahu Hoʻonā Hoʻokahi-Dose (1 g/kg a hiki i 50 g) + Whole-Bowel Irrigation (PEG) no ka hoʻokuʻu lōʻihi."]
    GI_Decon -->|No or Intubated First| DiffClue{"E nānā i nā hōʻailona o ke koko koko a me ka puʻuwai"}
    GiveCharcoal --> DiffClue

    DiffClue -->|Hyperglycemia (High Blood Sugar) + Hypotension| SuspectCCB["ʻO ka hōʻailona ikaika no ka mea hoʻopaʻa ʻana i ke kahawai Calcium (CCB) i ka ʻawaʻawa (Paʻa ʻia nā Kanal Kēleʻa L-Type Pancreatic)"]
    DiffClue -->|Hypoglycemia or Normal Sugar + Bradycardia / Seizures| SuspectBB["Manaʻo ikaika no ka Beta-Blocker (BB) Toxicity (Paʻa Glycogenolysis; E nānā iā QRS/QTc no Propranolol/Sotalol)"]

    SuspectCCB --> RescueProtocol["Hoʻopakele ICU: IV Crystalloids, IV Calcium (Chloride/Gluconate), Atropine, Norepinephrine/Epinephrine, High-Dose Insulin Euglycemic Therapy (HIET 1-10 U/kg/hr + Dextrose)"]
    SuspectBB --> RescueProtocol2["Hoʻopakele ICU: IV Atropine, IV Glucagon Bolus + Infusion, IV Calcium, Catecholamine Vasopressors, High-Dose Insulin (HIET), Sodium Bicarbonate inā QRS> 100 ms"]

    RescueProtocol --> RefractoryShock{"ʻO Refractory Shock a i ʻole ka hopu ʻia ʻana o ka naʻau me ka ʻoi loa o ka lāʻau lapaʻau?"}
    RescueProtocol2 --> RefractoryShock
    RefractoryShock -->|Yes| ECMO_Rescue["Kūkākūkā koke o Veno-Arterial ECMO (VA-ECMO), Intravenous Lipid Emulsion (20% Intralipid), a i ʻole Methylene Blue no Vasoplegia"]

Ka ʻike ʻana i ka lāʻau lapaʻau hewa: Nā papa lāʻau, nā inoa inoa, a me nā suffix¶

ʻO ka ʻike inā he beta-blocker ka lāʻau lapaʻau i hoʻomoʻa ʻia a i ʻole he paʻa kaila calcium, a nona ka papa haʻahaʻa, e hoʻoholo pololei i nā pilikia e manaʻo ʻia e ka hui pilikia.

1. Beta-adrenergic receptor blockers (nā inoa maʻamau e pau ana i ka "-olol", "-alol", a i ʻole "-ilol")¶

ʻO nā beta-blockers hoʻokūkū hoʻokūkū kūʻē i ka beta-1 adrenergic receptors i loko o ka puʻuwai (e hoʻolōʻihi i ka helu sinoatrial pacemaker, hoʻolōʻihi i ka hoʻokele nodal atrioventricular, a me ka emi ʻana o ka contractility) a me nā mea loaʻa beta-2 i loko o ka māmā, nā kīʻaha koko, a me ka ate (ke kumu o ka bronchospasm a me ka hoʻokuʻu ʻana o ka glucose hepatic). Lawe nā mea hana kūikawā i ka make make beta non-beta i ka overdose:

• Propranolol (Inderal, Inderal LA), Acebutolol (Sectral), Carvedilol (Coreg), a me Labetalol (Trandate): Voltage-Gated Sodium Channel Blockade:
• ʻO Propranolol ka beta-blocker make loa i ka overdose koʻikoʻi. No ka mea he lipophilic (momona-soluble) nui loa, hele ia i ka pale koko-lolo i loko o 20 a 60 mau minuke e ho'āla ai i ka coma hikiwawe a me ka nui seizures. I ka manawa like, pale ia i ka puʻuwai wikiwiki i ka uila uila ** sodium channel , e hoʻonui ana i ka ** QRS complex (> 100 a 120 ms), e hana ana i kahi hawewe R ma ke alakaʻi aVR, a e hoʻoulu ai i nā arrhythmias ventricular e koi ai i ka intravenous hypertonic sodium bicarbonate.
• Sotalol (Betapace, Sorine): Hoʻopaʻa ʻia ka Channel Potassium a me Torsades de Pointes:
• Hoʻopaʻa ʻo Sotalol i ka naʻau i waho ** nā kaila potassium**, me ka hoʻolōʻihi ʻana i ka QTc interval a me ka hoʻoulu ʻana i ka polymorphic ventricular tachycardia (Torsades de Pointes), e koi ana i ka intravenous magnesium sulfate, potassium repletion, a me ka overdrive pacing.
• Ka Cardioselective Beta-1 Blockers: Atenolol (Tenormin), Metoprolol (Lopressor, Toprol-XL), Bisoprolol (Zebeta), a me Nebivolol (Bystolic):
• Ua nalowale ke koho ʻana o ka mea hoʻokipa ma nā overdoses nui. No ka mea hiki ke hoʻoheheʻe ʻia ka atenolol a me sotalol i ka wai me ka hoʻopaʻa haʻahaʻa o ka protein a me ka hoʻomaʻemaʻe renal, ʻo ia nā beta-blockers ʻelua i hoʻomaʻemaʻe maikaʻi ʻia e hemodialysis.

