Evaluation of children poisoned with calcium channel blocker or beta blocker drugs

Öz

Aim: Calcium channel blockers CCB and beta blockers BB are primarily used to treat hypertension Overdose of these medications can occur by accidental ingestion or ingestion for suicide attempt Morbidity and mortality are higher in these poisonings compared to other poisonings In this study BB or CCB drug poisoning cases are discussed and the literature is reviewed Material and Method: Between January 2011 and July 2012 590 cases of drug poisoning were admitted in the Pediatric Intensive Care Unit In this study 16 of these 590 subjects who were poisoned with calcium channel blockers or beta blockers were evaluated 11 68 8 patients were female and 5 31 2 were male Mean age of the patients was 11 8 plusmn;5 94 2 5 18 years Results: Hypotension was the most common clinical sign in CCB poisoning Two patients were asymptomatic On ECG QT prolongation was found in four patients AV block was found in two patients and ST depression was found in one patient Nausea vomiting hypotension lethargy and tremor were the most common clinical findings in patients with BB intoxication Although seven patients had normal ECG one patient had QT prolongation and one patient had Wolff ndash;Parkinson ndash;White syndrome Only dopamine was given to two patients with CCB poisoning dopamine and dobutamine were given to one patient and dopamine dobutamine epinephrine norepinephrine glucagon and insulin were given to another patient Inotropic drugs were not given to any patient with BB poisoning IV Ca gluconate was given to all patients with CCB poisoning except two patients who were asymptomatic 15 patients were discharged while one patient with CCB poisoning was lost Conclusions: Because the prognosis of CCB or BB poisoning may be very severe these patients should be followed up in a fully equipped pediatric intensive care unit Turk Arch Ped 2013; 48: 138 44

Anahtar Kelimeler

• Beta blockers, calcium channel blockers, childhood, poisoning

Kalsiyum kanal blokeri veya beta bloker ilaçlarla zehirlenen çocukların değerlendirilmesi

Öz

Amaç: Kalsiyum kanal blokeri ve beta bloker ilaçlar çoğunlukla hipertansiyon tedavisinde kullanılmaktadır Çocuklarda bazen yanlışlıkla bazen de özkıyım amaçlı doz aşımı meydana gelebilmektedir Bu tip zehirlenmelerde hastalık ve ölüm diğer zehirlenmelere kıyasla daha fazla olmaktadır Bu çalışmada kalsiyum kanal blokeri veya beta bloker ilaçlar ile oluşan zehirlenme olguları literatür bilgileri ışığında tartışılmıştır.

Gereç ve Yöntem: Ocak 2011 ile Temmuz 2012 ayları arasında Çocuk Yoğun Bakım Birimi rsquo;nde izlenen 590 ilaç zehirlenmesi olgusundan kalsiyum kanal blokeri veya beta bloker ilaçlar ile zehirlenen 16 olgu değerlendirmeye alındı Hastaların 11 39;i 68 8 kız beşi 31 2 erkekti Hastaların ortalama yaşı 11 8 plusmn;5 94 2 5 18 yıl idi.

Bulgular: Kalsiyum kanal bloker ilaç zehirlenmesi hastalarında en sık klinik bulgu hipotansiyon idi İki hasta ise bulgusuzdu Elektrokardiyografide dört hastada QT uzaması iki hastada AV blok ve bir hastada ST çökmesi saptandı Beta bloker ilaç zehirlenmesi hastalarında bulantı kusma hipotansiyon uykuya eğilim ve ellerde titreme en sık gözlenen klinik bulgulardı Yedi hastada elektrokardiyografi normal iken; bir hastada QT uzaması ve bir hastada da Wolff ndash;Parkinson ndash;White sendromu vardı İki kalsiyum kanal bloker ilaç zehirlenmesi hastasına sadece dopamin birine dopamin ve dobutamin birine de dopamin dobutamin adrenalin noradrenalin glükagon ve insülin verilmişti Hiçbir beta bloker ilaç zehirlenmesi hastasına inotrop verilmemişti Bulgusuz olan iki hasta dışında tüm kalsiyum kanal bloker ilaç zehirlenmesi hastalarına damardan Ca glükonat destek tedavisi verilmişti On beş hasta şifa ile taburcu edilmiş iken; bir kalsiyum kanal bloker zehirlenmesi kaybedilmişti.

Çıkarımlar: Kalsiyum kanal blokeri veya beta bloker ilaçlarla oluşan zehirlenmeler çok ağır seyredebilen zehirlenmeler olduğundan bu hastalar tam donanımlı çocuk yoğun bakım birimlerinde izlenmelidir.

