Beta-Blocker ndi Calcium Channel Blocker Overdose: Slow Heart Rate ndi Shock Triage¶

Ma Beta-blockers ndi calcium channel blockers (CCBs) ali m'gulu la mankhwala omwe amaperekedwa kawirikawiri padziko lonse lapansi, omwe amagwiritsidwa ntchito tsiku ndi tsiku ndi mamiliyoni a anthu akuluakulu kuti athetse kuthamanga kwa magazi, angina, kulephera kwa mtima, matenda a mtima, migraines, ndi kunjenjemera. Komabe, mukumwa mankhwala osokoneza bongo, kapena mwana wokonda chidwi akameza piritsi limodzi kapena awiri, magulu awiriwa amatengera kuchuluka kwa mankhwala oopsa amtima omwe amanenedwa m'malo owongolera poyizoni padziko lonse lapansi. Ngati mukukayikira kuti munthu wina wamwa mowa mopitirira muyeso wa mapiritsi a kuthamanga kwa magazi kapena kugunda kwa mtima, kapena ngati mwana waika piritsi limodzi pakamwa pake, imbani nambala yanu yadzidzidzi yapafupi (911 ku United States ndi Canada, 112 ku European Union, 999 ku United Kingdom) kudzera pa tsamba lathu manambala angozi directory nthawi yomweyo. Chifukwa kugwa kwakukulu kwamtima kumatha kukulirakulira kapena kugunda patatha maola angapo pambuyo pochedwetsa mwachinyengo, pendaninso. poyizoni thandizo loyamba, kuzindikira kugwedezeka kwachipatala,ndi kutsitsimula mtima kwa mtima (CPR) podikira azachipatala.

Chomwe chimapangitsa kuti beta-blocker ndi calcium blocker overdose kukhala achinyengo mwapadera ndikuphatikiza kugwa kwachangu kwa hemodynamic ndi mapiritsi otuluka nthawi yomweyo komanso kukhala chete kwanthawi yayitali kwa maola 6 mpaka 24 ndikutulutsa kwanthawi yayitali (ER, XL, SR, CD, kapena LA). Wodwala amene wameza verapamil, diltiazem, amlodipine, metoprolol, kapena propranolol wochuluka akhoza kupita ku dipatimenti yodzidzimutsa akukambitsirana bwinobwino ndi kugunda kwabwino kwa magazi ndiponso kuthamanga kwa magazi bwinobwino, kenako n’kulowa mu refractory bradycardia (kuthamanga kwapamtima pang’onopang’ono), kutsekeka kwa mtima wathunthu, kugwedezeka kwa mtima, kutsekeka kwa mtima, kutsekeka kwa mtima, kutsekeka kwa mtima, kapena kutsekeka kwapang’onopang’ono. Sera kapena zokutira za osmotic zimasungunuka m'munsi mwa m'mimba. Bukuli limafotokoza zochitika zachipatala asanagone, kupha ana a piritsi limodzi, momwe mungasiyanitsire beta-blocker kuchokera ku calcium channel blocker toxicity pogwiritsa ntchito glucose wa magazi ndi electrocardiogram, kuchotsa m'mimba mwamsanga, ndi ndondomeko zopulumutsira zachipatala chachikulu kuphatikizapo mlingo waukulu wa insulin euglycemic therapy (HIET), mtsempha wa magazi, calcium, glucamugon, ndi glucamugon.