2. ʻO nā mea hoʻopaʻa ʻana i ke kahawai calcium (Non-Dihydropyridines vs. Dihydropyridines)¶

Kāohi nā mea hoʻopaʻa awāwa calcium i ka puka uila L-type calcium channels e hoʻokele i ka sinoatrial/atrioventricular nodal conduction, cardiac myocyte contraction, and vascular smooth muscle sound:

1. Non-Dihydropyridine ("Cardioselective") CCBs: Verapamil (Calan, Isoptin, Verelan) a me Diltiazem (Cardizem, Cardizem CD, Cartia XT, Tiazac):
2. E hoʻopaʻa me ka pili kiʻekiʻe i nā ala L-type ma nā ** cardiac pacemaker/myocyte cell** a me ** peripheral blood vessels**, e hana ana i ka triad lethal of severe bradycardia/AV block, cardiogenic pump failure, a me peripheral vasodilation. Lawe ʻo Verapamil a me diltiazem i ka make kiʻekiʻe loa o nā lāʻau lapaʻau cardiovascular āpau.
3. Dihydropyridine ("Vascular-Selective") CCB (e pau ana ma "-dipine"): Amlodipine (Norvasc), Nifedipine (Procardia XL, Adalat CC), Felodipine (Plendil), a me Nicardipine (Cardene):
4. E hana nui ma luna o peripheral vascular smooth muscle, e hoʻoulu ai i ka arterial vasodilation a me hypotension i ka mua me reflex sinus tachycardia (paʻi puʻuwai wikiwiki). I nā overdoses nui, nalowale ke koho a hoʻomohala ka puʻuwai puʻuwai. ʻO Amlodipine he 30-a-50-hola hapalua-ola (a hiki i 100 mau hola i ka overdose), e koi ana i nā lā o ke kākoʻo ICU.

No ke aha ke Koko Koko (Hyperglycemia vs. Hypoglycemia) He hōʻailona koʻikoʻi no ka diagnostic diagnostic¶

ʻO ka ** hoʻāʻo koko koko ma ka ʻaoʻao o kahi moe** e hoʻokaʻawale koke i ka beta-blocker mai ka calcium channel blocker i nā mea ʻawaʻawa a wānana i ka nui o ka haʻalulu:

1. No ke aha e hoʻonui ai i ka nui o ka calcium Channel Blocker i ka Hyperglycemia koʻikoʻi¶

Pono nā pūnaewele beta-islet pancreatic i ka hoʻokomo ʻana o ka calcium ma o ** mau kaha calcium L-type-voltage-gate ** no ka hoʻokuʻu ʻana i ka insulin i loko o ke koko. Ke hoʻopaʻa ʻo verapamil, diltiazem, amlodipine, a i ʻole nifedipine i kēia mau awāwa, hoʻoki ʻia ka huna ʻana o ka insulin endogenous a hoʻomaka ke kūpaʻa ʻana o ka insulin: - Ma lalo o ke koʻikoʻi a me ka haʻalulu, hoʻololi ka ʻiʻo o ka naʻau i kāna wahie ikehu pono mai nā ʻakika momona manuahi i glucose. - Me ka ʻole o ka insulin, ʻaʻole hiki i ka puʻuwai pōloli ke huki i ka glucose mai ke kahe koko i loko o nā myocytes cardiac. - Piʻi wikiwiki ka glucose koko (pinepine 200 a 400+ mg/dL [11.1 a 22.2+ mmol/L] i ka poʻe maʻi maʻi ʻole), a ʻo ke kiʻekiʻe o ka hyperglycemia e hoʻopili pololei me ka nui o ka overdose a me ka pilikia o ka make.

