Document Type : Original Article
Authors
- Maha Abdelhamied Ghanem 1
- Manal A Hassan 1
- Mohamed mostafa Megahed 2
- Esraa El-Sayed Ghoneim 1
- Sara Attia Ghitani 1
1 Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Alexandria University, Egypt
2 Intensive Care Unit, Faculty of Medicine, Alexandria University, Egypt
Abstract
Background: Despite different antidotes, antihypertensive toxicity, especially beta-blockers (BB) and calcium channel blockers (CCB), have a significant morbidity and mortality. This study aimed to determine the prevalence and characteristics of antihypertensive toxicity among the admitted patients to Alexandria Poison Center (APC).
Method: A cross-sectional study was carried out on all patients with antihypertensive toxicity, admitted to APC throughout year 2022. The management plan with adding methylene blue (MB) as a single bolus dose of 1mg/kg over 10 min to shocked cases was assessed.
Results: This work included 105 patients; with a mean age of (23.3 ± 13.3 years), (22.9%) were males and (77.1%) were females. The majority ingested BB and CCB. ECG showed bradycardia (8.6%), prolonged QTC (11.4%), prolonged PR interval (9.5%) and wide QRS complex (1.9%). Of all patients, (8.6%) received atropine, (4.8%) received vasopressors, (7.6%) received intravenous (IV) calcium and (4.8%) received high insulin glucose. In the current work, two cases presented with shock (1.9%) received IV MB early and survived. Refractory shock was the cause of death in (1.9%) of the cases who died before starting MB. The mean length of hospital stay was 34.06 ± 21.42 hours. Ingestion of antihypertensive agents from different classes and prolonged PR interval were the main predictors of the length of hospital stay where P = 0.012, 0.021 at 95% CI respectively.
Conclusion: Beta-blockers were the commonest ingested antihypertensive agent. Simultaneous ingestion of antihypertensive agents from different classes and prolonged PR interval have a significant prediction of the hospital stay length.
Keywords
Main Subjects
- St-Onge M, Anseeuw K, Cantrell FL, Gilchrist IC, Hantson P, Bailey B, et al. Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Crit Care Med. 2017; 45(3):e306-15.
- Hessler R. Cardiologic Principles II: Hemodynamics. In: Hoffman R, Howland M, Lewin N, Nelson L, Goldfrank L (eds). Goldfrank’s Toxicologic Emergencies 10th New York: McGraw-Hill; 2015. p. 222-30.
- Karbek Akarca F, Akceylan E, Kıyan S. Treatment of amlodipine intoxication with intravenous lipid emulsion therapy: a case report and review of the literature Cardiovasc Toxicol. 2017; 17: 482-6.
- Arroyo AM, Kao LW. Calcium channel blocker toxicity. Pediatr Emerg Care. 2009; 25: 532-40.
- Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul 13;2(7872):81-4.
- Persson H, Sjöberg G, Haines J, Pronczuk de Garbino J. Poisoning Severity Score: Grading of acute poisoning. J Toxicology - Clinical Toxicology. 1998; 36:205-13.
- Saeed NM, Ghanem M, Alhoshy HA, Atef M. A five-year study on the profile of acute poisoning cases admitted to poison center, Alexandria, Egypt. Asia Pac. J. Med. Toxicol. 2023; 12(2): 42-48.
- Masry MKE, Tawfik HM. Annual Report of the Poison Control Centre of Ain Shams University Hospital, Cairo, Egypt. 2013. https://api.semanticscholar.org/CorpusID:92983307@inproceedings{Masry2013AnnualRO
- Hurtado D, Quintero JA, Rodríguez YA, Pérez DE, Paz RF, Diez-Sepúlveda J. Principal causes of acute poisoning in an emergency service: experience between 2014 and 2021 at a University Hospital in Southwestern Colombia. Sci Rep. 2024;14(1):3544. doi: 10.1038/s41598-024-54159-w. PMID: 38347059; PMCID: PMC10861590.
- Eizadi-Mood N, Adib M, Otroshi A, Dorooshi G, Meamar R. A Clinical-Epidemiological Study on Beta-Blocker Poisonings Based on the Type of Drug Overdose. J Toxicol. 2023; 2023:1064955. doi: 10.1155/2023/1064955. PMID: 36875968; PMCID: PMC9984257.