Chitani izi tsopano¶

1. Imbani zithandizo zachipatala zadzidzidzi ndikuwongolera poizoni nthawi yomweyo: Imbani 911 (US ndi Canada), 112 (EU), kapena 999 (UK) nthawi yomweyo ngati munthuyo wamwa mowa mwadala, ali ndi chizungulire, kugona, kusokonezeka, kupuma movutikira, kapena kugunda kwapang'onopang'ono kapena kutsika kwa magazi, kapena ngati mwana wameza ngakhale piritsi limodzi. Ku United States, inu kapena wothandizira mutha kuyimbiranso Poison Control pa 1-800-222-1222 podikirira ambulansi kuti katswiri wamankhwala owopsa adziwitse achipatala omwe akulandira chithandizo chamankhwala pasadakhale.
2. Sonkhanitsani botolo lililonse lamapiritsi, paketi ya matuza, ndi okonza mapiritsi a mlungu ndi mlungu: Tetezani mabotolo enieni kapena mapepala a zojambulazo kuti odwala opaleshoni ndi madokotala adzidzidzi athe kuwerenga dzina la mankhwala, mphamvu ya milligram pa piritsi, ndi suffix yotulutsa (monga ER, XL, SR, XT, LA, CD, kapena kumasulidwa mwamsanga). Werengani mapiritsi otsalawo ngati n'kotheka ndipo dziwani nthawi yeniyeni ya wotchi yomwe mapiritsiwo adamezedwa.
3. Mugoneke munthu chagada chamsana kuti asaimirire: Ma beta-blockers ndi ma calcium channel blockers amalepheretsa thupi kutsekereza mitsempha yamagazi kapena kufulumizitsa mtima utayima. Kuyimirira kapena kuyenda pagalimoto kumatha kuyambitsa mwadzidzidzi orthostatic syncope (kukomoka), kupwetekedwa mutu, kapena kumangidwa kwamtima nthawi yomweyo. Yesetsani munthuyo kukhala wosagona (chapamwamba) ndi miyendo yake yokwezeka pang'ono pa pilo pokhapokha ngati akuvutika kupuma kuchokera kumadzimadzi m'mapapu awo (pulmonary edema), pamene mutu ndi mapewa awo azikhala mmwamba pa madigiri 30 mpaka 45.
4. **Musamayendetse wodwalayo kuchipatala nokha **: Chifukwa kugwidwa mwadzidzidzi (makamaka ndi propranolol), kutsekeka kwa mtima wachitatu, ndi kumangidwa kwa mtima kumatha kuchitika popanda chenjezo mkati mwa galimoto yamunthu yomwe ikuyenda, nthawi zonse dikirani ambulansi yachipatala yokhala ndi owunika a mtima, intravenous atropine, calcium, glucagon, vasopressors, ndi transcutaneous transcutaneous cardiac.
5. Musamachititse kusanza kapena kupereka chakudya, mkaka, kapena madzi: Osayesa kusanza kapena kusanza. Mu beta-blocker kapena calcium blocker overdose, kugwedeza kumayambitsa mitsempha ya vagus, yomwe imatulutsa acetylcholine ku node yoponderezedwa ya sinoatrial ndi atrioventricular ndipo imatha kuyimitsa mtima nthawi yomweyo (vagal asystole). Khalani opanda kanthu m'mimba ngati dipatimenti yazadzidzidzi ingafunike kupereka makala, kuthirira m'matumbo onse, kapena intubation mwachangu.
6. Yang'anani kuyankha ndi kupuma masekondi 60 aliwonse ndikukonzekera CPR: Khalani pafupi ndi munthuyo. Akapanda kuyankha ndikusiya kupuma bwinobwino (kapena kupuma movutikira), yambani kukanikiza pachifuwa nthawi yomweyo pamlingo wa 100 mpaka 120 pa mphindi imodzi ndi kuya kwa 5 mpaka 6 centimita (2 mpaka 2.4 mainchesi) kwa munthu wamkulu mpaka azachipatala atenga.

Mtengo wosankha: Beta-blocker ndi calcium channel blocker overdose triage¶

flowchart TD
    Start["Oganiziridwa kuti Beta-Blocker (BB) kapena Calcium Channel Blocker (CCB) Ingestion"] --> CallEMS["Imbani 911/112/999 ndi Kuwongolera Poizoni Wachigawo Nthawi yomweyo"]
    CallEMS --> Position["Khalani Oleza Mtima Pogona Pathyathyathya (Osalola Kuyima) ndi Kusonkhanitsa Mabotolo Onse a Mapiritsi"]
    Position --> CheckVitals{"Kodi Wodwala Samva Kapena Sakupuma Mwachizolowezi?"}

    CheckVitals -->|Yes| StartCPR["Yambitsani CPR Yapamwamba Kwambiri (100-120 / min) ndi Ikani AED"]
    CheckVitals -->|No, Awake or Drowsy| IdentifyForm{"Chongani Chilembo cha Botolo: Kutulutsidwa Kwaposachedwa (IR) vs Kutulutsidwa Kwawonjezedwa (ER / XL / SR / CD)?"}

    IdentifyForm -->|Immediate-Release (IR) or Liquid| EarlyWindow["Yambani Pakati pa 30 Min mpaka 2 Maola: Yang'anirani Rapid Bradycardia, Hypotension, kapena Kukomoka."]
    IdentifyForm -->|Extended-Release (ER/XL/SR) or Amlodipine| DelayedWindow["Kuchedwa Kuyamba mpaka 6 mpaka 24 Maola: Zovomerezeka za 24-Hour ICU / Telemetry Observation Ngakhale Ngati Asymptomatic"]

    EarlyWindow --> HospitalArrival["Kufika kwachipatala ED: 12-Lead ECG, Point-of-Care Blood Glucose, Serum Electrolytes, Lactate"]
    DelayedWindow --> HospitalArrival

    HospitalArrival --> GI_Decon{"Zoperekedwa Mkati mwa Maola a 1-2 (IR) kapena Kugwiritsa Ntchito Kutulutsidwa Kokhazikika / Kulemera Kwambiri Kwa Piritsi?"}
    GI_Decon -->|Yes, Airway Protected| GiveCharcoal["Makala a Mlingo Umodzi (1 g/kg mpaka 50 g) + Irrigation wamatumbo onse (PEG) kuti atulutse"]
    GI_Decon -->|No or Intubated First| DiffClue{"Yang'anani shuga wamagazi a Fingerstick ndi Zizindikiro za Kugunda kwa Mtima"}
    GiveCharcoal --> DiffClue

    DiffClue -->|Hyperglycemia (High Blood Sugar) + Hypotension| SuspectCCB["Chidziwitso Champhamvu cha Calcium Channel Blocker (CCB) Poizoni (Matenda Otsekedwa Pancreatic L-Type Calcium Channels)"]
    DiffClue -->|Hypoglycemia or Normal Sugar + Bradycardia / Seizures| SuspectBB["Chidziwitso Champhamvu cha Beta-Blocker (BB) Poizoni (Yotsekedwa Glycogenolysis; Onani QRS/QTc ya Propranolol/Sotalol)"]

