Pharmacology, pathophysiology and management of calcium channel blocker and β-blocker toxicity

Toxicological Reviews

Volumn 23, Issue 4, 2004, Pages 223-238

  DeWitt, Christopher R ^a,b,e   Waksman, Javier C ^c,d  

^a ROCKY MOUNTAIN POISON AND DRUG CENTER   (United States)

^b DENVER HEALTH MEDICAL CENTER   (United States)

^c Health Sciences Center ^*

^d Division of Cardiology   (Canada)

^e ST PAUL S HOSPITAL   (Canada)

Author keywords

[No Author keywords available]

Indexed keywords

AMLODIPINE; ATENOLOL; BENZOTHIAZEPINE DERIVATIVE; BETA 1 ADRENERGIC RECEPTOR BLOCKING AGENT; BETA 2 ADRENERGIC RECEPTOR BLOCKING AGENT; BETA ADRENERGIC RECEPTOR BLOCKING AGENT; CALCIUM; CALCIUM CHANNEL BLOCKING AGENT; CATECHOLAMINE; DIHYDROPYRIDINE DERIVATIVE; DILTIAZEM; FELODIPINE; GLUCAGON; HYPERTENSIVE FACTOR; INFUSION FLUID; INSULIN; ISRADIPINE; METOPROLOL; NICARDIPINE; NIFEDIPINE; NIMODIPINE; NISOLDIPINE; OXPRENOLOL; PHENYLALKYLAMINE; PHOSPHODIESTERASE INHIBITOR; PINDOLOL; PROPRANOLOL; SOTALOL; UNINDEXED DRUG; VERAPAMIL;

BRADYCARDIA; CARDIOVASCULAR EFFECT; CENTRAL NERVOUS SYSTEM DISEASE; CLINICAL FEATURE; DIFFERENTIAL DIAGNOSIS; DRUG ABSORPTION; DRUG ACTIVITY; DRUG BIOAVAILABILITY; DRUG DETOXIFICATION; DRUG DISTRIBUTION; DRUG EFFECT; DRUG ELIMINATION; DRUG EXCRETION; DRUG FORMULATION; DRUG HALF LIFE; DRUG INTOXICATION; DRUG MECHANISM; DRUG METABOLISM; DRUG OVERDOSE; DRUG SELECTIVITY; DRUG SOLUBILITY; EPIDEMIOLOGICAL DATA; FIRST PASS EFFECT; HEART PACING; HEMODIALYSIS; HUMAN; HYPERGLYCEMIA; HYPOKALEMIA; HYPOTENSION; LETHARGY; LIPID SOLUBILITY; MEMBRANE STABILIZATION; NONHUMAN; PATHOPHYSIOLOGY; REVIEW; SEDATION; SEIZURE; TREATMENT OUTCOME; TREATMENT PLANNING;

EID: 22544463997     PISSN: 11762551     EISSN: 11762551     Source Type: Journal    
DOI: 10.2165/00139709-200423040-00003     Document Type: Review

References (183)

