Interpretation of 2023 American Heart Association guideline for the management of patients with cardiac arrest or life-threatening toxicity due to poisoning (Ⅱ): management of cardiovascular substances poisoning_West China Medical Journal

Authors：

LIAO Dengyong ^1,2 , CHU Lili ^1,2 , YAO Peng ^1,2 , XIE Xuxin ^1,2 , PENG Aihua ^1,2 ,  CAO Yu ^1,2

1. Department of Emergency Medicine and Institute of Disaster Medicine, Institute of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
2. Disaster Medical Center, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

CAO Yu, Email: yuyuer@126.com

Keywords：

Guideline; poisoning; cardiac arrest; cardiovascular drug; resuscitation

DOI：

10.7507/1002-0179.202409126

Video：

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On September 18th, 2023, the American Heart Association published clinical management guidelines for patients with poisoning-induced cardiac arrest and critical cardiovascular illness in Circulation. Considering the important role of the guidelines in clinical practice, our team has divided them into three sections for detailed interpretation based on the different toxic effects of the drugs. This article is the second part of the interpretation, which combines the literature to interpret the recommendations related to cardiotoxic substance poisoning in the guidelines, mainly involving the clinical management of beta blockers, calcium channel blockers, digoxin and other cardiac glycosides, as well as sodium channel blocker poisoning, aiming to assist colleagues in their clinical practice through a detailed explanation of the key recommendations in the guidelines.