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

    RescueProtocol --> RefractoryShock{"Refractory Shock Kapena Kumangidwa Kwa Mtima Ngakhale Kuti Ndi Ochuluka Kwambiri Kuchipatala?"}
    RescueProtocol2 --> RefractoryShock
    RefractoryShock -->|Yes| ECMO_Rescue["Kufunsira kwa Veno-Arterial ECMO (VA-ECMO), Intravenous Lipid Emulsion (20% Intralipid), kapena Methylene Blue ya Vasoplegia"]

Kuzindikiritsa mankhwala omwe ali ndi vuto: Magulu a mankhwala osokoneza bongo, mayina amtundu, ndi zokwanira¶

Kudziwa ngati mankhwala omwe amwedwa ndi beta-blocker kapena calcium channel blocker, komanso kuti ndi a gulu liti, zimatsimikizira mwachindunji mavuto omwe gulu ladzidzidzi liyenera kuyembekezera.

1. Beta-adrenergic receptor blockers (mayina odziwika omwe amatha ndi "-olol", "-alol", kapena "-ilol")¶

Ma beta-blockers amapikisana ndi beta-1 adrenergic zolandilira mu mtima (kuchedwetsa sinoatrial pacemaker rate, kuchedwetsa atrioventricular nodal conduction, ndi kuchepa kwa contractility) ndi ma beta-2 receptors m'mapapu, mitsempha yamagazi, ndi chiwindi (kuyambitsa bronchospasm ndi kutulutsa kwachiwindi kwa glucose). Othandizira apadera amakhala ndi kawopsedwe wakupha wopanda beta mu overdose:

• Propranolol (Inderal, Inderal LA), Acebutolol (Sectral), Carvedilol (Coreg), ndi Labetalol (Trandate): Voltage-Gated Sodium Channel Blockade:
• Propranolol ndiye beta-blocker wakupha kwambiri pakumwa mopitirira muyeso. Chifukwa ndi kwambiri lipophilic (kusungunuka kwamafuta), imawoloka chotchinga chamagazi muubongo mkati mwa mphindi 20 mpaka 60 kuyambitsa chikomokere chadzidzidzi komanso kukomoka. Nthawi yomweyo, imatchinga mtima wothamanga wamagetsi manjira a sodium, kukulitsa QRS complex (> 100 mpaka 120 ms), kupanga ma terminal R wave mu lead aVR, ndikupangitsa ma ventricular arrhythmias omwe amafunikira intravenous hypertonic sodium bicarbonate.
• Sotalol (Betapace, Sorine): Potaziyamu Channel Blockade ndi Torsades de Pointes:
• Sotalol imatchinga mtima wakunja **njira za potaziyamu **, kukulitsa nthawi ya QTc ndikuyambitsa polymorphic ventricular tachycardia (Torsades de Pointes), yomwe imafunikira mtsempha magnesium sulfate, kubwezeretsanso potaziyamu, komanso kuthamanga kwambiri.
• Cardioselective Beta-1 blockers: Atenolol (Tenormin), Metoprolol (Lopressor, Toprol-XL), Bisoprolol (Zebeta), ndi Nebivolol (Bystolic):
• Receptivity selectivity imatayika muzowonjezera zambiri. Chifukwa atenolol ndi sotalol amasungunuka m'madzi ndipo amamangiriza mapuloteni otsika komanso kuchotsedwa kwaimpso, ndi ma beta-blockers awiri omwe amachotsedwa bwino ndi hemodialysis.

2. Calcium channel blockers (Non-Dihydropyridines vs. Dihydropyridines)¶

Ma calcium blockers amaletsa ma voltage-gated L-mtundu wa calcium channel omwe amayendetsa sinoatrial/atrioventricular nodal conduction, mtima wa myocyte contraction, ndi vascular smooth muscle tone:

1. Non-Dihydropyridine ("Cardioselective") CCBs: Verapamil (Calan, Isoptin, Verelan) ndi Diltiazem (Cardizem, Cardizem CD, Cartia XT, Tiazac):
2. Kumangirira ndi kuyanjana kwakukulu kumayendedwe amtundu wa L pa onse **ma cell a mtima pacemaker/myocyte ** ndi **mitsempha yamagazi yozungulira **, zomwe zimapangitsa kuti katatu koopsa kwa bradycardia/AV block yoopsa, **kulephera kwapampu yamtima **, ndi **zotumphukira vasodilation **. Verapamil ndi diltiazem amafa kwambiri kuposa mankhwala osokoneza bongo amtima.
3. Dihydropyridine ("Vascular-Selective") CCBs (otsiriza "-dipine"): Amlodipine (Norvasc), Nifedipine (Procardia XL, Adalat CC), Felodipine (Plendil), ndi Nicardipine (Cardene):
4. Chitani makamaka pa ** zotumphukira vascular yosalala minofu **, kuchititsa kwambiri **arterial vasodilation ndi hypotension ** limodzi ndi poyamba reflex sinus tachycardia (kuthamanga kwa mtima). Mu overdose chachikulu, kusankha kumatayika ndipo chipika chamtima chimayamba. Amlodipine ali ndi theka la moyo wa maola 30 mpaka 50 (mpaka maola 100 atamwa mowa mopitirira muyeso), zomwe zimafuna masiku a chithandizo cha ICU.