2. No ke aha o Beta-Blocker overdose ke kumu o ka Hypoglycemia a me ka huna i kona mau hōʻailona¶

Kāohi ʻia nā beta-blockers i ka beta-2 adrenergic receptors i loko o ke ake, e ālai ana i ka glycogenolysis a me gluconeogenesis. I nā kamaliʻi, nā kamaliʻi, a me nā mākua hoʻokē ʻai, hoʻoulu kēia i ka ** hypoglycemia aʻe (ke koko ma lalo o 70 mg/dL a i ʻole 3.9 mmol/L)** i ka manawa like e hoʻopiʻi ana i nā hōʻailona adrenergic (ka haʻalulu a me ka palpitations), e hoʻoulu ai i ka hypoglycemic coma a i ʻole ka hopu ʻana.

Pediatric Single-Pill Lethality and the Extended-Release Time Bomb¶

1. No ke aha e hiki ai i ka papa makua hookahi ke make i ke keiki opiopio¶

He mau lālā koʻikoʻi o ka papa inoa "One-Pill Can Kill" pediatric nā mea hoʻopaʻa aʻa i ka calcium. - ʻO kahi papa hoʻokuʻu kākoʻo hoʻokahi makua hoʻokahi o verapamil (120 a 240 mg), diltiazem CD (180 a 360 mg), nifedipine XL (30 a 90 mg), a i ʻole amlodipine (5 a 10 mg) i ʻai ʻia e kahi **10 a 15 kg i hoʻopaʻa ʻia i ka hypotension (22 a hiki i ka 15 kg) ke kumu hoʻomaha. paʻa puʻuwai, a me ka hopu ʻana i ka naʻau make. - Ma muli o ka hoʻopaneʻe ʻana o nā mea hoʻokuʻu hoʻokuʻu ʻia, hiki i ke keiki e ʻai i hoʻokahi pila i ke kakahiaka ke ʻike maʻamau i ke awakea a pau a loaʻa i ka maʻi maʻi maʻi i ko lākou hiamoe ʻana i kēlā pō. - Mandatory Pediatric Protocol: ʻO kēlā me kēia keiki i ʻike ʻia a i manaʻo ʻia ka ʻai ʻana i hoʻokahi mea hoʻokuʻu hoʻokuʻu calcium channel blocker a i ʻole beta-blocker ** pono e lawe ʻia e ka kaʻa kaʻa i kahi keʻena pilikia a ʻae ʻia no nā hola he 24 o ka nānā ʻana i ka telemetry cardiac hoʻomau **, ʻoiai inā ʻaʻohe asymptomatic.

2. Hoʻokaʻawale i nā Suffix i hoʻokuʻu ʻia ma ka ʻōmole Pill¶

ʻO ka hoʻomaʻemaʻe ʻana i ka ʻōpū: hoʻōki i ka hoʻoheheʻe ʻana ma mua o ka hemo ʻana o ka uhi¶

No ka mea hiki ke hoʻopili ʻia nā lāʻau lapaʻau hoʻokuʻu mau i loko o kahi pharmacobezoar lohi lohi a lawe i ka make nui i ka wā e komo ai, he mea koʻikoʻi ka **decontamination mua o ka ʻōpū:

1. Single-Dose Activated Charcoal (SDAC): Hāʻawi ʻia ma 1 g/kg (a hiki i 50 g) i loko o 1 a 2 hola o ka ʻai ʻana i hoʻokuʻu koke ʻia, a i ʻole ** a hiki i 4 a 6+ mau hola ** ma hope o ka ʻai ʻana o ka hoʻokuʻu lōʻihi, inā e ala ka mea maʻi a pale i ko lākou ala ea (a i ʻole i hoʻokomo ʻia).
2. Whole-Bowel Irrigation (WBI): Hoʻohana ʻia ma o ka paipu nasogastric me ka hoʻohana ʻana i ka ** polyethylene glycol electrolyte solution (PEG-ELS)** ma 1.5 a i ka 2 L/hola i nā pākeke (25 a 40 mL/kg/hola i nā keiki) no ka ʻai nui ʻana i ka verapamil hoʻokuʻu paʻa, difelatiarelease a i ʻole ka verapamil, beta-block. holo pono ka effluent. Hoʻopaʻa ʻia i ka ʻākea ʻana o ka ʻōpū, ke ea pale ʻole, a i ʻole ka haʻalulu nui me ka ileus.