- Cai Z, Canetto SS, Chang Q, Yip PSF. Women's suicide in low-, middle-, and high-income countries: Do laws discriminating against women matter? Soc Sci Med. 2021 Aug; 282:114035. doi: 10.1016/j.socscimed.2021.114035. Epub 2021 May 14. PMID: 34147270.
- Hetterich N, Lauterbach E, Stürer A, Weilemann LS, Lauterbach M. Toxicity of antihypertensives in unintentional poisoning of young children. J Emerg Med. 2014; 47(2):155-62. doi: 10.1016/j.jemermed.2014.02.006. Epub 2014 Apr 18. PMID: 24746907.
- Tenebeim M. Poisoning pearls regarding the very young. Clin Pediatr Emerg Med. 2000; 1:176–9.
- Graudins A, Lee HM, Druda D. Calcium channel antagonist and beta-blocker overdose: antidotes and adjunct therapies. Br J Clin Pharmacol. 2016; 81(3):453-61. doi: 10.1111/bcp.12763. Epub 2015 Oct 30. PMID: 26344579; PMCID: PMC4767195.
- Love JN. Beta blocker toxicity after overdose: when do symptoms develop in adults? J Emerg Med.1994; 12:799–802.
- Kulkarni S, O'Farrell I, Erasi M, Kochar MS. Stress and hypertension. WMJ. 1998; 97(11):34-8. PMID: 9894438
- Goldfine CE, Troger A, Erickson TB, Chai PR. Beta-blocker and calcium-channel blocker toxicity: current evidence on evaluation and management. Eur Heart J Acute Cardiovasc Care. 2024; 13(2):247-253. doi: 10.1093/ehjacc/zuad138. PMID: 37976176.
- Love JN, Enlow B, Howell JM, Klein-Schwartz W, Litovitz TL. Electrocardiographic changes associated with beta-blocker toxicity. Ann Emerg Med. 2002; 40(6):603-10. doi: 10.1067/mem.2002.129829. PMID: 12447337.
- Lodhi FAK, Shogren SL, Vedre JG, Haque N, Reriani M, Ali R. Calcium Channel Blocker Toxicity Causing Acute Respiratory Distress Syndrome: A Commonly Used Drug Triggering a Life-Threatening Condition. WMJ. 2020; 119(1):66-68. PMID: 32348076.
- Khalid MM, Galuska MA, Hamilton RJ. Beta-Blocker Toxicity. [Updated 2023 Jul 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448097/
- Lashari BH, Minalyan A, Khan W, Naglak M, Ward W. The Use of High-dose Insulin Infusion and Lipid Emulsion Therapy in Concurrent Beta-blocker and Calcium Channel Blocker Overdose. Cureus. 2018; 10(11):e3534. doi: 10.7759/cureus.3534. PMID: 30648068; PMCID: PMC6318115.
- Levine M, Boyer EW, Pozner CN, Geib AJ, Thomsen T, Mick N, Thomas SH. Assessment of hyperglycemia after calcium channel blocker overdoses involving diltiazem or verapamil. Crit Care Med. 2007; 35(9):2071-5. doi: 10.1097/01.ccm.0000278916.04569.23. PMID: 17855820.
- DeWitt CR, Waksman JC. Pharmacology, pathophysiology and management of calcium channel blocker and beta-blocker toxicity. Toxicol Rev. 2004;23(4):223-38. doi: 10.2165/00139709-200423040-00003. PMID: 15898828.
- Chakraborty RK, Hamilton RJ. Calcium Channel Blocker Toxicity. [Updated 2023 Jul 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537147/
- Mahajan VS, Jarolim P. How to interpret elevated cardiac troponin levels. Circulation. 2011; 124(21):2350-4. doi: 10.1161/CIRCULATIONAHA.111.023697. PMID: 22105197.
- Manini AF, Stimmel B, Hoffman RS, Vlahov D. Utility of Cardiac Troponin to Predict Drug Overdose Mortality. Cardiovasc Toxicol. 2016; 16(4):355-60. doi: 10.1007/s12012-015-9345-8. PMID: 26541348; PMCID: PMC4970948.