Chifukwa Chake Shuga Wamagazi (Hyperglycemia vs. Hypoglycemia) Ndi Chizindikiro Chofunikira Chofunikira¶

Kuyeza kwa shuga m'magazi ndi chala chapabedi kumasiyanitsa msanga beta-blocker ndi kawopsedwe ka calcium channel blocker ndikulosera kuopsa kwa mantha:

1. Chifukwa Chake Calcium Channel Blocker Overdose Imayambitsa Hyperglycemia Yoopsa¶

Pancreatic beta-islet cell amafuna calcium influx kudzera voltage-gated L-type calcium channel kuti atulutse insulini m'magazi. ** verapamil, diltiazem, amlodipine, kapena nifedipine** ikatsekereza njirazi, **kutulutsa kwa insulin komweko kumayima ** ndipo kukana insulini kumayamba: - Pansi pa kupsinjika kwapoizoni komanso kugwedezeka, minofu yamtima imasintha mafuta ake ofunikira kuchokera kumafuta aulere kupita ku glucose. - Popanda insulini, minofu yamtima yomwe ili ndi njala siyingatulutse shuga kuchokera m'magazi kupita ku ma myocyte amtima. - Kuchuluka kwa shuga m'magazi kumakwera mwachangu (nthawi zambiri 200 mpaka 400+ mg/dL [11.1 mpaka 22.2+ mmol/L] mwa anthu omwe si odwala matenda a shuga), ndipo kuchuluka kwa hyperglycemia kumagwirizana mwachindunji ndi kuopsa kwa mankhwala osokoneza bongo komanso chiwopsezo cha kufa.

2. Chifukwa chiyani Beta-blocker Overdose Imayambitsa Hypoglycemia ndi Masks Zizindikiro Zake¶

Ma beta-blockers amalepheretsa beta-2 adrenergic receptors m'chiwindi, kutsekereza glycogenolysis ndi gluconeogenesis. Mwa makanda, ana, ndi akuluakulu osala kudya, izi zimayambitsa hypoglycemia yamphamvu (shuga wa m'magazi pansi pa 70 mg/dL kapena 3.9 mmol/L) kwinaku akubisa zizindikiro zochenjeza za adrenergic (kunjenjemera ndi kugunda kwa mtima), zomwe zimayambitsa chikomokere mwadzidzidzi kapena kukomoka.

Kuopsa kwa Piritsi Limodzi la Ana ndi Bomba la Nthawi Yowonjezera Yotulutsidwa¶

1. Chifukwa Chake Tabuleti Yachikulu Imodzi Ikhoza Kupha Mwana Wamng'ono¶

Oletsa ma channel a calcium ndi mamembala ofunikira pamndandanda wa ana "Piritsi Limodzi Limatha Kupha": - Piritsi limodzi laling'ono lomwe limatulutsidwa nthawi zonse la verapamil (120 mpaka 240 mg), diltiazem CD (180 mpaka 360 mg), nifedipine XL (30 mpaka 90 mg), kapena amlodipine (5 mpaka 10 mg) kumezedwa ndi **kg 10 mpaka 2*200000000000005000000000000. refractory hypotension, kutsekeka kwamtima kwathunthu, komanso kutsekeka kwamtima koopsa. - Chifukwa chakuti zomatira zosalekeza zimachedwetsa kuyamwa, mwana amene wameza piritsi limodzi m'mawa amatha kuwoneka bwino masana onse ndipo mtima wake umakhala wovuta kwambiri usiku womwewo. - Mandatory Pediatric Protocol: Mwana aliyense yemwe amadziwika kapena akuganiziridwa kuti wamwa ngakhale chotsekereza njira imodzi yokha ya calcium kapena beta-blocker ayenera kunyamulidwa ndi ambulansi kupita ku dipatimenti yazadzidzidzi ndikuloledwa kwa maola osachepera 24 akuwunika mosalekeza mtima kwa telemetry, ngakhale asymptomatic kwathunthu.

2. Tsimikizirani Zokwanira Zotulutsa-Zowonjezera pa Botolo la Mapiritsi¶

Kuwonongeka kwa M'mimba: Kuyimitsa Kutsekemera Kusanayambe Kusungunuka¶

Chifukwa mapiritsi osatulutsidwa amatha kulowa pang'onopang'ono pharmacobezoar ndikukhala ndi imfa zambiri akangoyamwa, **kuchotsa m'mimba m'mimba ** ndikofunikira kwambiri:

1. Makala Amodzi Amodzi (SDAC): Amaperekedwa pa 1 g/kg (mpaka 50 g) mkati mwa 1 mpaka maola 2 atamwedwa mwachangu, kapena mpaka maola 4 mpaka 6+ atamwa nthawi yayitali, malinga ngati wodwala ali maso komanso atateteza kale njira yawo yolowera mpweya.
2. Kuthirira M'matumbo Athunthu (WBI): Amayendetsedwa kudzera mu chubu cha nasogastric pogwiritsa ntchito polyethylene glycol electrolyte solution (PEG-ELS) pa 1.5 mpaka 2 L/ola mwa akulu (25 mpaka 40 mL/kg/ola mwa ana) pomwa kwambiri, dirapamildiasel dirapamil, dirapamil, dirapamil, kapena dirapamil- beta-blockers mpaka utsi wa ngalande utayera. Zotsutsana ndi kutsekeka kwa matumbo, mayendedwe oyenda osatetezedwa, kapena kugwedezeka kwakukulu ndi ileus.