Stepwise Hospital and ICU Rescue Protocols¶

Ke hoʻomohala ka mea maʻi i ka bradycardia hōʻailona, conduction blocks, a i ʻole hypotension mai ka beta-blocker a i ʻole ka calcium channel blocker overdose, nā lāʻau lapaʻau maʻamau single-agent advanced cardiac life support (ACLS) e like me atropine wale nō ʻaneʻane pau ʻole no ka mea ua hoʻopiha ʻia nā mea hoʻokipa a i ʻole nā ​​kanilā mamao. Hoʻopuka nā hui mālama koʻikoʻi i kahi ** pūʻolo hoʻopakele hoʻopakele hemodynamic me ka nui i ka manawa hoʻokahi **:

KaʻAnuʻu Hana 1: Ea Alaala Makaala, Intravenous wai, a me Atropine¶

• ** Makaʻala loa me ka hoʻokomo wikiwiki ʻana (RSI)**: ʻO ka hoʻokomo ʻana i ka mea maʻi i ka cardiogenic a i ʻole ka haʻalulu vasoplegic e hoʻoneʻe i ka hopena aloha aloha a hāʻule i ka hoʻihoʻi venous ma o ka ventila-pressure maikaʻi, hiki ke hoʻomaka i ka hopu ʻana i ka puʻuwai peri-intubation. Ma mua o ka hoʻokomo ʻana, hoʻomaka nā kauka ulia pōpilikia i ka epinephrine push-dose a i ʻole ka infusion norepinephrine mau, hāʻawi i ka calcium intravenous, a hoʻohana i ka hemodynamically stable induction agents (e like me ketamine a i ʻole etomidate).
• Judicious Intravenous Crystalloids: Hāʻawi i kahi bolus mua o 10 a 20 mL/kg (500 a 1,000 mL i loko o ke kanaka makua) o ka isotonic crystalloid kaulike e hoʻoponopono i ka hypovolemia pili mai ka vasodilation. E hōʻalo i ka hoʻonui ʻana i ka nui o ka wai no ka mea ʻo ka hoʻohaʻahaʻa ʻana o ka myocardial contractility a me ka insulin kiʻekiʻe e hoʻolalelale koke i ka edema pulmonary acute.
• Intravenous Atropine: Hāʻawi 0.5 mg i 1 mg IV (a i ʻole 0.02 mg/kg i nā keiki, liʻiliʻi 0.1 mg) i kēlā me kēia 3 a 5 mau minuke a hiki i ka 3 mg ka nui no ka bradycardia hōʻailona ma ke ʻano he alahaka mua i ka wā e hoʻomākaukau ai ka calcium, glucagon, a me ka insulin kiʻekiʻe.

KaʻAnuʻu 2: Intravenous Calcium Salts (Chloride or Gluconate)¶

ʻO ka hoʻokiʻekiʻe ʻana i ka calcium ionized extracellular e hoʻokumu i ka gradient concentrate e hoʻoikaika i nā ion calcium ma o nā kaila calcium L-type i wehe ʻole ʻia i loko o nā myocytes naʻau a me nā ʻiʻo ʻiʻo maʻemaʻe vascular, e hoʻomaikaʻi ana i ka contractility myocardial a me ke koko.

• 10% Calcium Chloride (Central Line or Cardiac Arrest): Loaʻa i ʻekolu manawa ʻoi aku ka nui o ka calcium elemental no ka mililita ma mua o ka calcium gluconate (10 mL of 10% Calcium Chloride = 1 gram = 272 mg [13.6 mEq] elemental calcium). Hāʻawi ʻia e like me **10 a 20 mL (1 a 2 grams) IV lohi ma luna o 5 a 10 mau minuke ** (a i ʻole 0.2 mL/kg i nā keiki), hana hou ʻia i kēlā me kēia 10 a 20 mau minuke a i ʻole e ukali ʻia e ka infusion mau (0.2 to 0.4 mL/kg/hour), e huli ana i ka pae calcium ionized ma kahi o ʻelua manawa maʻamau (2.0 a 2.5 mmol/L). Hoʻokumu ka calcium chloride i ka necrosis koʻikoʻi o ka ʻiʻo inā e hoʻonui ʻia mai kahi peripheral IV.
• 10% Calcium Gluconate (Pale no nā Laina IV Peripheral): Loaʻa 90 mg (4.65 mEq) elemental calcium per 10 mL vial. No ka mea he hoʻokahi hapakolu e like me ka concentrated, hāʻawi i ʻekolu manawa i ka nui: 30 mL a 60 mL (3 a 6 grams) IV ma luna o 10 mau minuke (a i ʻole 0.6 mL/kg i nā keiki), e hana hou i kēlā me kēia 10 a 20 mau minuke a i ʻole holo ma ke ʻano he infusion mau (0.6 to 1.5 mL/kg/hour).
• Hoʻokoe: Mai hāʻawi i ka calcium intravenous inā loaʻa i ka mea maʻi ke ʻawaʻawa digoxin.