1. Litovitz TL, Klein-Schwartz W, Rodgers Jr GC, et al. 2001 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2002; 20 (5): 391-452
2. Litovitz TL, Klein-Schwartz W, White S, et al. 2000 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2001; 19 (5): 337-95
3. Litovitz TL, Klein-Schwartz W, White S, et al. 1999 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2000; 18 (5): 517-74
4. Litovitz TL, Klein-Schwartz W, Caravati EM, et al. 1998 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1999; 17 (5): 435-87
5. Litovitz TL, Klein-Schwartz W, Dyer KS, et al. 1997 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1998; 16 (5): 443-97
6. American Association of Poison Control Centers [online]. Available from URL: http://www.aapcc.org [Accessed 2005 Apr 2]
7. Katz AM. Calcium channel diversity in the cardiovascular system. J Am Coll Cardiol 1996; 28 (2): 522-9
8. Katz AM. Cardiac ion channels. N Engl J Med 1993; 328 (17): 1244-51
9. Katz AM. Selectivity and toxicity of antiarrhythmic drugs: molecular interactions with ion channels. Am J Med 1998; 104 (2): 179-95
10. Rasmussen H. The calcium messenger system (1). N Engl J Med 1986; 314 (17): 1094-101
11. Yamaguchi I, Akimoto Y, Nakajima H, et al. Effect of diltiazem on insulin secretion I: experiments in vitro. Jpn J Pharmacol 1977; 27 (5): 679-87
12. Devis G, Somers G, Van Obberghen E, et al. Calcium antagonists and islet function I: inhibition of insulin release by verapamil. Diabetes 1975; 24 (6): 247-51
13. Abernathy DR, Schwartz JB. Calcium-antagonist drugs. N Engl J Med 1999; 341 (19): 1447-57
14. Sperelakis N, Xiong Z, Haddad G, et al. Regulation of slow calcium channels of myocardial cells and vascular smooth muscle cells by cyclic nucleotides and phosphorylation. Mol Cell Biochem 1994; 140 (2): 103-17
15. Striessnig J. Pharmacology, structure and function of cardiac L-type Ca (2+) channels. Cell Physiol Biochem 1999; 9 (4-5): 242-69
16. Hoffman BB. Catecholamines, sympathomimetic drugs, adrenergic receptor antag-onists. In: Hardman JG, Limbird LE, Gilman AG, editors. Goodman and Gilman's the pharmacologic basis of therapeutics. 10th ed. New York: McGraw-Hill, 2001: 215-68
17. Salhanick SD, Shannon MW. Management of calcium channel antagonist overdose. Drug Saf 2003; 26 (2): 65-79
18. Hutchison TA, Shahan DR, editors. DRUGDEX® system. Greenwood Village (CO): MICROMEDEX Inc. (edition expires [11/2003])
19. Proano L, Chiang WK, Wang RY. Calcium channel blocker overdose. Am J Emerg Med 1995; 13 (4): 444-50
20. Kerins DM, Robertson RM, Robertson D. Drugs used for treatment of myocardial ischemia. In: Hardman JG, Limbird LE, Gilman AG, editors. Goodman and Gilman's the pharmacologic basis of therapeutics. 10th ed. New York: McGraw-Hill, 2001: 843-70
21. Herrington DM, Insley BM, Weinmann GG. Nifedipine overdose. Am J Med 1986; 81 (2): 344-6
22. Lee DC, Greene T, Dougherty T, et al. Fatal nifedipine ingestions in children. J Emerg Med 2000; 19 (4): 359-61
23. Haddad LM. Resuscitation after nifedipine overdose exclusively with intravenous calcium chloride. Am J Emerg Med 1996; 14 (6): 602-3
24. Boyer EW, Shannon M. Treatment of calcium-channel-blocker intoxication with insulin infusion [letter]. N Engl J Med 2001; 344 (22): 1721-2
25. Howarth DM, Dawson AH, Smith AJ, et al. Calcium channel blocking drug overdose: an Australian series. Hum Exp Toxicol 1994; 13 (3): 161-6
26. Ramoska EA, Spiller HA, Winter M, et al. A one-year evaluation of calcium channel blocker overdoses: toxicity and treatment. Ann Emerg Med 1993; 22 (2): 196-200
27. Wells TG, Graham CJ, Moss MM, et al. Nifedipine poisoning in a child. Pediatrics 1990; 86 (1): 91-4
28. Ramoska EA, Spiller HA, Myers A. Calcium channel blocker toxicity. Ann Emerg Med 1990; 19 (6): 649-53
29. Hofer CA, Smith JK, Tenholder MF. Verapamil intoxication: a literature review of overdoses and discussion of therapeutic options. Am J Med 1993; 95 (4): 431-8
