Outcomes of unintentional beta-blocker or calcium channel blocker overdoses: a retrospective review of poison center data.

Outcomes following unintentional, supratherapeutic ingestions of a patient's own beta-blocker (BB) or calcium channel blocker (CCB) have not been well studied. A retrospective review of all poison control center (PCC) charts from January 2007 through December 2009 yielded 4,099 cases involving a BB or CCB. Of these, 436 (10.6%) met inclusion criteria. Data abstracted included patient age/gender, medication(s) involved, dose(s), time interval between ingestions, symptoms, and outcome. Exclusion criteria included intentional ingestions, ingesting someone else's medication, and ingestion intervals >12 h. Outcomes were defined as the development of symptoms, management site, hospital admission, and death. Mean age was 65.1 years (range 2-91; SD 17.9); 284 (65.1%) were women. Eighty-two (18.8%) cases resulted in ED evaluation; 44 (53.7%) of these were referred in by the PCC. Symptoms developed in 44 (10.1%) cases and 32 (7.3%) were admitted due to the ingestion. Of those admitted, five (15.6%) received treatment (three intravenous fluids, one glucagon, one calcium). Of the 343 (78.7%) cases initially observed on site, three (0.9%) were later referred to an ED; none required treatment. There was one death under extenuating circumstances. The validity of data abstraction was determined for six variable using 43 charts [0.97; 95% CI (0.91-0.99)]. Based on a retrospective analysis of PCC cases, home observation of asymptomatic patients following unintentional supratherapeutic ingestions of their own BB or CCB was safe in most cases. Further, prospective study is required to identify risks factors for becoming symptomatic or requiring treatment.

Toxicology in the ICU: Part 1: general overview and approach to treatment.

Poisonings, adverse drug effects, and envenomations continue to be commonly encountered. Patients often present critically ill and warrant ICU admission. Many other patients who are initially stable have the potential for rapid deterioration and require continuous cardiopulmonary and neurologic monitoring. Given the potential for rapid deterioration, and because patients need continuous monitoring, ICU admission is frequently required. This article is the first of a three-part series to be published in CHEST; it discusses general management, laboratory tests, enhanced elimination, and emerging therapies. The second article will address the management of specific overdoses; the last will cover plants, mushrooms, envenomations, and heavy metals.

Cardiotoxicity and serotonin syndrome complicating a milnacipran overdose.

Milnacipran is a selective serotonin and norepinephrine reuptake inhibitor, recently approved for use in the USA for treatment of fibromyalgia. This case report describes a 59-year-old woman who ingested 3,000 mg of milnacipran in a suicide attempt. Following the ingestion, she became obtunded and developed autonomic instability. She required mechanical ventilation, treatment for hypertension, and then ultimately vasopressor support for refractory hypotension. In addition, she developed a transient, acute cardiac dysfunction with global hypokinesis and an ejection fraction of 30%. Resolution of the cardiac dysfunction was documented on repeat echocardiogram 2 days after the initial study. This was confirmed by cardiac catheterization performed 4 days after the acute ingestion in which coronary arteriogram was normal and left ventricular ejection fraction was 70%. Acute overdose was confirmed by quantification of plasma milnacipran concentration of 8,400 ng/mL obtained 5 h post-ingestion. To our knowledge, this represents the first case of cardiac toxicity complicating a milnacipran overdose in the medical literature.