Stepwise Hospital ndi ICU Rescue Protocols¶

Wodwala akayamba symptomatic bradycardia, conduction blocks, kapena hypotension from beta-blocker kapena calcium channel blocker overdose, muyezo umodzi wothandizira advanced cardiac life support (ACLS) mankhwala monga atropine okha pafupifupi nthawi zonse amalephera chifukwa zolandilira kapena distal ngalande ndi saturated. Magulu osamalira odwala kwambiri amatumiza mtolo wopulumutsira wamitundu yambiri ndi hemodynamic nthawi imodzi:

Khwerero 1: Chenjezo la Airway, Madzimadzi Olowera m'mitsempha, ndi Atropine¶

• Kusamala Kwambiri ndi Rapid Sequence Intubation (RSI): Kulowetsa wodwala mu cardiogenic kapena vasoplegic shock kumachotsa chiwongola dzanja chamtundu wina ndikugwetsa venous kubwerera kudzera mpweya wabwino, womwe ungayambitse kumangidwa kwa mtima wa peri-intubation. Asanalowetse, madotolo azadzidzidzi amayamba kumwa mankhwala a epinephrine kapena kulowetsedwa kosalekeza kwa norepinephrine, kupereka calcium m'mitsempha, ndikugwiritsa ntchito mankhwala ochepetsa mphamvu ya hemodynamically (monga ketamine kapena etomidate).
• Judicious Intravenous Crystalloids: Perekani bolus yoyambirira ya 10 mpaka 20 mL/kg (500 mpaka 1,000 mL mwa munthu wamkulu) ya isotonic crystalloid yolinganiza bwino kuti mukonze hypovolemia kuchokera ku vasodilation. Pewani kuchuluka kwa madzimadzi okwanira malita ambiri chifukwa kupsinjika kwa myocardial contractility komanso kuchuluka kwa insulin kumayambitsa edema yam'mapapo yam'mapapo.
• Intravenous Atropine: Perekani 0.5 mg ku 1 mg IV (kapena 0.02 mg/kg mwa ana, osachepera 0.1 mg) mphindi 3 mpaka 5 mpaka **3 mg okwana ** kwa bradycardia yodziwika ngati mlatho woyambirira pomwe calcium, glucagon, ndi insulini yochuluka imakonzedwa.

Khwerero 2: Mchere wamchere wa Calcium (Chloride kapena Gluconate)¶

Kukweza kashiamu wowonjezera wa ionized kumapangitsa kuti ma ayoni a calcium azitha kupitilira njira zosatsekeka zamtundu wa L kukhala myocyte wamtima ndi ma cell osalala a minofu, kumapangitsa kuti myocardial contractility ikhale ndi kuthamanga kwa magazi:

• 10% Calcium Chloride (Central Line or Cardiac Arrest): Ili ndi calcium yochulukirapo yochulukirapo katatu pa mililita kuposa calcium gluconate (10 mL of 10% Calcium Chloride = 1 gram = 272 mg [13.6 mEq] elemental calcium). Kutumikiridwa monga 10 mpaka 20 mL (1 mpaka 2 magalamu) IV pang'onopang'ono kupitirira mphindi 5 mpaka 10 (kapena 0.2 mL/kg mwa ana), mobwerezabwereza mphindi 10 mpaka 20 zilizonse kapena kutsatiridwa ndi kulowetsedwa kosalekeza.0.2 to 0.4 mL/kg/hour), kulunjika mulingo wa ionized calcium pafupifupi kawiri wamba (2.0 mpaka 2.5 mmol/L). Calcium chloride imayambitsa necrosis yayikulu ya minofu ngati ituluka kuchokera ku zotumphukira IV.
• 10% Calcium Gluconate (Yotetezedwa Pamizere ya IV): Ili ndi 90 mg (4.65 mEq) elemental calcium per 10 mL vial. Chifukwa ndi gawo limodzi mwa magawo atatu aliwonse, perekani kuwirikiza katatu kuchuluka kwake: ** 30 mL mpaka 60 mL (3 mpaka 6 magalamu) IV kwa mphindi 10 ** (kapena ** 0.6 mL/kg mwa ana **), mobwerezabwereza mphindi 10 mpaka 20 kapena kuthamanga ngati kulowetsedwa kosalekeza (0.6 to 1.5 mL/kg/hour).
• Kupatulapo: Osapereka kashiamu m'mitsempha ngati wodwalayo ali ndi poizoni wa digoxin.

Khwerero 3: Glucagon Wamkulu (Makamaka pa Beta-Blocker Overdose)¶

Mu beta-blocker overdose, beta-1 adrenergic receptor imatsekedwa, kulepheretsa catecholamines kupanga intracellular cyclic adenosine monophosphate (cAMP).

