Verapamil toxicity: Yet another transport nightmare
While I can't speak intelligently to referral patterns, I am guessing what transpired on this next transport could possibly be labeled as "out of the ordinary."
The communications center of a large, university-based air medical transport program is requested by a regional EMS service to respond to a community health center 20 nautical miles away. The ambulance crew had been requested to transport a 16 year-old female to the local ("local" being 25 miles away) emergency department secondary to respiratory failure and shock. The patient was brought in to the health center by her mother secondary to general weakness. It was later discovered that the grandmother's bottle of verapamil (calan) was missing.
The helicopter was rerouted to the local hospital as the patient acutely deteriorated and was emergently transported there. In the emergency room (ER), the patient continued to deteriorate. It could not be determined how long ago the suspected ingestion had occurred. Interventions between the community health center and the ER included intubation, atropine secondary to bradycardia, volume resuscitation and activated charcoal via gastric tube. Laboratory values that had arrived at the same time as the transport team included a bedside glucose of 346 mg/dl, and an arterial blood gas that included:
pH 7.16 paCO2 71 mmHg paO2 235 mmHg HCO3- 21 mg/dl SaO2 95% Anion gap 15 Delta Delta 0.7Where Do You Start? Reading thus far, it may be inherently obvious that the course of action to take is to manage calcium channel blocker toxicity. While this is a very logical starting point, remember that a general rule of thumb when it comes to toxicology cases is to expect that multiple substances may have been ingested. With that said, initial intervention by paramedics and referral ER staff were very appropriate. Airway management, attempts at decontamination/absorption and hemodynamic management were primary concerns and reasonable initial therapy.
Pathophysiology
Treatment goals in the acute setting include airway and ventilatory management, as well as hemodynamic support. Aggressive airway management may be warranted secondary to profound shock, obtundation, pulmonary edema and the possible need for decontamination and absorption therapy with activated charcoal (note to use activated charcoal without sorbitol)4. Ventilatory management should be guided by blood gases and the need for PEEP to manage non-cardiogenic pulmonary edema. Monitor electrolyte values, specifically serum potassium and calcium and select appropriate induction agents if the rapid sequence approach is employed.
Renal Dose Dopamine Effects On Svr - News
decrease in systemic vascular resistance (SVR) and bradycardia. Maintenance of hemodynamic status includes atropine, intravenous calcium chloride (bolus dosing and if necessary, continuous infusion), catecholamine infusions (eg., dopamine,
Review and Update on Inotropes and Vasopressors
Patients presenting with shock have inadequate perfusion of tissues and lack adequate oxygen delivery to vital organs. Shock must be treated immediately to prevent multisystem organ failure and death. The components of blood pressure are cardiac output and systemic vascular resistance (SVR). Therefore, patients presenting with shock will have either an inadequate cardiac index (CI) or a low SVR due to arterial vasodilation (or rarely both). The classification of shock originates from the etiology of the physiologic state. Shock is classified as hypovolemic, cardiogenic, extracardiac obstructive, or distributive. Hypovolemic shock results from decreased preload secondary to dehydration or hemorrhage. Cardiogenic shock results from heart failure due to various causes (myopathy, cardiac valve disorders, or arrhythmias). Extracardiac obstruction can be secondary to tension pneumothorax or pulmonary emboli. Distributive shock can be due to sepsis, anaphylaxis, or neurogenic. Hypovolemic, cardiogenic, and extracardiac obstructive shock result from poor CI, and these patients will usually have an elevated SVR as a mechanism for compensation. Distributive shock results from excessive vasodilation and low SVR, and these patients will most commonly have a normal or elevated CI.
Pharmacologic agents that increase blood pressure by causing arteriole vasoconstriction are called vasopressors, and agents that increase cardiac contractility and therefore CI are considered inotropes. The purpose of this article is to review the common vasopressors and inotropes, which are used in the intensive care unit (ICU) to treat shock or congestive heart failure (CHF) or support patients in the postoperative setting. These include the catecholamines (dobutamine [Dobutrex], isoproterenol [Isuprel], dopamine, epinephrine, norepinephrine [Levophed], and phenylephrine [Neosynephrine]), phosphodiesterase inhibitors (PDIs) (milrinone [Primacor] and inamrinone [Inocor, formerly called amrinone]), and vasopressin (Pitressin) and its analog terlipressin.
Pharmacology CatecholaminesThe catecholamines or sympathomimetic agents all act on receptors of the sympathetic (or adrenergic) nervous system. Stimulation of the beta ) receptors results in smooth muscle relaxation including arterioles, which can result in vasodilation and a decrease in SVR. Stimulation of alpha-([alpha]) receptors results in vasoconstriction and an increase in SVR and blood pressure, but can cause a reduction in CI due to the increase in afterload. The actions and hemodynamic effects of the various catecholamines are summarized in Table 1 .
Renal Dose Dopamine Effects On Svr - Bookshelf
Pediatric critical care medicine, basic science and clinical evidence
However, the ascribed renal protective effect of renal-dose dopamine has not ... augmenting SVR as occurs most commonly with pure cardiogenic shock (eg, ...Resuscitation and Stabilization of the Critically Ill Child
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'Renal dose dopamine' confers no renal protection and is no longer used. ... The effects on individual SVR can be defined by administering during CPB when ...Handbook of Drugs in Intensive Care, An A-Z Guide
Dopamine exerts its haemodynamic effects in a dose-dependent ... causing increased SVR, decreased renal blood flow and increased potential for arrhythmias. ...Critical care, the requisites in anesthesiology
Dopamine The effects of dopamine (DA) are dose-dependent, ... This dose range has been referred to as “renal dose dopamine” with the expectation that the ...Detailed Information Directory
Inotropes & vasopressors in Intensive Care
Low dose dopamine does not prevent renal failure in critically ill patients ... as dopamine but has a bulky ring substitution on the terminal amino group. ...
Pressors Scott Forman, D.O.
At low doses, dopamine acts predominately on dopamine-1 receptors in the renal mesenteric, cerebral, and ... dose-dependent effects of dopamine mean that increasing the dose of ...
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Accurate, FDA approved Dopamine Injection information for healthcare professionals and patients - brought to you by Drugs.com.
Dopamine - Drug Info, Side Effects, Research, Clinical Trials
Dopamine - Drug Info, Side Effects, Research, Clinical Trials ... with low-dose dopamine on diuresis, clinical status, renal function, electrolyte balance, length of stay, and ...
DOPamine: Drug Information Provided by Lexi-Comp: Merck ...
Low-dose dopamine is often used in the intensive care setting for presumed beneficial effects on renal function. However, there is no clear evidence ...