Anahtar Kelimeler

• Beta bloker
• çocukluk çağı
• kalsiyum kanal blokeri
• zehirlenme

Kaynakça

1. DeWitt CR, Waksman JC. Pharmacology, pathophysiology and management of calcium channel blocker and beta-blocker toxicity. Toxicol Rev 2004; 23(4): 223-38.
2. Triggle DJ, Janis RA. Recent development in calcium channel antagonists. Magnesium 1989; 8(5-6): 213-22.
3. Kline JA, Raymond RM, Schroeder JD, Watts JA. The diabetogenic effects of acute verapamil poisoning. Toxicol Appl Pharmacol 1997; 145(2): 357-62.
4. Heard K, Kline JA. Calcium Channel Blockers. In: Tintinalli JE, (ed). Emergency medicine: a comprehensive study guide. New york: McGraw&Hill, 2004: 1108-12.
5. Magdalan J. New treatment methods in verapamil poisoning: experimental studies. Pol J Pharmacol 2003; 55(3): 425-32.
6. Lüscher TF, Cosentino F. The classification of calcium antagonists and their selection in the treatment of hypertension. A reappraisal. Drugs 1998;55(4): 509-17.
7. Enyeart JJ, Price WA, Hoffman DA, Woods L. Profound hyperglycemia and metabolic acidosis after verapamil overdose. J Am Coll Cardiol 1983; 2(6): 1228-31.
8. Assimes TL, Malcolm I. Torsade de pointes with sotalol overdose treated successfully with lidocaine. Can J Cardiol 1998; 14(5): 753Reith DM, Dawson AH, Epid D, Whyte IM, Buckley NA, Sayer GP. Relative toxicity of beta blockers in overdose. J Toxicol Clin Toxicol 1996; 34(3): 273-8.

9. Love JN, Howell JM, Litovitz TL, Klein-Schwartz W. Acute beta blocker overdose: factors associated with the development of cardiovascular morbidity. J Toxicol Clin Toxicol 2000; 38(3): 275-81. Davutoğlu M. Beta bloker ilaçlarla olan zehirlenmeler ve kalsiyum kanal blokeri ilaçlarla olan zehirlenmeler. İçinde: Karaböcüoğlu M, Yılmaz HL, Duman M, (yazarlar). Çocuk acil tıp kitabı. 1.baskı. İstanbul: İstanbul Tıp Kitabevi. 2012: 1693-704.
10. Shepherd G. Treatment of poisoning caused by beta-adrenergic and calcium-channel blockers. Am J Health-Syst Pharm 2006; 63(19): 1828-35.
11. Love JN, Leasure JA, Mundt DJ, Janz TG. A comparison of amrinone and glucagon therapy for cardiovascular depression associated with propranolol toxicity in a canine model. J Toxicol Clin Toxicol 1992; 30(3): 399-412.
12. Reith DM, Dawson AH, Epid D, Whyte IM, Buckley NA, Sayer GP. Relative toxicity of beta blockers in overdose. J Toxicol Clin Toxicol 1996; 34(3): 273-8.
13. Salhanick SD, Shannon MW. Management of calcium channel antagonist overdose. Drug Saf 2003; 26(3): 65-79.
14. Shepherd G, Klein-Schwartz W. High-dose insulin therapy for calcium-channel blocker overdose. Ann Pharmacother 2005; 39(5): 923-30.
15. Kolcz J, Pietrzyk J, Januszewska K, Procelewska M, Mroczek T, Malec E. Extracorporeal life support in severe propranolol and verapamil intoxication. J Intensive Care Med 2007; 22(6): 381-5.
16. Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality (PRISM) score. Crit Care Med 1988; 16(11): 1110-6.
17. Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated Pediatric risk of mortality score. Crit Care Med 1996; 24(5): 743
18. Shann F, Pearson G, Slater A, Wilkinson K. Paediatric index of mortality (PIM): a mortality prediction model for children in intensive care. Intensive Care Med 1997; 23(2): 201-7.
19. Slater A, Shann F, Pearson G; Paediatric Index of Mortality (PIM) Study Group. PIM2: a revised version of the Paediatric Index of Mortality. Intensive Care Med 2003; 29(2): 278-85.
20. Pollack MM, Yeh TS, Ruttiman UE, Holbrook PR, Fields AI. Evaluation of pediatric intensive care. Crit Care Med 1984; 12(4): 376Pollack MM. Clinical scoring systems in pediatric intensive care. In: Zimmerman JJ, (ed). Pediatric critical care. St. Louis: Mosby Year Book, 1992: 153-62.
21. Gemke RJ, Bonsel GJ, van Vught AJ. Effectiveness and efficiency of a Dutch pediatric intensive care unit: validity and application of the Pediatric Risk of Mortality score. Crit Care Med 1994; 22(9): 1477Gemke RJ, van Vught J. Scoring systems in pediatric intensive care: PRISM III versus PIM. Intensive Care Med 2002; 28(2): 204-7.
22. Lacroix J, Cotting J; Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Severity of illness and organ dysfunction scoring in children. Pediatr Crit Care Med 2005; 6(Suppl 3): 126-34.