KaʻAnuʻu Hana 3: High-Dose Glucagon (Scific no Beta-Blocker Overdose)¶

I loko o ka beta-blocker overdose, ua ālai ʻia ka beta-1 adrenergic receptor, e pale ana i nā catecholamine mai ka hana ʻana i intracellular cyclic adenosine monophosphate (cAMP).

• Mechanism: Hoʻopaʻa ʻo Glucagon i kona puʻuwai glucagon receptor ponoʻī, hoʻōla i ka adenylyl cyclase a hana i ka cAMP intracellular kūʻokoʻa loa mai ka loaʻa beta-1 e hoʻonui ai i ka puʻuwai a me ka contractility.
• Dosing Protocol: Hāʻawi i kahi bolus IV mua o 5 mg a 10 mg o Glucagon i nā pākeke (a i ʻole 0.05 a i 0.15 mg/kg i nā keiki) ma luna o 1 a 2 mau minuke. No ka mea he pōkole ka hapalua o ke ola o ka glucagon he 8 a 16 mau minuke, e hahai koke i ka pane maikaʻi me ka hoʻomau IV infusion ma 2 mg a 10 mg i kēlā me kēia hola.
• Antiemetic Pre-Treatment: Hoʻomaha ka glucagon maʻa kiʻekiʻe i ka sphincter esophageal haʻahaʻa a hoʻoulu i ka luaʻi projectile. E mālama mua i nā manawa a pau me ka ondansetron (4 a 8 mg IV) a pale i ke ala ea.

KaʻAnuʻu Hana 4: Catecholamine Vasopressors, Sodium Bicarbonate, a me Magnesium¶

Manaʻo nā alakaʻi toxicology o kēia manawa e hoʻomaka i ka infusion catecholamine kiʻekiʻe me ka wai a me ka calcium:

• Epinephrine a me Norepinephrine: Hoʻokomo ʻia ma ka laina waena e hāʻawi i ka beta-1 adrenergic inotropic/chronotropic kākoʻo (no ka bradycardia a me ka pau ʻana o ka pauma) a me ka alpha-1 adrenergic vasoconstriction (no ka dihydropyridine vasoplegic shock).
• Sodium Bicarbonate no Propranolol Widened QRS: Inā ʻai ka mea maʻi i ka propranolol, acebutolol, a carvedilol a hōʻike ka ECG i kahi ākea QS waena i ʻoi aku ma mua o 100 a 120 milliseconds, e hāʻawi iā 1 i ka 2 mEq/kg Hypertonic Sodium Bicarbonate IV e hoʻokuʻu ʻia ** ma lalo o ka 1000 pH ms a hiki i ka 1000mm arterial. 7.55.
• Magnesium Sulfate no Sotalol Prolonged QTc: Inā ʻai ka mea maʻi i ka sotalol a loaʻa iā ia ka QTc lōʻihi a i ʻole Torsades de Pointes, e hoʻohana i ka 2 grams o Magnesium Sulfate IV ma luna o 5 a 10 mau minuke, e hoʻopiha i ka potassium i 4.5 a i 5.0 mEq/L, a e hoʻohana i ka isoprotecing heart rate a ma luna o ka isoproterenol a i ʻole.

KaʻAnuʻu Hana 5: High-Dose Insulin Euglycemic Therapy (HIET): ʻO ka Hoʻopakele Metabolic Kūlana Gula¶

High-Dose Insulin Euglycemic Therapy (HIET) ʻo ia ka pōhaku kihi e hoʻopakele ai i ka lāʻau lapaʻau no ka overdose a me ka haʻalulu puʻupuʻu cardiogenic beta-blocker. No ka mea, lawe ʻo HIET i ka 15 a i 45 mau minuke e hiki ai i ka hopena inotropic kiʻekiʻe, e hoʻomaka koke ia i ka wā i manaʻo ʻia ai ka pilikia o ka myocardial a i ʻole ka haʻalulu:

1. Mechanism of Action: Ua lanakila ka nui o ka insulin i ka pancreatic calcium blockade a me ka insulin resistance, e hoʻololi i nā mea lawe GLUT4 i ka myocardial cell membrane i hiki i ka puʻuwai koʻikoʻi ke puhi i ka glucose/pyruvate no ATP, hoʻomaikaʻi pololei i ka lawelawe ʻana i ka calcium intracellular sarcoplasmic reticulum (hoʻoikaika ikaika i ka contractility cardiac), a hoʻomaikaʻi i ka microvascular perfusion ma o ka endothelial nits
2. Ke Kiʻi Kūlohelohe a me ka Potassium: Inā ʻoi aku ka nui o ka glucose o ke koko ma lalo o 200 mg/dL (11.1 mmol/L), e hāʻawi mua iā 25 a 50 grams o IV Dextrose; inā emi ka serum potassium ma lalo o 3.0 mEq/L, e hoʻomaka i ka hoʻololi ʻana i ka potassium.
3. Bolus Insulin IV Mau a me Infusion Hoʻomau: Hāʻawi i 1 Unit/kg Regular Human Insulin IV bolus (e.g., 70 a 80 Units i loko o ke kanaka makua), a ukali koke ʻia me ka hoʻomau ʻana o ka Insulin Insulin mau e hoʻomaka ana ma 1 Unit/kg/hour a hoʻonui ʻia i luna i kēlā me kēia 15 a 30 mau minuke a hiki i ka **10 mau minuke a hiki i ka **10 mau ʻāpana.
4. Concentrated Dextrose Co-Infusion: Infuse D10W, D20W, a i ʻole D50W (ma ka laina waena) ma 0.5 a i 1.0 g/kg/hola, e nānā ana i ka glucose koko i kēlā me kēia 15 a 30 mau minuke no ka mālama ʻana i ka euglycemia (110 a i 180 mg/dL [6.1 mmol/L]). Pono e hoʻomau pinepine ʻia ʻo Dextrose infusion no 24+ hola ma hope o ka hoʻōki ʻana i ka insulin ke hoʻomaka hou ka hoʻokuʻu ʻana o ka insulin pancreatic endogenous.
5. Ka nānā ʻana i ka Potassium: Hoʻololi ka insulin nui i ka pāpaʻa i loko o nā cell me ka pau ʻole o nā hale kūʻai kino. E nānā i ka serum potassium i kēlā me kēia 1 a i 2 mau hola a mālama i nā pae ma waena o 2.8 a me 3.2 mEq/L i mea e pale aku ai i ka hyperkalemia hou i ka wā e hemo ai ka insulin.

KaʻAnuʻu 6: Hoʻopakele Refractory: Pacing, Methylene Blue, Lipid Emulsion, a me VA-ECMO¶

• Transcutaneous and Transvenous Pacing: Hoʻāʻo ʻia no ka bradycardia koʻikoʻi a i ʻole poloka AV kiʻekiʻe, ʻoiai ʻaʻole pinepine ka hopu ʻana i ka uila a me ka mīkini i ka myocardium pōloli nui.
• Methylene Blue: Hāʻawi ʻia (1 to 2 mg/kg IV over 20 minutes) no ka refractory dihydropyridine (amlodipine/nifedipine) vasoplegic shock e kāohi i ka guanylyl cyclase a hoʻihoʻi i ke kani vascular.
• Intravenous Lipid Emulsion (20% Intralipid): Hāʻawi ʻia (1.5 mL/kg IV bolus, alaila 0.25 mL/kg/min) no ka lāʻau make lipophilic weliweli i ke ola (verapamil, diltiazem, amlodipine, propranolol) i pane ʻole i nā lāʻau lapaʻau maʻamau.
• Veno-Arterial ECMO (VA-ECMO): ʻO ka cannulation VA-ECMO mua ke alahaka ho'ōla ola no ka haʻalulu cardiogenic refractory a i ʻole ka hopu ʻana i ka naʻau, kākoʻo i ke kahe ʻana a me ka oxygenation no 3 a 7 mau lā a hiki i ka metabolized ka lāʻau.