30. Ashraf M, Chaudhary K, Nelson J, et al. Massive overdose of sustained-release verapamil: a case report and review of literature. Am J Med Sci 1995; 310 (6): 258-63
31. Szekely LA, Thompson BT, Woolf A. Use of partial liquid ventilation to manage pulmonary complications of acute verapamil-sustained release poisoning. J Toxicol Clin Toxicol 1999; 37 (4): 475-9
32. Brass BJ, Winchester-Penny S, Lipper BL. Massive verapamil overdose complicated by noncardiogenic pulmonary edema. Am J Emerg Med 1996; 14 (5): 459-61
33. Kuo MJ, Tseng YZ, Chen TF, et al. Verapamil overdose and severe hypocalcemia [letter]. J Toxicol Clin Toxicol 1992; 30 (2): 309-11
34. Goenen M, Col J, Compere A, et al. Treatment of severe verapamil poisoning with combined amrinone-isoproterenol therapy. Am J Cardiol 1986; 58 (11): 1142-3
35. Hendren WG, Schieber RS, Garrettson LK. Extracorporeal bypass for the treatment of verapamil poisoning. Ann Emerg Med 1989; 18 (9): 984-7
36. Wolf LR, Spadafora MP, Otten EJ. Use of amrinone and glucagon in a case of calcium channel blocker overdose. Ann Emerg Med 1993; 22 (7): 1225-8
37. da Silva OA, de Melo RA, Jorge Filho JP. Verapamil acute self-poisoning. Clin Toxicol 1979; 14 (4): 361-7
38. Doyon S, Roberts JR. The use of glucagon in a case of calcium channel blocker overdose. Ann Emerg Med 1993; 22 (7): 1229-33
39. Crump BJ, Holt DW, Vale JA. Lack of response to intravenous calcium in severe verapamil poisoning [letter]. Lancet 1982; II (8304): 939-40
40. Luscher TF, Noll G, Sturmer T, et al. Calcium gluconate in severe verapamil intoxication. N Engl J Med 1994; 330 (10): 718-20
41. Satchithananda DK, Stone DL, Chauhan A, et al. Lesson of the week: unrecognised accidental overdose with diltiazem. BMJ 2000; 321 (7254): 160-1
42. Luomanmaki K, Tiula E, Kivisto KT, et al. Pharmacokinetics of diltiazem in massive overdose. Ther Drug Monit 1997; 19 (2): 240-2
43. Isbister GK. Delayed asystolic cardiac arrest after diltiazem overdose; resuscitation with high dose intravenous calcium. Emerg Med J 2002; 19 (4): 355-7
44. Roper TA, Sykes R, Gray C. Fatal diltiazem overdose: report of four cases and review of the literature. Postgrad Med J 1993; 69 (812): 474-6
45. Williamson KM, Dunham GD. Plasma concentrations of diltiazem and desacetyldiltiazem in an overdose situation. Ann Pharmacother 1996; 30 (6): 608-11
46. Snover SW, Bocchino V. Massive diltiazem overdose. Ann Emerg Med 1986; 15 (10): 1221-4
47. Fauville JP, Hantson P, Honore P, et al. Severe diltiazem poisoning with intestinal pseudo-obstruction: case report and toxicological data. J Toxicol Clin Toxicol 1995; 33 (3): 273-7
48. Beno JM, Nemeth DR. Diltiazem and metoclopramide overdose. J Anal Toxicol 1991; 15 (5): 285-7
49. Erickson FC, Ling LJ, Grande GA, et al. Diltiazem overdose: case report and review. J Emerg Med 1991; 9 (5): 357-66
50. Buckley N, Dawson AH, Howarth D, et al. Slow-release verapamil poisoning: use of polyethylene glycol whole-bowel lavage and high-dose calcium. Med J Aust 1993; 158 (3): 202-4
51. Whitebloom D, Fitzharris J. Nifedipine overdose. Clin Cardiol 1988; 11 (7): 505-6
52. Walter FG, Frye G, Mullen JT, et al. Amelioration of nifedipine poisoning associated with glucagon therapy. Ann Emerg Med 1993; 22 (7): 1234-7
53. Welch RD, Todd K. Nifedipine overdose accompanied by ethanol intoxication in a patient with congenital heart disease. J Emerg Med 1990; 8 (2): 169-72
54. Lam YM, Tse HF, Lau CP. Continuous calcium chloride infusion for massive nifedipine overdose. Chest 2001; 119 (4): 1280-2
55. Koch AR, Vogelaers DP, Decruyenaere JM, et al. Fatal intoxication with amlodipine. J Toxicol Clin Toxicol 1995; 33 (3): 253-6
56. Yuan TH, Kerns II WP, Tomaszewski CA, et al. Insulin-glucose as adjunctive therapy for severe calcium channel antagonist poisoning. J Toxicol Clin Toxicol 1999; 37 (4): 463-74