1.	Lavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2023, 148(16): e149-e184.
2.	向昕杰, 褚莉莉, 姚鹏, 等. 2023 年美国心脏协会中毒所致心脏骤停及心脏危重症管理指南解读(一):神经系统毒性物质中毒的管理. 华西医学, 2023, 38(11): 1616-1624.
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7.	Barnes PJ. Beta-adrenergic receptors and their regulation. Am J Respir Crit Care Med, 1995, 152(3): 838-860.
8.	DeWitt CR, Waksman JC. Pharmacology, pathophysiology and management of calcium channel blocker and beta-blocker toxicity. Toxicol Rev, 2004, 23(4): 223-238.
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10.	Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 2019, 140(8): e382-e482.
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12.	Xu J, Qin X, Cai X, et al. Mitochondrial JNK activation triggers autophagy and apoptosis and aggravates myocardial injury following ischemia/reperfusion. Biochim Biophys Acta, 2015, 1852(2): 262-270.
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1. Lavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 2023, 148(16): e149-e184.
2. 向昕杰, 褚莉莉, 姚鹏, 等. 2023 年美国心脏协会中毒所致心脏骤停及心脏危重症管理指南解读(一):神经系统毒性物质中毒的管理. 华西医学, 2023, 38(11): 1616-1624.
3. Freemantle N, Cleland J, Young P, et al. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ, 1999, 318(7200): 1730-1737.
4. Cruickshank JM. Beta blockers in hypertension. Lancet, 2010, 376(9739): 415, author reply 415-416.
5. Borlaug BA, Omote K. Beta-blockers and exercise hemodynamics in hypertrophic cardiomyopathy. J Am Coll Cardiol, 2022, 79(16): 1576-1578.
6. Balligand JL. β-adrenergic receptors cooperate with transcription factors: the “STAT” of their union. Circulation, 2016, 133(1): 4-7.
7. Barnes PJ. Beta-adrenergic receptors and their regulation. Am J Respir Crit Care Med, 1995, 152(3): 838-860.
8. DeWitt CR, Waksman JC. Pharmacology, pathophysiology and management of calcium channel blocker and beta-blocker toxicity. Toxicol Rev, 2004, 23(4): 223-238.
9. Rotella JA, Greene SL, Koutsogiannis Z, et al. Treatment for beta-blocker poisoning: a systematic review. Clin Toxicol (Phila), 2020, 58(10): 943-983.
10. Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 2019, 140(8): e382-e482.
11. Holger JS, Stellpflug SJ, Cole JB, et al. High-dose insulin: a consecutive case series in toxin-induced cardiogenic shock. Clin Toxicol (Phila), 2011, 49(7): 653-658.
12. Xu J, Qin X, Cai X, et al. Mitochondrial JNK activation triggers autophagy and apoptosis and aggravates myocardial injury following ischemia/reperfusion. Biochim Biophys Acta, 2015, 1852(2): 262-270.
13. Lazzarin T, Tonon CR, Martins D, et al. Post-cardiac arrest: mechanisms, management, and future perspectives. J Clin Med, 2022, 12(1): 259.
14. Iliadis F, Kadoglou N, Didangelos T. Insulin and the heart. Diabetes Res Clin Pract, 2011, 93(Suppl 1): S86-S91.
15. Yuan TH, Kerns WP 2nd, Tomaszewski CA, et al. Insulin-glucose as adjunctive therapy for severe calcium channel antagonist poisoning. J Toxicol Clin Toxicol, 1999, 37(4): 463-474.
16. Page CB, Ryan NM, Isbister GK. The safety of high-dose insulin euglycaemia therapy in toxin-induced cardiac toxicity. Clin Toxicol (Phila), 2018, 56(6): 389-396.
17. Estall JL, Drucker DJ. Glucagon and glucagon-like peptide receptors as drug targets. Curr Pharm Des, 2006, 12(14): 1731-1750.
18. Farah A, Tuttle R. Studies on the pharmacology of glucagon. J Pharmacol Exp Ther, 1960, 129: 49-55.
19. Lucchesi BR. Cardiac actions of glucagon. Circ Res, 1968, 22(6): 777-787.
20. Lvoff R, Wilcken DE. Glucagon in heart failure and in cardiogenic shock. Experience in 50 patients. Circulation, 1972, 45(3): 534-542.
21. Boyd R, Ghosh A. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Glucagon for the treatment of symptomatic beta blocker overdose. Emerg Med J, 2003, 20(3): 266-267.
22. Zeljković I, Bulj N, Kolačević M, et al. Failure of intracardiac pacing after fatal propafenone overdose: a case report. J Emerg Med, 2018, 54(4): e65-e68.
23. Bouchard J, Shepherd G, Hoffman RS, et al. Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup. Crit Care, 2021, 25(1): 201.
24. Daubin C, Lehoux P, Ivascau C, et al. Extracorporeal life support in severe drug intoxication: a retrospective cohort study of seventeen cases. Crit Care, 2009, 13(4): R138.
25. Duburcq T, Goutay J, Preau S, et al. Venoarterial extracorporeal membrane oxygenation in severe drug intoxication: a retrospective comparison of survivors and nonsurvivors. ASAIO J, 2022, 68(7): 907-913.
26. Hayes BD, Gosselin S, Calello DP, et al. Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration. Clin Toxicol (Phila), 2016, 54(5): 365-404.
27. Levine M, Skolnik AB, Ruha AM, et al. Complications following antidotal use of intravenous lipid emulsion therapy. J Med Toxicol, 2014, 10(1): 10-14.
28. Elkayam U, Shotan A, Mehra A, et al. Calcium channel blockers in heart failure. J Am Coll Cardiol, 1993, 22(4 Suppl A): 139A-144A.
29. Levine M, Curry SC, Padilla-Jones A, et al. Critical care management of verapamil and diltiazem overdose with a focus on vasopressors: a 25-year experience at a single center. Ann Emerg Med, 2013, 62(3): 252-258.
30. Cole JB, Arens AM, Laes JR, et al. High dose insulin for beta-blocker and calcium channel-blocker poisoning. Am J Emerg Med, 2018, 36(10): 1817-1824.
31. Schult RF, Nacca N, Grannell TL, et al. Evaluation of high-dose insulin/euglycemia therapy for suspected β-blocker or calcium channel blocker overdose following guideline implementation. Am J Health Syst Pharm, 2022, 79(7): 547-555.
32. Howarth DM, Dawson AH, Smith AJ, et al. Calcium channel blocking drug overdose: an Australian series. Hum Exp Toxicol, 1994, 13(3): 161-166.
33. Ramoska EA, Spiller HA, Winter M, et al. A one-year evaluation of calcium channel blocker overdoses: toxicity and treatment. Ann Emerg Med, 1993, 22(2): 196-200.
34. Hofer CA, Smith JK, Tenholder MF. Verapamil intoxication: a literature review of overdoses and discussion of therapeutic options. Am J Med, 1993, 95(4): 431-438.
35. Yao LF, MacLeod KM, McNeill JH. Glucagon-induced densensitization: correlation between cyclic AMP levels and contractile force. Eur J Pharmacol, 1982, 79(1-2): 147-150.
36. St-Onge M, Dubé PA, Gosselin S, et al. Treatment for calcium channel blocker poisoning: a systematic review. Clin Toxicol (Phila), 2014, 52(9): 926-944.
37. Warrick BJ, Tataru AP, Smolinske S. A systematic analysis of methylene blue for drug-induced shock. Clin Toxicol (Phila), 2016, 54(7): 547-555.
38. Cole JB, Olives TD, Ulici A, et al. Extracorporeal membrane oxygenation for poisonings reported to U.S. Poison Centers from 2000 to 2018: an analysis of the National Poison Data System. Crit Care Med, 2020, 48(8): 1111-1119.
39. Lewis J, Zarate M, Tran S, et al. The recommendation and use of extracorporeal membrane oxygenation (ECMO) in cases reported to the California Poison Control System. J Med Toxicol, 2019, 15(3): 169-177.
40. Ramoska EA, Spiller HA, Myers A. Calcium channel blocker toxicity. Ann Emerg Med, 1990, 19(6): 649-653.
41. Snover SW, Bocchino V. Massive diltiazem overdose. Ann Emerg Med, 1986, 15(10): 1221-1224.
42. Doyon S, Roberts JR. The use of glucagon in a case of calcium channel blocker overdose. Ann Emerg Med, 1993, 22(7): 1229-1233.
43. Smolinske S, Hoffman RS, Villeneuve E, et al. Utilization of lipid emulsion therapy in fatal overdose cases: an observational study. Clin Toxicol (Phila), 2019, 57(3): 197-202.
44. Gosselin S, Hoegberg LC, Hoffman RS, et al. Evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning. Clin Toxicol (Phila), 2016, 54(10): 899-923.
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Latest ArticlesInterpretation of 2023 American Heart Association guideline for the management of patients with cardiac arrest or life-threatening toxicity due to poisoning (Ⅱ): management of cardiovascular substances poisoning

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