Document Type : Case Report

Authors

• Miet Darshan Shah ¹
• Advait Kulkarni ²
• Murtuza Ghiya ³
• Atiullah Malik ⁴
• Niharika Gill ⁵

¹ Junior resident, Department of general medicine, KJ Somaiya medical college and research center, Mumbai, India

² Senior resident, Department of general medicine, KJ Somaiya hospital, Mumbai, India

³ MD, Emergency medicine, EM physician at CHFT, NHS, UK

⁴ Department of general medicine, Assistant professor, KJ Somaiya medical college and research center, Mumbai, India

⁵ Department of general medicine, Professor and head, KJ Somaiya medical college and research center, Mumbai, India

Abstract

Introduction: Amlodipine is a commonly prescribed anti-hypertensive drug. Its inadvertent exposure and intentional overdose is the leading cause of drug overdose seen in the practice of cardiovascular medicine. It can lead to profound hypotension, refractory shock, acute renal failure and end organ damage.
Case reports: A case series of three patients with serious calcium channel blocker (CCBs) overdose, out of which two survived and one succumbed despite aggressive treatment is presented here.
Discussion: Our 3 patients presented with giddiness caused by hypotension attributable to generalized vasodilatation due to direct effect on vascular smooth muscle; and negative effect on the cardiac pacemaker and myocardial contractility. Hyperglycemia due to reduced insulin release and lactic acidosis also contributes to reduced dromotropic effect. Abdominal pain and vomiting seen in our patients has been ascribed to reduced gastrointestinal motility and stasis of gastric contents. Oliguric renal failure with features of fluid overload seen is attributable to prolonged hypotension and reduced effective circulatory volume. An unusual finding in our cases was non-cardiogenic pulmonary edema. We attribute this to capillary leak syndrome as a result of generalized vasodilatation, resulting in excessive pulmonary capillary transudation.
Conclusion: Thus, management of CCB poisoning can be challenging. Outcome can be improved by early and aggressive intensive care, fluid resuscitation, inotropic support, calcium infusion, glucagon infusion, hyperinsulinemia-euglycemia therapy and other supportive measures. The pulmonary edema can complicate fluid resuscitation, and one might need to stop IV fluids and give diuretics, ventilatory support and increase inotropes in such a scenario.

Keywords

• Amlodipine
• Non-cardiogenic pulmonary edema
• IV calcium therapy
• Hyperinsulinemia-euglycemia therapy
• Glucagon infusion

Main Subjects

• Medical Toxicology