57. Stanek EJ, Nelson CE, DeNofrio D. Amlodipine overdose. Ann Pharmacother 1997; 31 (7-8): 853-6
58. Brubacher JR. Beta-adrenergic antagonists. In: Goldfrank LR, Flomenbaum NE, Lewin NA, et al., editors. Goldfrank's toxicologic emergencies. 7th ed. New York: McGraw-Hill, 2002: 741-57
59. Wood AJ. Pharmacologic differences between beta blockers. Am Heart J 1984; 108 (4 Pt 2): 1070-7
60. Frishman W, Jacob H, Eisenberg E, et al. Clinical pharmacology of the new beta-adrenergic blocking drugs. Part 8. Self-poisoning with beta-adrenoceptor blocking agents: recognition and management. Am Heart J 1979; 98 (6): 798-811
61. Prichard BN, Battersby LA, Cruickshank JM. Overdosage with beta-adrenergic blocking agents. Adverse Drug React Acute Poisoning Rev 1984; 3 (2): 91-111
62. Reith DM, Dawson AH, Epid D, et al. Relative toxicity of beta blockers in overdose. J Toxicol Clin Toxicol 1996; 34 (3): 273-8
63. Kulling P, Eleborg L, Persson H. Beta-adrenoceptor blocker intoxication: epidemiological data: prenalterol as an alternative in the treatment of cardiac dysfunction. Hum Toxicol 1983; 2 (2): 175-81
64. Love JN, Howell JM, Litovitz TL, et al. Acute beta blocker overdose: factors associated with the development of cardiovascular morbidity. J Toxicol Clin Toxicol 2000; 38 (3): 275-81
65. Love JN, Litovitz TL, Howell JM, et al. Characterization of fatal beta blocker ingestion: a review of the American Association of Poison Control Centers data from 1985 to 1995. J Toxicol Clin Toxicol 1997; 35 (4): 353-9
66. Love JN. Acebutolol overdose resulting in fatalities. J Emerg Med 2000; 18 (3): 341-4
67. Weinstein RS. Recognition and management of poisoning with beta-adrenergic blocking agents. Ann Emerg Med 1984; 13 (12): 1123-31
68. Sangster B, de Wildt D, van Dijk A, et al. A case of acebutolol intoxication. J Toxicol Clin Toxicol 1983; 20 (1): 69-77
69. Nicolas F, Villers D, Rozo L, et al. Severe self-poisoning with acebutolol in association with alcohol. Crit Care Med 1987; 15 (2): 173-4
70. Gengo FM, Huntoon L, McHugh WB. Lipid-soluble and water-soluble beta-blockers: comparison of the central nervous system depressant effect. Arch Intern Med 1987; 147 (1): 39-43
71. Hong CY, Yang WC, Chiang BN. Importance of membrane stabilizing effect in massive overdose of propranolol: plasma level study in a fatal case. Hum Toxicol 1983; 2 (3): 511-7
72. Heath A. Beta-adrenoceptor blocker toxicity: clinical features and therapy. Am J Emerg Med 1984; 2 (6): 518-25
73. Love JN, Enlow B, Howell JM, et al. Electrocardiographic changes associated with beta-blocker toxicity. Ann Emerg Med 2002; 40 (6): 603-10
74. Boehnert MT, Lovejoy Jr FH. Value of the QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. N Engl J Med 1985; 313 (8): 474-9
75. Henry JA, Cassidy SL. Membrane stabilising activity: a major cause of fatal poisoning. Lancet 1986; I (8495): 1414-7
76. Hohnloser SH, Woosley RL. Sotalol. N Engl J Med 1994; 331 (1): 31-8
77. Kontopoulos A, Filindris A, Manoudis F, et al. Satalol-induced torsade de pointes. Postgrad Med J 1981; 57 (667): 321-3
78. Arstall MA, Hii JT, Lehman RG, et al. Sotalol-induced torsade de pointes: management with magnesium infusion. Postgrad Med J 1992; 68 (798): 289-90
79. Totterman KJ, Turto H, Pellinen T. Overdrive pacing as treatment of sotalol-induced ventricular tachyarrhythmias (torsade de pointes). Acta Med Scand Suppl 1982; 668: 28-33
80. Neuvonen PJ, Elonen E, Vuorenmaa T, et al. Prolonged Q-T interval and severe tachyarrhythmias, common features of sotalol intoxication. Eur J Clin Pharmacol 1981; 20 (2): 85-9
81. Elonen E, Neuvonen PJ, Tarssanen L, et al. Sotalol intoxication with prolonged Q-T interval and severe tachyarrhythmias. BMJ 1979; 1 (6172): 1184
82. Donovan KD, Gerace RV, Dreyer JF. Acebutolol-induced ventricular tachycardia reversed with sodium bicarbonate. J Toxicol Clin Toxicol 1999; 37 (4): 481-4