• Njira: Glucagon imamangiriza ku cholandirira chake chamtima cha glucagon, kuyambitsa adenylyl cyclase ndikupanga cAMP ya intracellular yosadalira beta-1 cholandilira kuti iwonjezere kugunda kwa mtima ndi contractility.
• Dosing Protocol: Perekani mlingo woyambirira wa IV wa 5 mg mpaka 10 mg wa Glucagon mwa akulu (kapena 0.05 mpaka 0.15 mg/kg mwa ana) kupitirira mphindi 1 mpaka 2. Chifukwa glucagon ali ndi theka lalifupi la moyo wa mphindi 8 mpaka 16, tsatirani yankho labwino nthawi yomweyo ndi kulowetsedwa kwa IV mosalekeza pa **2 mg mpaka 10 mg pa ola **.
• Chithandizo cha Antiemetic Pre-Treatment: Mlingo wambiri wa glucagon umapumula m'munsi mwa esophageal sphincter ndikuyambitsa kusanza. Nthawi zonse perekani mankhwala ndi mtsempha ondansetron (4 mpaka 8 mg IV) ndikuteteza njira yodutsa mpweya.

Khwerero 4: Catecholamine Vasopressors, Sodium Bicarbonate, ndi Magnesium¶

Malangizo aposachedwa a toxicology amalimbikitsa kuti muyambe kumwa mowa kwambiri wa catecholamine msanga pamodzi ndi madzi ndi calcium:

• Epinephrine ndi Norepinephrine: Kulowetsedwa kudzera pamzere wapakati kuti apereke chithandizo cha beta-1 adrenergic inotropic/chronotropic (kwa bradycardia ndi kulephera kwa pampu) ndi alpha-1 adrenergic vasoconstriction (kwa dihydropyridine vasoplegic shock).
• Sodium Bicarbonate for Propranolol Widened QRS: Ngati wodwala amwa propranolol, acebutolol, kapena carvedilol ndipo ECG ikuwonetsa nthawi yowonjezera QRS interval yoposa 100 mpaka 120 milliseconds, perekani klzzwxh:0090 ksika ndi kukankhira IV1 luso la Sodium Bicarbonate pH ifika 7.45 mpaka 7.55.
• Magnesium Sulfate for Sotalol Prolonged QTc: Ngati wodwala amwa sotalol ndipo ali ndi QTc yaitali kapena Torsades de Pointes, perekani 2 magalamu a Magnesium Sulfate IV kupitirira mphindi 5 mpaka 10, onjezerani potaziyamu ku 4.5 mpaka 5.0 mEq/L mtunda wothamanga kwambiri, ndikugwiritsa ntchito kuthamanga kwa mtima mopitirira muyeso.

Khwerero 5: Mlingo Wapamwamba wa Insulin Euglycemic Therapy (HIET): Gold-Standard Metabolic Rescue¶

High-Dose Insulin Euglycemic Therapy (HIET) ndiye mwala wapangodya wopulumutsira mankhwala owopsa kwambiri a calcium blocker overdose ndi refractory beta-blocker cardiogenic shock. Chifukwa HIET imatenga 15 mpaka mphindi 45 kuti ifike pachimake cha inotropic, yambani msanga mukangoganiziridwa kuti myocardial kukanika kapena kugwedezeka kukuchitika:

1. Njira Yochitirapo kanthu: Mlingo waukulu wa insulini umagonjetsa kutsekeka kwa kashiamu wa kapamba komanso kulephera kwa insulini, kusuntha zonyamula za GLUT4 kupita ku nembanemba ya cell ya myocardial kotero kuti mtima wopsinjika uwotcha shuga/pyruvate wa ATP, umathandizira mwachindunji kugwira ntchito kwa intracellular sarcoplasmic reticulum calcium (kukulitsa kugunda kwa mtima), komanso kupititsa patsogolo kaphatikizidwe ka microvascular perfusion kudzera mu endolitric synoxide.
2. Kuwunika kwa Glucose ndi Potaziyamu: Ngati shuga wamagazi woyambira ali pansi pa 200 mg/dL (11.1 mmol/L), perekani 25 mpaka 50 magalamu a IV Dextrose choyamba; Ngati seramu potaziyamu ili pansi 3.0 mEq/L, yambani kusintha potaziyamu.
3. Bolus Insulin IV Bolus ndi Kulowetsedwa Kosalekeza: Perekani 1 Unit/kg Regular Human Insulin IV bolus (mwachitsanzo, Mayunitsi 70 mpaka 80 mwa munthu wamkulu), kutsatiridwa nthawi yomweyo ndi kulowetsedwa kwa Insulin Nthawi Zonse kuyambira 1 Unit/kg/ola ndikukwera mmwamba mayunitsi 30 mpaka 15 mphindi*** mpaka 15/kg* mtima contractility ndi minyewa perfusion amachira.
4. Concentrated Dextrose Co-Infusion: Yambani D10W, D20W, kapena D50W (kudzera pakati pa mzere) pa 0.5 mpaka 1.0 g/kg/ola, kuyang'ana shuga m'magazi mphindi 15 mpaka 30 zilizonse kuti mukhale ndi euglycemia (**110 mpaka 180 mg/180 mg/dl) [6. 180 mg/dL] [6.1 mg/dL]). Kulowetsedwa kwa dextrose nthawi zambiri kuyenera kupitilira kwa maola 24+ mutayimitsa insulini pomwe kutulutsidwa kwa insulin ya kapamba kumayambiranso.
5. Potassium Monitoring: Insulin ya mlingo waukulu imasamutsa potaziyamu m'maselo popanda kuwononga nkhokwe zonse za thupi. Yang'anani kuchuluka kwa potaziyamu m'magazi maola 1 mpaka 2 aliwonse ndikusunga milingo yapakati pa 2.8 ndi 3.2 mEq/L kuti mupewe kuyambiranso kwa hyperkalemia pamene insulin yasiya kuyamwa.