Nā helu ulia pōpilikia āpana a me nā protocols oihana¶

Nīnau pinepine¶

Ua hoʻokomo paha kaʻu keiki liʻiliʻi i kekahi o nā lāʻau paʻi koko a ko lākou kupuna kāne i hoʻokuʻu ʻia i loko o ko lākou waha, 4 mau hola i hala, a ke holo nei lākou me ka hana maʻamau. Pono anei mākou e hele i ke keʻena pilikia?¶

ʻAe, pono ʻoe e lawe koke i ke keiki i ke keʻena pilikia o ka haukapila a i ʻole e kelepona iā 911. Hiki ke make i kahi keiki makua hoʻokahi papa hoʻokuʻu lōʻihi o verapamil, diltiazem, nifedipine, a i ʻole amlodipine. No ka mea, ua hoʻolālā ʻia nā pale hoʻokuʻu hoʻokuʻu ʻia e hoʻoheheʻe mālie i ka ʻāpana digestive haʻahaʻa ma mua o 12 a 24 mau hola, hiki i ke keiki ke nānā i 100 pakeneka olakino a pāʻani no nā hola 6 a hiki i 14 mua a laila e ʻeha koke ʻia ka puʻuwai piha a me ka hopu ʻana i ka naʻau i ka hiamoe ʻana i ka pō. ʻO kēlā me kēia keiki me ka ʻai ʻana i ʻike ʻia a i manaʻo ʻia paha i ka ʻai ʻana i kahi mea hoʻokuʻu hoʻokuʻu ʻia ka calcium channel blocker a i ʻole beta-blocker e koi i ka liʻiliʻi o 24 mau hola o ka nānā mau ʻana i ka naʻau i loko o kahi haukapila.

He aha ka hopena inā lawe ʻino ke kanaka makua i ʻelua pānaʻi (ʻelua mau huaʻai ma mua o hoʻokahi) o kā lākou lāʻau lapaʻau i kuhikuhi ʻia i kēlā me kēia lā?¶

Inā lawe wale kekahi kanaka makua i hoʻokahi papa pālua o kā lākou beta-blocker maʻamau i kēlā me kēia lā (e like me ka metoprolol a i ʻole atenolol) a i ʻole ka mea hoʻopaʻa ala calcium (e like me ka amlodipine a i ʻole diltiazem), e kelepona koke i kāu kikowaena Poison Control Center (1-800-222-1222 ma US) me ka ʻōmole ma ka lima. I ka nui o na hihia ina ua hoomanawanui mua ka mea ma'i i ko lakou palapala kauoha i kela la i keia la a aohe ona puuwai ko'iko'i o lalo, e lawe ana i elua o ko lakou mau papa maa mau i mea e hoonawaliwali wale ai a i ole ka lohi iki paha e hiki ke kiai pono ia ma hope o ka helu ana o ke kanaka laau make i ka nui o ka milligram, koe nae ka pilikia o ke kanaka, e lawe i ka beta-blocker a me ka verapamil/diltiazem hui, ka puuwai, a me ka ma'i pu'uwai. 50 paʻi i ka minuke.

No ke aha e hāʻawi ai nā kauka pilikia i ka nui o ka insulin i ka mea maʻi ʻaʻole i maʻi maʻi ma hope o ka overdose o ka calcium channel blocker?¶

Hoʻopaʻa ʻia nā kaila calcium ʻano L i loko o ka puʻuwai a me ka pancreas, e pani ana i ka hoʻokuʻu ʻana o ka insulin maoli o ke kino i ka manawa like me ka koi ʻana i ka ʻiʻo puʻuwai koʻikoʻi e hilinaʻi i ka glucose ma mua o nā waikawa momona no ka ikehu. Me ka ʻole o ka insulin, ʻaʻole hiki i ka ʻiʻo puʻuwai pōloli ke komo i ka glucose mai ke koko a nalowale kona mana ʻomi. ʻO ka hoʻokomo ʻana i ka insulin maʻamau kiʻekiʻe (1 a 10 mau ʻāpana i ka kilokani i kēlā me kēia hola, a hiki i 10 mau manawa kiʻekiʻe ma mua o ka maʻi diabetic doses) me ke kō (dextrose) i hoʻopaʻa ʻia e hoʻoikaika pono i ka ikehu i loko o nā puʻuwai puʻuwai, hoʻomaikaʻi i ka mālama ʻana i ka calcium intracellular, a hoʻihoʻi hou i ka ikaika o ka pume puʻuwai ma mua o nā lāʻau lapaʻau ʻē aʻe.