83. Brimacombe JR, Scully M, Swainston R. Propranolol overdose a dramatic response to calcium chloride. Med J Aust 1991; 155 (4): 267-8
84. Spiller HA, Meyers A, Ziemba T, et al. Delayed onset of cardiac arrhythmias from sustained-release verapamil. Ann Emerg Med 1991; 20 (2): 201-3
85. Tom PA, Morrow CT, Kelen GD. Delayed hypotension after overdose of sustained release verapamil. J Emerg Med 1994; 12 (5): 621-5
86. Love JN. Beta blocker toxicity after overdose: when do symptoms develop in adults? J Emerg Med 1994; 12 (6): 799-802
87. Kerns II W, Kline J, Ford MD. Beta-blocker and calcium channel blocker toxicity. Emerg Med Clin North Am 1994; 12 (2): 365-90
88. Roberts D, Honcharik N, Sitar DS, et al. Diltiazem overdose: pharmacokinetics of diltiazem and its metabolites and effect of multiple dose charcoal therapy. J Toxicol Clin Toxicol 1991; 29 (1): 45-52
89. Ori Y, Korzets A, Caneti M, et al. Lymphocytic intracellular calcium in a patient with complicated verapamil overdose. Am J Med Sci 2000; 319 (1): 63-7
90. Frierson J, Bailly D, Shultz T, et al. Refractory cardiogenic shock and complete heart block after unsuspected verapamil-SR and atenolol overdose. Clin Cardiol 1991; 14 (11): 933-5
91. Kline JA, Raymond RM, Schroeder JD, et al. The diabetogenic effects of acute verapamil poisoning. Toxicol Appl Pharmacol 1997; 145 (2): 357-62
92. Kline JA, Leonova E, Raymond RM. Beneficial myocardial metabolic effects of insulin during verapamil toxicity in the anesthetized canine. Crit Care Med 1995; 23 (7): 1251-63
93. Abbasi IA, Sorsby S. Prolonged toxicity from atenolol overdose in an adolescent. Clin Pharm 1986; 5 (10): 836-7
94. McBride JT, McBride MC, Viles PH. Hypoglycemia associated with propranolol. Pediatrics 1973; 51 (6): 1085-7
95. Hesse B, Pedersen JT. Hypoglycaemia after propranolol in children. Acta Med Scand 1973; 193 (6): 551-2
96. Rooney M, Massey KL, Jamali F, et al. Acebutolol overdose treated with hemodialysis and extracorporeal membrane oxygenation. J Clin Pharmacol 1996; 36 (8): 760-3
97. Shore ET, Cepin D, Davidson MJ. Metoprolol overdose. Ann Emerg Med 1981; 10 (10): 524-7
98. Weinstein RS, Cole S, Knaster HB, et al. Beta blocker overdose with propranolol and with atenolol. Ann Emerg Med 1985; 14 (2): 161-3
99. Gutierrez H, Jorgensen M. Colonic ischemia after verapamil overdose [letter]. Ann Intern Med 1996; 124 (5): 535
100. Sporer KA, Manning JJ. Massive ingestion of sustained-release verapamil with a concretion and bowel infarction. Ann Emerg Med 1993; 22 (3): 603-5
101. Samniah N, Schlaeffer F. Cerebral infarction associated with oral verapamil overdose. J Toxicol Clin Toxicol 1988; 26 (5-6): 365-9
102. Smit AJ, Mulder PO, de Jong PE, et al. Acute renal failure after overdose of labetalol. BMJ (Clin Res Ed) 1986; 293 (6555): 1142-3
103. Pertoldi F, D'Orlando L, Mercante WP. Electromechanical dissociation 48 hours after atenolol overdose: usefulness of calcium chloride. Ann Emerg Med 1998; 31 (6): 777-81
104. Lewis M, Kallenbach J, Germond C, et al. Survival following massive overdose of adrenergic blocking agents (acebutolol and labetalol). Eur Heart J 1983; 4 (5): 328-32
105. Schofield PM, Beath SV, Mant TG, et al. Recovery after severe oxprenolol overdose complicated by rhabdomyolysis. Hum Toxicol 1985; 4 (1): 57-60
106. Lagerfelt J, Matell G. Attempted suicide with 5.1g of propranolol: a case report. Acta Med Scand 1976; 199 (6): 517-8
107. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 7: the era of reperfusion. Section 1: acute coronary syndromes (acute myocardial infarction). Circulation 2000; 102 (8 Suppl.): I172-203
108. Love JN, Howell JM, Newsome JT, et al. The effect of sodium bicarbonate on propranolol-induced cardiovascular toxicity in a canine model. J Toxicol Clin Toxicol 2000; 38 (4): 421-8
109. Kerns II W, Ransom M, Tomaszewski C, et al. The effects of extracellular ions on beta-blocker cardiotoxicity. Toxicol Appl Pharmacol 1996; 137 (1): 1-7
