Intoxications of long acting calcium channel blockers

Giriş: Özkıyım amaçlı verapamil intoksikasyonu olan iki olguda kalsiyum kanal blokerleri intoksikasyonu ve tedavisinin irdelenmesi amaçlanmıştır. Olgu 1: Toplam 5,04 gr verapamil ve 56 mg trandolapril peroral alınımından 14 saat sonra hastaneye getirilmiş. Genel durumu kötü, bilinci konfü, arteriyel tansiyon 60/30 mmHg, kalp atım sayısı 65.dk-1'di. Dopamin, dobutamin, adrenalin ve kalsiyum infüzyonu, nazogastrik lavaj ve aktif kömür başlandı. Olgumuza 3 mg glukagon uygulandı. Pacemaker sonrası plazmaferez uygulanırken kalp atım sayısının 45.dk-1'ya düşmesi ve desatüre olması üzerine entübe edildi. Kardiopulmoner resüsitasyona (CPR) başlandı ve CPR'ın 2. saatinde femoral ven-femoral arter yoluyla ekstrakorporeal dolaşım uygulandı. 10 saat ekstrakoorporeal dolaşımda kalan, plazmaferezi devam eden, kalsiyum replasmanı süren hasta, intraaortik balon pompası ve maksimum dozda inotropik ve vazokonstrüktör destek ile ekstrakorporeal dolaşımdan çıkartıldı. Maksimum dozda inotropik desteğe rağmen arteriyel tansiyon değerleri düşen, trombositopeni, ARDS, renal tedavi gerektiren zehirlenmelerdir. Agresif resüsitasyon, plazmaferez, intraaortik balon pompası ve ekstrakoorporeal dolaşım uygulamalarının da destek tedavide yeri vardırIntroduction: The aim is to evaluate calcium channel blocker intoxication and treatment of two cases of verapamil intoxication with suicidal intention.Case 1: The patient was brought to hospital 14 hours after oral intake of a total of 5.04 g verapamil and 56 mg trandolapril. General situation was bad, the patient was confused, arterial blood pressure was 60/30 mmHg, and heart rate was 65 min-1. Dopamine, dobutamine, adrenaline and calcium infusion, nasogastric lavage and activated carbon were begun. The case was given 3 mg glucagon. After pacemaker while administering plasmapheresis, heart rate fell to 45 min-1 and upon desaturation the patient was intubated. Cardiopulmonary resuscitation (CPR) was begun and in the 2nd hour of CPR extracorporeal circulation was applied through the femoral vein-femoral artery. Extracorporeal circulation lasted for 10 hours, while plasmapheresis and calcium replacement continued. The patient was removed from extracorporeal circulation with support of intraaortic balloon pump and maximum doses of inotropics and vasoconstrictors. Despite support with maximum dose inotropics arterial blood pressure values fell and a tableau of thrombocytopenia, ARDS and renal failure developed. On the 5th day after admission the patient arrested, did not respond to CPR and was declared dead.Case 2: Twelve hours after oral intake of a total of 3.6 g verapamil the patient was brought to hospital. General condition was moderate, aware with arterial blood pressure of 60/30 mmHg, and heart rate of 44 min-1. Nasogastric lavage, activated carbon and dopamine infusion were begun. Fifteen hours after medication intake arterial blood pressure was 50/30 mmHg, heart rate was 30 min-1, the patient lost consciousness and developed cardiac arrest and was intubated. CPR was begunand the patient responded. Calcium infusion continued while the patient was monitored with a mechanic ventilator. Cardiac arrest developed again and CPR was administered. Seventeen hours after medication intake urination began and arterial blood pressure values in the 24th hour rose to 120/50 mmHg. Hemoperfusion was administered for 5.5 hours. On the 2nd day in intensive care the patient’s vital signs stabilized, on the 15th day they were extubated and on the 50th day they were discharged. Conclusion: Calcium channel blocker poisoning may cause life-threatening complications and requires emergency, aggressive support and antidotal treatment. Aggressive resuscitation, plasmapheresis, intraaortic balloon pump and extracorporeal circulation all have a place in supportive treatment