Khwerero 6: Refractory Rescue: Pacing, Methylene Blue, Lipid Emulsion, ndi VA-ECMO¶

• Transcutaneous and Transvenous Pacing: Kuyesedwa koopsa kwa bradycardia kapena AV block yapamwamba kwambiri, ngakhale kugwidwa kwamagetsi kapena kumakina nthawi zambiri kumalephera m'miyocardium yoopsa kwambiri ya calcium.
• Methylene Blue: Amayendetsedwa (1 to 2 mg/kg IV over 20 minutes) kwa refractory dihydropyridine (amlodipine/nifedipine) vasoplegic shock kuletsa guanylyl cyclase ndikubwezeretsa mitsempha yamagazi.
• Mtsempha wa Lipid Emulsion (20% Intralipid): Amayendetsedwa (1.5 mL/kg IV bolus, ndiye 0.25 mL/kg/min) chifukwa cha chiwopsezo cha moyo wa lipophilic mankhwala kawopsedwe (verapamil, diltiazem, amlodipine, propranolol) osamvera mankhwala ochiritsira.
• Veno-Arterial ECMO (VA-ECMO): Kuwombera koyambirira kwa VA-ECMO ndiye mlatho wotsimikizika wopulumutsa moyo wa kugwedezeka kwa mtima wamtima kapena kumangidwa kwa mtima, kuthandizira kufalikira ndi okosijeni kwa 3 mpaka masiku 7 mpaka mankhwalawa asinthidwa.

Nambala zangozi zachigawo ndi ndondomeko za bungwe¶

Mafunso omwe amafunsidwa pafupipafupi¶

Mwana wanga wamng'ono ayenera kuti adayikapo mapiritsi a agogo awo otulutsa magazi kwa nthawi yayitali mkamwa mwawo, maola anayi apita, ndipo akuthamanga mozungulira. Kodi tikufunikabe kupita kuchipinda chodzidzimutsa?¶

Inde, muyenera kutengera mwanayo kuchipatala mwamsanga kapena kumuimbira foni ku 911. Piritsi imodzi yokha ya verapamil, diltiazem, nifedipine, kapena amlodipine, yomwe ingathe kutulutsidwa nthawi yaitali, ikhoza kupha mwana. Chifukwa chakuti zokutira zosalekeza zimapangidwira kuti zisungunuke pang’onopang’ono m’chigayo cham’mimba kwa maola 12 mpaka 24, mwana angaoneke wathanzi ndi woseŵera bwino kwa maola 6 mpaka 14 oyambirira ndiyeno mwadzidzidzi amavutika ndi kutsekeka kwa mtima wonse ndi kugwidwa kwa mtima pamene akugona usiku. Mwana aliyense yemwe amadziwika kapena akuganiziridwa kuti wamwa mankhwala oletsa calcium channel blocker kapena beta-blocker amafunikira maola 24 akuwunika mosalekeza mtima m'chipatala.

Kodi chimachitika ndi chiyani ngati munthu wamkulu amwa mwangozi mlingo wowirikiza (mapiritsi awiri m'malo mwa amodzi) amankhwala omwe adawalembera tsiku ndi tsiku?¶

Ngati wachikulire amwa mwangozi mlingo umodzi wapawiri wa beta-blocker wake watsiku ndi tsiku (monga metoprolol kapena atenolol) kapena calcium channel blocker (monga amlodipine kapena diltiazem), imbani foni m'dera lanu la Poison Control Center (1-800-222-1222 ku US) nthawi yomweyo botolo lili m'manja. Nthawi zambiri pamene wodwala ali wololera kale mankhwala awo a tsiku ndi tsiku ndipo alibe kwambiri m'munsi chipika cha mtima, kutenga awiri a mapiritsi awo nthawi zonse kumayambitsa chizungulire pang'ono kapena pang'onopang'ono kugunda kwapang'onopang'ono kuti akhoza kuyang'aniridwa bwinobwino pambuyo poyizoni katswiri kuwerengera yeniyeni mlingo wa milligram, pokhapokha ngati munthu ali ndi vuto lalikulu la impso, amatenga onse beta-blocker ndi verapamil / diltiazem, kupweteka pachifuwa pamodzi, kupweteka pachifuwa, diltiazem, kapena kupweteka pachifuwa pamodzi. 50 kumenyedwa pamphindi.