110. Kerns II W, Ransom M, Tomaszewski C, et al. The effect of hypertonic sodium and dantrolene on propranolol cardiotoxicity. Acad Emerg Med 1997; 4 (6): 545-51
111. Belton P, Sheridan J, Mulcahy R. A case of sotalol poisoning. Ir J Med Sci 1982; 151 (4): 126-7
112. Assimes TL, Malcolm I. Torsade de pointes with sotalol overdose treated successfully with lidocaine. Can J Cardiol 1998; 14 (5): 753-6
113. Bond GR. The role of activated charcoal and gastric emptying in gastrointestinal decontamination: a state-of-the-art review. Ann Emerg Med 2002; 39 (3): 273-86
114. Seger D. Single-dose activated charcoal-backup and reassess. J Toxicol Clin Toxicol 2004; 42 (1): 101-10
115. American Academy of Clinical Toxicology, European Association of Poison Centers and Clinical Toxicologists. Position statements. J Toxicol Clin Toxicol 1997; 35: 699-762
116. American Academy of Clinical Toxicology, European Association of Poison Centres and Clinical Toxicologists. Position paper: whole bowel irrigation. J Toxicol Clin Toxicol 2004; 42 (6): 843-54
117. American Academy of Clinical Toxicology, European Association of Poison Centres and Clinical Toxicologists. Position paper: gastric lavage. J Toxicol Clin Toxicol 2004; 42 (7): 933-43
118. American Academy of Clinical Toxicology, European Association of Poison Centres and Clinical Toxicologists. Position paper: ipecac syrup. J Toxicol Clin Toxicol 2004; 42 (2): 133-43
119. Juurlink DN, McGuigan MA. Gastrointestinal decontamination for enteric-coated aspirin overdose: what to do depends on who you ask. J Toxicol Clin Toxicol 2000; 38 (5): 465-70
120. Tominack R. Gastrointestinal decontamination: maybe we're both right. J Toxicol Clin Toxicol 2000; 38 (7): 691-2
121. Hoffman RS. Does consensus equal correctness? J Toxicol Clin Toxicol 2000; 38 (7): 689-90
122. Laine K, Kivisto KT, Laakso I, et al. Prevention of amlodipine absorption by activated charcoal: effect of delay in charcoal administration. Br J Clin Pharmacol 1997; 43 (1): 29-33
123. Laine K, Kivisto KT, Neuvonen PJ. Effect of delayed administration of activated charcoal on the absorption of conventional and slow-release verapamil. J Toxicol Clin Toxicol 1997; 35 (3): 263-8
124. Kirshenbaum LA, Mathews SC, Sitar DS, et al. Whole-bowel irrigation versus activated charcoal in sorbitol for the ingestion of modified-release pharmaceuticals. Clin Pharmacol Ther 1989; 46 (3): 264-71
125. Tenenbein M. Position statement: whole bowel irrigation. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997; 35 (7): 753-62
126. Love JN, Hanfling D, Howell JM. Hemodynamic effects of calcium chloride in a canine model of acute propranolol intoxication. Ann Emerg Med 1996; 28 (1): 1-6
127. Hariman RJ, Mangiardi LM, McAllister Jr RG, et al. Reversal of the cardiovascular effects of verapamil by calcium and sodium: differences between electrophysiologic and hemodynamic responses. Circulation 1979; 59 (4): 797-804
128. De Roos F. Calcium channel blockers. In: Goldfrank LR, Flomenbaum NE, Lewin NA, et al., editors. Goldfrank's toxicologic emergencies. 7th ed. New York: McGraw-Hill, 2002: 762-74
129. Pearigen PD, Benowitz NL. Poisoning due to calcium antagonists: experience with verapamil, diltiazem and nifedipine. Drug Saf 1991; 6 (6): 408-30
130. Kenny J. Treating overdose with calcium channel blockers. BMJ 1994; 308 (6935): 992-3
131. Newton CR, Delgado JH, Gomez HF. Calcium and beta receptor antagonist overdose: a review and update of pharmacological principles and management. Sem Resp Crit Care Med 2002; 23 (1): 19-25
132. Howland MA. Calcium. In: Goldfrank LR, Flomenbaum NE, Lewin NA, et al., editors. Goldfrank's toxicologic emergencies. 7th ed. New York: McGraw-Hill, 2002: 1341-5
133. Kline JA. Calcium channel antagonists. In: Ford MD, Delaney KA, Ling LJ, et al., editors. Clinical toxicology. Philadelphia (PA): WB Saunders, 2001: 370-8
