glucagon IV in a full arrest

[Kaisu]

I have a question for you. Working a full arrest and thinking about the Hs and Ts.. in this case, I have good reason to suspect a beta blocker overdose.

As far as I know, epi/atropin is not going to do much to a heart thats od'd on beta blockers. Given that peripheral circulation is going to be compromised in a big way, what do you think about administering glucagon IV? Dose? Your input is much appreciated.

edited to add glucagon instead of the word antidote

Edited July 22, 2010 by CrapMagnet

[croaker260]

I have a question for you. Working a full arrest and thinking about the Hs and Ts.. in this case, I have good reason to suspect a beta blocker overdose.

As far as I know, epi/atropin is not going to do much to a heart thats od'd on beta blockers. Given that peripheral circulation is going to be compromised in a big way, what do you think about administering glucagon IV? Dose? Your input is much appreciated.

edited to add glucagon instead of the word antidote

Two comments:

1) Glucagon is a perfectly acceptable option in this scenarion...however one should be aware that doses of glucagn may be in the range of 5-10 mg (units), typically more than most EMS units carry.

2) Epi is still used, however depending on your protocols, high dose EPi may be indicated. I know, I know, we no longer do high dose/escalating dose epi in cardiac arrest...true for NORMAL cardiac arrest, but for Beta Blocker OD...doses up to 5 mg each are indicated. As an alternative, Epi drips may be useful as well.

Atropine may not be effective, but is not contraindicated weither.

[DartmouthDave]

Hello,

A hard situation because most of the drugs you needed are not available or you won't have enough on hand. However, an other consideration could be Dopamine for services that carry it.

Had a mix OD at work recently. One of the medication he OD on was Diltiazem SR tablets. The standard CaCl infusion wasn't helping. So, Poison Control suggested 'High Dose Insulin Therapy' and 'Lipid Therapy'. Crazy stuff.

In effect, you run an insulin infusion an 1-2 units/kg/hr (this fellow was at 250 units/hr) along with a D20W or a D50W infusion (to prevent hypoglycemia....a 1000cc bag of D50W is the oddest looking thing!!). Somehow, the insulin blocks the CCB cardiotoxic effects. Plus, the insulin/glucose increase cardiac output as well in a similar fashion to the 'stress response'.

The lipids (basically TPN solution) binds with the CCB as well.

I thought I would throw this out there because it was so unique and interesting.

Cheers

[Kaisu]

Thanks so much for the intelligent responses. You folks are invaluable to me...

Re the dosages.. I carry 2 mg, when I have acls 1st response (50% of the time) they have 2 mg in their box too. RN Emergency field guide suggests 3 - 5 mg dosage... thus doable in this situation.

On the calcium channel thing... very interesting. We don't carry insulin and I don't know of any EMS service that does (not that they may not be out there) so my option is all the CaCl I could throw at them and beat feet to the ED.

Thank you again for the answers.

[DartmouthDave]

Hello,

Sorry, the insulin therapy was started in the hospital. EMS used the standard Glucagon and the CaCl. All in all, things worked out well for this fellow despite a massive OD and numerous brady arrests.

Cheers

[Kaisu]

Hello,

Sorry, the insulin therapy was started in the hospital. EMS used the standard Glucagon and the CaCl. All in all, things worked out well for this fellow despite a massive OD and numerous brady arrests.

Cheers

Sounds like an awesome outcome and outstanding work by everyone involved. Good story... thanks for sharing it.

[JakeEMTP]

To be completely honest, I would have never thought to administer Glucagon IV in an arrest. Thanks for the info Dartmouth Dave and Crapmagnet for beginning the conversation!

[Doczilla]

You've got two different concepts presented here, both valid in this overdose but for different reasons. The glucagon is a positive inotrope because it activates the same cAMP G-protein mediated intracellular pathway that a beta agonist would. If the beta receptors are blocked by metoprolol or something, then the glucagon is a way to increase the inotropic effect since response to the beta agonist (like epinephrine) will be less. We use this technique with less effective result in CCB overdose, since the beta receptors aren't really the problem.

The insulin therapy is part of what webrefer to as GIK, for glucose, insulin, and potassium that we sometimes use in severe myocardial depression. The insulin forces the uptake of the glucose by the cell, while the dextrose provides carbohydrate substrate. In effect, you are force-feeding energy to the cells in hopes of increasing contractility and metabolic activity. The potassium is added because the intensive insulin therapy will also force the uptake of potassium into the cells, leading to potentially significant hypokalemia.

The lipid thing is something that has been getting more attention in toxicology. The idea is that you inject 200cc of intralipid (the lipid bottle you usually see hanging with tpn), and this will scavenge a lipophilic poison. There's not much harm to be done by it, and there are several case reports of lipid rescue from accidental intravascular marcaine (bupivicaine) injection during nerve blocks (very cardiotoxic if injected into a vessel, unlike lidocaine). There is thought that his may be useful for other overdoses, particularly lipophilic substances.

'zilla

Lurking from his iPhone.

[1EMT-P]

Yes Glucagon could be helpful in a Beta Blocker Overdose, but the fact is that most EMS agencies do not carry enough Glucagon with them for something like this, so with that being said another possible option would be to follow your ACLS protocols & to also consider mixing an Epinephrine Drip in the field you could try 1mg of the 1:1000 solution in a 250ML bag of NS & start at 30 gtts/min with a microdrip set & titrate or you could also try a Dopamine Drip.

[DartmouthDave]

Hello,

The case that I interject with was a interesting mixed-OD that came through the hospital.

There was one thing I wanted to ask poison control when they called. Our patient had chronic pain issues and required a fair bit of sedation to ventilated on A/C. Now, what I was wonder was this, "Could we use Propofol infusion for sedation?"

Propofol has a high lipid content. An infusion at 200mg/hr is 20cc/hr or 480cc of lipids (plus boluses prn) a day, for example.

I know this is sort of crazy idea. Just wondering.........

I have hit various data bases and I have not been able to find an answer. Nor, do I have the 'nads' to call up poison control and ask them. They are too busy.

Cheers

Edited August 9, 2010 by DartmouthDave