Chifukwa chiyani madotolo azadzidzidzi amapatsa insulini yochuluka kwa wodwala yemwe alibe matenda a shuga pambuyo poletsa njira ya calcium overdose?¶

Ma calcium blockers amaumitsa njira za calcium zamtundu wa L mu mtima ndi kapamba, zomwe zimatsekereza kutulutsa kwa insulin yachilengedwe m'thupi pomwe nthawi imodzi kukakamiza minofu yamtima yokhazikika kudalira shuga m'malo mwa mafuta acid kuti apeze mphamvu. Popanda insulini, minofu yamtima yomwe ili ndi njala simatha kuyamwa shuga m'magazi ndipo imataya mphamvu yake yofinya. Kulowetsedwa kwa insulin yokhazikika (1 mpaka 10 Units pa kilogalamu pa ola limodzi, mpaka kuwirikiza ka 10 kuposa mlingo wa shuga) komanso shuga wokhazikika (dextrose) kumapangitsa mphamvu kulowa m'maselo a minofu yamtima, kumathandizira kasamalidwe ka calcium mu intracellular, ndikubwezeretsa mphamvu yakupopa kwa mtima kuposa pafupifupi mankhwala ena aliwonse.

Chifukwa chiyani propranolol imawonedwa ngati yowopsa kwambiri pakumwa mopitirira muyeso kuposa ma beta-blockers ena monga metoprolol kapena atenolol?¶

Mosiyana ndi ma beta-blockers osungunuka m'madzi omwe amakhala kwambiri m'magazi, propranolol imakhala yosungunuka kwambiri ndi mafuta (lipophilic) komanso imatchinga njira zothamanga kwambiri za sodium mu mtima ndi ubongo. Chifukwa amawoloka chotchinga chamagazi-muubongo mwachangu, kuchuluka kwakukulu kwa propranolol kumatha kuyambitsa chikomokere mwadzidzidzi komanso kukomoka kwamphamvu mkati mwa mphindi 20 mpaka 60 mutameza mapiritsi. Nthawi yomweyo, kutsekeka kwake kwa sodium-channel kumakulitsa mphamvu yamagetsi yapamtima ya QRS ndikuyambitsa matenda oopsa a ventricular arrhythmias, zomwe zimafunika mwadzidzidzi kulowetsa sodium bicarbonate kuwonjezera pa machiritso a beta-blocker.

Kodi hemodialysis (makina a impso dialysis) amasefa beta-blockers kapena calcium channel blockers kutuluka m'magazi?¶

Pafupifupi ma calcium channel blockers (verapamil, diltiazem, amlodipine, nifedipine) ndi beta-blockers ambiri (propranolol, metoprolol, carvedilol, labetalol), hemodialysis SANGATHE kuchotsa mankhwalawa chifukwa mankhwalawa amamangiriridwa mwamphamvu ku mapuloteni a magazi ndipo amagawidwa mkati mwa mafuta a thupi ndi minofu. Komabe, pali zosiyana ziwiri zofunika: Atenolol ndi Sotalol ndizosungunuka m'madzi, zimakhala ndi mapuloteni ochepa kwambiri, ndipo zimatsukidwa ndi impso, choncho hemodialysis yadzidzidzi imatha kuchotsa bwino atenolol ndi sotalol m'magazi, makamaka odwala omwe ali ndi vuto la impso.

Maupangiri ogwirizana¶

• Aspirin (salicylate), mapiritsi a iron, ndi tricyclic antidepressant overdose
• Digoxin poizoni, yellow-green masomphenya halos, ndi mtima arrhythmia triage
• Thandizo loyamba la poyizoni ndi kuwongolera poyizoni
• Kuzindikira ndi kuchiza kugwedezeka kwachipatala
• Cardiopulmonary resuscitation (CPR) ndi AED guide

Magwero ndi malangizo ovomerezeka¶

• American College of Medical Toxicology (ACMT) & American Association of Poison Control Centers (AAPCC): Malangizo a Akatswiri a Consensus for Management of Calcium Channel Blocker and 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 ndi Calcium Channel Blockers) *.
• European Resuscitation Council (ERC): *Malangizo Otsitsimula: Kumangidwa kwa Mtima M'mikhalidwe Yapadera: Mavuto a Toxicologic *.
• ZOTHANDIZA (Zochizira Zowonjezereka mu Poizoni) Gulu la Ntchito: *Kubwereza Mwadongosolo ndi Malangizo a Chithandizo cha Extracorporeal mu Beta-Blocker ndi Calcium Channel Blocker Poisoning *.
• National Poisons Information Service (NPIS, United Kingdom) & World Health Organization (WHO): TOXBASE Clinical Management of Acute Cardiovascular Drug Overdose and High-Dose Insulin Euglycemic Therapy Protocols.

*Bukhuli ndi lofuna kudziwa zambiri ndipo sililowa m'malo mwa kuunika kwachipatala, kukaonana ndi Poison Control, kapena chisamaliro chachipatala. Chifukwa kuchulukitsitsa kwamankhwala amtima kungayambitse kukomoka kwadzidzidzi komanso kumangidwa kwa mtima, timalimbikitsa kwambiri kutenga chithandizo chovomerezeka chamanja ndi CPR kudzera ku International Federation of Red Cross ndi Red Crescent Societies (IFRC), gulu lanu la Red Cross, St John Ambulance, kapena wopereka chithandizo wamba.