134. Rouse AM, Pelucio M. Drugs and antidote dosages. In: Ford MD, Delaney KA, Ling LJ, et al., editors. Clinical toxicology. Philadelphia (PA): WB Saunders, 2001: 1055-61
135. Buckley NA, Whyte IM, Dawson AH. Overdose with calcium channel blockers [letter]. BMJ 1994; 308 (6944): 1639
136. Carlon GC, Howland WS, Goldiner PL, et al. Adverse effects of calcium administration: report of two cases. Arch Surg 1978; 113 (7): 882-5
137. Chin RL, Garmel GM, Harter PM. Development of ventricular fibrillation after intravenous calcium chloride administration in a patient with supraventricular tachycardia. Ann Emerg Med 1995; 25 (3): 416-9
138. Nola GT, Pope S, Harrison DC. Assessment of the synergistic relationship between serum calcium and digitalis. Am Heart J 1970; 79 (4): 499-507
139. Hack JB, Woody JH, Brewer K, et al. Pilot study: Use of calcium chloride to treat hyperkalemia due to acute digoxin toxicity in a swine model [abstract]. J Toxicol Clin Toxicol 2003; 41 (5): 696
140. Bower JO, Mengle HAK. The additional effect of calcium and digitalis: a warning with report of two deaths. JAMA 1936; 106: 1151
141. Lucchesi BR. Cardiac actions of glucagon. Circ Res 1968; 22 (6): 777-87
142. Levey GS, Epstein SE. Activation of adenyl cyclase by glucagon in cat and human heart. Circ Res 1969; 24 (2): 151-6
143. Howland MA. Glucagon. In: Goldfrank LR, Flomenbaum NE, Lewin NA, et al., editors. Goldfrank's toxicologic emergencies. 7th ed. New York: McGraw-Hill, 2002: 758-60
144. Kerns W. Beta-adrenergic receptor antagonists. In: Ford MD, Delaney KA, Ling LJ, et al., editors. Clinical toxicology. Philadelphia (PA): WB Saunders, 2001: 362-9
145. Bailey B. Glucagon in beta-blocker and calcium channel blocker overdoses: a systematic review. J Toxicol Clin Toxicol 2003; 41 (5): 595-602
146. Kosinski EJ, Malindzak Jr GS. Glucagon and isoproterenol in reversing propranolol toxicity. Arch Intern Med 1973; 132 (6): 840-3
147. Peterson CD, Leeder JS, Sterner S. Glucagon therapy for beta-blocker overdose. Drug Intell Clin Pharm 1984; 18 (5): 394-8
148. Wilkinson J. Beta blocker overdoses [letter]. Ann Emerg Med 1986; 15 (8): 982
149. Anthony T, Jastremski M, Elliott W, et al. Charcoal hemoperfusion for the treatment of a combined diltiazem and metoprolol overdose. Ann Emerg Med 1986; 15 (11): 1344-8
150. Freestone S, Thomas HM, Bhamra RK, et al. Severe atenolol poisoning: treatment with prenalterol. Hum Toxicol 1986; 5 (5): 343-5
151. McVey FK, Corke CF. Extracorporeal circulation in the management of massive propranolol overdose. Anaesthesia 1991; 46 (9): 744-6
152. Parmley WW, Glick G, Sonnenblick EH. Cardiovascular effects of glucagon in man. N Engl J Med 1968; 279 (1): 12-7
153. Parmley WW. The role of glucagon in cardiac therapy. N Engl J Med 1971; 285 (14): 801-2
154. Mofenson HC, Caraccio TR, Laudano J. Glucagon for propranolol overdose [letter]. JAMA 1986; 255 (15): 2025-6
155. Burda AM, Kapustka CA. Reformulated glucagon diluent phenol-free [letter]. J Toxicol Clin Toxicol 1999; 37 (1): 127
156. Albertson TE, Dawson A, de Latorre F, et al. TOX-ACLS: toxicologic-oriented advanced cardiac life support. Ann Emerg Med 2001; 37 (4 Suppl.): S78-90
157. Kalman S, Berg S, Lisander B. Combined overdose with verapamil and atenolol: treatment with high doses of adrenergic agonists. Acta Anaesthesiol Scand 1998; 42 (3): 379-82
158. Halloran TJ, Phillips CE. Propranolol intoxication: a severe case responding to norepinephrine therapy. Arch Intern Med 1981; 141 (6): 810-1
159. Lindvall K, Personne M, Sjogren A. High-dose prenalterol in beta-blockade intoxication. Acta Med Scand 1985; 218 (5): 525-8
160. Wallin CJ, Hulting J. Massive metoprolol poisoning treated with prenalterol. Acta Med Scand 1983; 214 (3): 253-5
161. Gandy W. Severe epinephrine-propranolol interaction. Ann Emerg Med 1989; 18 (1): 98-9