No ke aha i manaʻo ʻia ai ʻoi aku ka pōʻino o ka propranolol i kahi overdose nui ma mua o nā beta-blockers e like me metoprolol a i ʻole atenolol?¶

ʻAʻole like me ka wai-soluble beta-blockers e noho nui ana i loko o ke kahe koko, ʻo propranolol ka momona-soluble (lipophilic) a hoʻopaʻa pū hoʻi i nā kahawai sodium i loko o ka puʻuwai a me ka lolo. Ma muli o kona hele wikiwiki ʻana i ka pale koko-lolo, hiki i ka nui o ka propranolol overdose ke hoʻoulu i ka coma a me ka hoʻopaʻapaʻa ākea i loko o 20 a 60 mau minuke ma hope o ka ʻai ʻana i nā lāʻau. I ka manawa like, hoʻomāhuahua ka sodium-channel blockade i ka paʻakikī QRS uila o ka puʻuwai a hoʻoulu i nā arrhythmias ventricular lethal, e koi ana i ka sodium bicarbonate intravenous e hoʻohui i nā lāʻau lapaʻau beta-blocker.

Hiki i ka hemodialysis (he mīkini dialysis kidney) ke kānana i nā beta-blockers a i ʻole nā ​​​​mea hoʻopaʻa ala calcium mai ke koko?¶

No ka mea kokoke i nā mea hoʻopaʻa ala calcium (verapamil, diltiazem, amlodipine, nifedipine) a me ka hapa nui o nā beta-blockers (propranolol, metoprolol, carvedilol, labetalol), ʻAʻole hiki i ka hemodialysis ke wehe i ka lāʻau no ka mea ua paʻa paʻa kēlā mau lāʻau i nā protein koko a māhele ʻia i loko o ka momona a me nā ʻiʻo. Eia nō naʻe, ʻelua mau ʻokoʻa koʻikoʻi: ʻo Atenolol a me Sotalol he wai-soluble, haʻahaʻa loa ka paʻa ʻana o ka protein, a hoʻomaʻemaʻe ʻia e nā puʻupaʻa, no laila hiki i ka hemodialysis pilikia ke wehe pono i ka atenolol a me ka sotalol mai ke kahe koko, ʻoi aku i nā maʻi me ka hōʻeha ʻeha.

Nā alakaʻi pili¶

• ʻO ka aspirin (salicylate), ka paila hao, a me ka tricyclic antidepressant overdose
• ʻO ka ʻawaʻawa o Digoxin, nā halo ʻōmaʻomaʻo melemele, a me ka triage arrhythmia cardiac
• ʻO ke kōkua mua a me ka hoʻāʻo ʻana i ka lāʻau make
• ʻO ka ʻike a me ka mālama ʻana i ka haʻalulu olakino
• ʻO ka hoʻōla ʻana o ka puʻuwai puʻuwai (CPR) a me ke alakaʻi AED

Nā kumu a me ke alakaʻi kūhelu¶

• American College of Medical Toxicology (ACMT) & American Association of Poison Control Centers (AAPCC): * Nā Manaʻo Manaʻo Kūkākūkā no ka mālama ʻana i ka Calcium Channel Blocker a me Beta-Blocker Poisoning in Critical Care *.
• American Heart Association (AHA): 2023 Focused Update and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Management of Critical Poisoning (Beta-Blockers and Calcium Channel Blockers).
• ʻAha Hoʻōla Ola ʻEulopa (ERC): Nā alakaʻi no ka hoʻōla hou ʻana: Hoʻopaʻa ʻia ka naʻau ma nā Kūlana Kūikawā: ʻO nā pilikia pilikia o ka Toxicologic.
• EXTRIP (Extracorporeal Treatments in Poisoning) Workgroup: Systematic Review and Recommendations for Extracorporeal Treatment in Beta-Blocker and Calcium Channel Blocker Poisoning.
• ʻOihana Hoʻonaʻauao Lapaʻau Lahui (NPIS, United Kingdom) & World Health Organization (WHO): TOXBASE Clinical Management of Acute Cardiovascular Drug Overdose and High-Dose Insulin Euglycemic Therapy Protocols.

• ʻO kēia alakaʻi no ka ʻike ʻike a ʻaʻole ia e pani i ka loiloi lapaʻau ʻoihana, kūkākūkā Poison Control, a i ʻole ka mālama koʻikoʻi o ka haukapila. Ma muli o ka nui o ka lāʻau lapaʻau cardiovascular hiki ke hoʻopau koke i ka noʻonoʻo a me ka hopu ʻana i ka naʻau, makemake mākou e lawe i kahi kōkua mua a me ka papa CPR i ʻae ʻia ma o ka International Federation of Red Cross and Red Crescent Societies (IFRC), kou lāhui Red Cross, St John Ambulance, a i ʻole kahi mea lawelawe kūloko.*