UMEM Educational Pearls


US, Canadian and European critical care and toxicology societies recently published a consensus recommendation is the management of CCB poisoning.

Bottom line:

1. First line therapy remains unchanged: IV calcium, atropin, high-dose insulin (HIE) therapy, vasopressor support (norepinephrine and/or epinephrine).

2. Refractory to first line therapy: increase HIE, lipid-emulsion, transvenous pacemaker

3. Refractory shock, periarrest or cardiac arrest: Above (#1 & #2) plus ECMO if available.


Overall, there has not been a signficant changes to the current management of CCB poisoning. However, there is a nice flow chart of the algorithm/recommendation in the article. The authors note that the "level of evidenc was very low" for all intervention.


A. asymptomatic patients

  1. Observation up to 24 hours for potentially toxic ingestion
  2. GI decontamination

B. First line therapy

  1. IV calcium
  2. atropine in symptomatic bradycardia or conduction disturbance
  3. high-dose insulin therapy
  4. norepineprhine and/or epinephrine
  5. In the presence of cardiogenic shock: epinephrine or dobutamine

C. Refractory to first line therapy

  1. Incremental increase of high-dose insulin therapy (up to 10 unit/kg/hr) in presence of myocardia dysfunction
  2. IV lipid-emulsion therapy
  3. pacemaker in the presence of unstable bradycardia or high-grade AV block

D. Refratory shock or periarrest

  1. incremental increase of high-dose insulin therapy
  2. IV lipid-emulsion therapy if not administered
  3. pacermaker in the presence of unstable bradycardia or high-grade AV block in absence of myocardial dysfunction if not initated previously
  4. ECMO, if available

E. Cardiac arrest

  1. IV calcium
  2. ACLS guided resuscitation
  3. IV lipid-emulsion therapy
  4. ECMO


St-Onge, M et al. Experts consensus recommendations for the management of calcium channel blocker poisoning in adults. Crit Care Med 2016 (