162. Alousi AA, Canter JM, Fort DJ. The beneficial effect of amrinone on acute drug-induced heart failure in the anaesthetised dog. Cardiovasc Res 1985; 19 (8): 483-94
163. Love JN, Leasure JA, Mundt DJ, et al. A comparison of amrinone and glucagon therapy for cardiovascular depression associated with propranolol toxicity in a canine model. J Toxicol Clin Toxicol 1992; 30 (3): 399-412
164. Sato S, Tsuji MH, Okubo N, et al. Milrinone versus glucagon: comparative hemodynamic effects in canine propranolol poisoning. J Toxicol Clin Toxicol 1994; 32 (3): 277-89
165. Whitehurst VE, Vick JA, Alleva FR, et al. Reversal of propranolol blockade of adrenergic receptors and related toxicity with drugs that increase cyclic AMP. Proc Soc Exp Biol Med 1999; 221 (4): 382-5
166. Hoeper MM, Boeker KH. Overdose of metoprolol treated with enoximone [letter]. N Engl J Med 1996; 335 (20): 1538
167. Kollef MH. Labetalol overdose successfully treated with amrinone and alpha-adrenergic receptor agonists. Chest 1994; 105 (2): 626-7
168. Tuncok Y, Apaydin S, Gidener S, et al. The effects of amrinone and glucagon on verapamil-induced myocardial depression in a rat isolated heart model. Gen Pharmacol 1997; 28 (5): 773-6
169. Tuncok Y, Apaydin S, Kalkan S, et al. The effects of amrinone and glucagon on verapamil-induced cardiovascular toxicity in anaesthetized rats. Int J Exp Pathol 1996; 77 (5): 207-12
170. Sato S, Tsuji MH, Okubo N, et al. Combined use of glucagon and milrinone may not be preferable for severe propranolol poisoning in the canine model. J Toxicol Clin Toxicol 1995; 33 (4): 337-42
171. Love JN, Leasure JA, Mundt DJ. A comparison of combined amrinone and glucagon therapy to glucagon alone for cardiovascular depression associated with propranolol toxicity in a canine model. Am J Emerg Med 1993; 11 (4): 360-3
172. Farah AE, Alousi AA. The actions of insulin on cardiac contractility. Life Sci 1981; 29 (10): 975-1000
173. Tune JD, Mallet RT, Downey HF. Insulin improves cardiac contractile function and oxygen utilization efficiency during moderate ischemia without compromising myocardial energetics. J Mol Cell Cardiol 1998; 30 (10): 2025-35
174. Kline JA, Tomaszewski CA, Schroeder JD, et al. Insulin is a superior antidote for cardiovascular toxicity induced by verapamil in the anesthetized canine. J Pharmacol Exp Ther 1993; 267 (2): 744-50
175. Kerns II W, Schroeder D, Williams C, et al. Insulin improves survival in a canine model of acute beta-blocker toxicity. Ann Emerg Med 1997; 29 (6): 748-57
176. Masters TN, Glaviano VV. Effects of dl-propranolol on myocardial free fatty acid and carbohydrate metabolism. J Pharmacol Exp Ther 1969; 167 (1): 187-93
177. Place R, Carlson A, Leiken J, et al. Hyperinsulin therapy in the treatment of verapamil overdose [abstract]. J Toxicol Clin Toxicol 2000; 38: 576-7
178. Morris-Kukoski CL, Biswas AK, Parra M, et al. Insulin 'euglycemia' therapy for accidental nifedipine overdose [abstract]. J Toxicol Clin Toxicol 2000; 38: 577
179. Herbert JX, O'Malley C, Treacey JA, et al. Verapamil therapy unresponsive to dextrose/insulin therapy [abstract]. J Toxicol Clin Toxicol 2001; 39: 293-4
180. Cumpston K, Mycyk M, Pallasch E, et al. Failure of hyperinsulinemia/ euglucemia therapy in severe diltiazam overdose [abstract]. J Toxicol Clin Toxicol 2002; 40: 618
181. Jolly SR, Wilson VP, Movahed A, et al. Effect of hyperkalemia on myocardial depression by verapamil in isolated hearts. Pharmacology 1993; 47 (5): 286-94
182. Megarbane B, Karyo S, Baud FJ. The role of insulin and glucose (hyperinsulinaemia/euglycaemia) therapy in acute calcium channel antagonist and β-blocker poisoning. Toxicol Rev 2004; 23 (4): 215-22
183. Holzer M, Sterz F, Schoerkhuber W, et al. Successful resuscitation of a verapamil-intoxicated patient with percutaneous cardiopulmonary bypass. Crit Care Med 1999; 27 (12): 2818-23