Toxic Bradycardias in the Critically Ill Poisoned Patient

Melissa L Givens

doi:10.1155/2012/852051

Abstract

Cardiovascular drugs are a common cause of poisoning, and toxic bradycardias can be refractory to standard ACLS protocols. It is important to consider appropriate antidotes and adjunctive therapies in the care of the poisoned patient in order to maximize outcomes. While rigorous studies are lacking in regards to treatment of toxic bradycardias, there are small studies and case reports to help guide clinicians' choices in caring for the poisoned patient. Antidotes, pressor support, and extracorporeal therapy are some of the treatment options for the care of these patients. It is important to make informed therapeutic decisions with an understanding of the available evidence, and consultation with a toxicologist and/or regional Poison Control Center should be considered early in the course of treatment.

Highlights

2000 poisoned patients are seen per day in Emergency Departments across the United States, and unintentional poisoning is a significant cause of mortality even surpassing motor vehicle accidents as a cause of death in people aged 35–54 [1]
ACLS protocols may be of limited utility when treating poisoned patients with toxic bradycardia
Use of specific antidotes/adjunctive therapies may prove helpful and should be considered early in the course of treatment in consultation with a medical toxicologist or regional poison control center

Summary

Background

2000 poisoned patients are seen per day in Emergency Departments across the United States, and unintentional poisoning is a significant cause of mortality even surpassing motor vehicle accidents as a cause of death in people aged 35–54 [1]. Calcium channel blockers, and cardiac glycosides (digoxin) represent the classes of medication most described in association with fatality due to drug exposure according to the American Association of Poison Control Centers. This discussion will briefly cover clonidine and acetylcholinesterase inhibitors, such as organophosphates and carbamates, because both have therapeutic consideration outside of standard supportive care. This paper discusses common treatment considerations that apply to the critically ill poisoned patient with a toxic bradycardia. While this paper highlights current literature, it is important to remember that toxicology research is often limited to case series, case reports, and animal studies with few controlled trials. Many treatment guidelines are based on expert consensus, and further research is encouraged to strengthen an evidence-based approach to the care of the poisoned patient

Decontamination

Therapy

Conclusion