- Newton CR, Delgado JH, Gomez HF. Calcium and beta receptor antagonist overdose: a review and update of pharmacological principles and management. Semin Respir Crit Care Med. 2002; 23(1):19-25. doi: 10.1055/s-2002-20585. PMID: 16088594.
- Imamura T, Matsuura Y, Nagoshi T, Ishikawa T, Date H, Kita T, et al. Hyperkalemia induced by the calcium channel blocker, benidipine. Intern Med. 2003; 42(6):503-6. doi: 10.2169/internalmedicine.42.503. PMID: 12857049.
- Varghese G, Madi L, Ghannam M, Saad R. A possible increase in liver enzymes due to amlodipine: A case report. SAGE Open Med Case Rep. 2020; 8:2050313X20917822. doi: 10.1177/2050313X20917822. PMID: 32637107; PMCID: PMC7315662.
- Choi WJ, Kim GA, Park J, Jang S, Jung WJ, Shim JJ, et al. Incidence and Pattern of Aminotransferase Elevation during Anti-Hypertensive Therapy with Angiotensin-II Receptor Blockers. J Korean Med Sci. 2022; 37(33):e255. doi: 10.3346/jkms.2022.37.e255. PMID: 35996932; PMCID: PMC9424746.
- Sakboonyarat B, Poovieng J, Lertsakulbunlue S, Jongcherdchootrakul K, Srisawat P, Mungthin M, et al. Association between raised blood pressure and elevated serum liver enzymes among active-duty Royal Thai Army personnel in Thailand. BMC Cardiovasc Disord 2020; 23(1): 143. https://doi.org/10.1186/s12872-023-03181-3
- Schmidt M, Mansfield KE, Bhaskaran K, Nitsch D, Sørensen HT, Smeeth L, et al. Serum creatinine elevation after renin-angiotensin system blockade and long term cardiorenal risks: cohort study. BMJ. 2017; 356:j791. doi: 10.1136/bmj.j791. PMID: 28279964; PMCID: PMC5421447.
- Price D, Radke J, Albertson T. Hypocalcaemia after an occult calcium channel blocker overdose: a case report and literature review. Basic Clin Pharmacol Toxicol. 2014 Feb; 114(2):217-21. doi: 10.1111/bcpt.12121. Epub 2013 Sep 18. PMID: 24034162.
- Zahorec R. Ratio of neutrophil to lymphocyte counts–rapid and simple parameter of systemic inflammation and stress in critically ill. Bratisl Lek Listy. 2001; 102(1):5-14. https://www.ncbi.nlm.nih.gov/pubmed/11723675.
- Josse JM, Cleghorn MC, Ramji KM, Jiang H, Elnahas A, Jackson TD, at al. The neutrophil/lymphocyte ratio predicts major perioperative complications in patients undergoing colorectal surgery. Color. Dis. 2016; 18:O236–O242. doi: 10.1111/codi.13373.
- Goldfine CE, Troger A, Erickson TB, Chai PR. Beta-blocker and calcium-channel blocker toxicity: current evidence on evaluation and management. Eur Heart J Acute Cardiovasc Care. 2024; 13(2): 247–53. https://doi.org/10.1093/ehjacc/zuad138
- Janga C, Naeem I, Mehreen R, Muhammad M, Khan U, Hassan S, et al. Methylene blue magic in beta blocker overdose. Chest 2023; 164(4):A2843.
- Hacker A, Marin D, Gross M. Calcium channel blocker toxicity: the role of methylene blue and hydroxocobalamin in ICU management: a case report. Chest 2024; 166(4): A2886 - A2887.
- Aggarwal N, Kupfer Y, Seneviratne C, Tessler S. Methylene blue reverses recalcitrant shock in β-blocker and calcium channel blocker overdose. BMJ Case Rep. 2013 Jan 18; 2013:bcr2012007402. doi: 10.1136/bcr-2012-007402. PMID: 23334490; PMCID: PMC3604019.
- Ahmed S, Barnes S. Hemodynamic improvement using methylene blue after calcium channel blocker overdose. World J Emerg Med. 2019; 10(1):55-58. doi: 10.5847/wjem.j.1920-8642.2019.01.009. PMID: 30598720; PMCID: PMC6264975.
- Khalid MM, Galuska MA, Hamilton RJ. Beta-Blocker Toxicity. [Updated 2023 Jul 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448097/