Zatrucie werapamilem 15-letniej dziewczynki – opis przypadku

*Bogumiła Wołoszczuk-Gębicka, Marcin Rawicz, Paulina Kremky, Bożena Sitkowska, Paweł Witt, Włodzimierz Retka

Summary
s is usually associated with severe hypotension and heart failure. The toxicity of calcium channel blockers can lead to a wide variety of manifestations in the cardiovascular, gastrointestinal, endocrine-metabolic, hematologic and respiratory systems. The clinical picture includes hypotension with bradycardia, sinus arrhythmia, mental state disturbance, lactic acidosis, hyperglycemia, and refractory shock.
Case report. A 15 year-old girl was transferred to the ITU three hours after ingestion of 5.6 g of verapamil. She was unconscious, with a GCS of 7, deeply hypotensive and bradycardic (40 bpm). Her core temperature was 32°C. She was initially resuscitated with 1 g of calcium, 1 mg of adrenaline, and infusion of 3 l of crystalloid/6% hydroxyethylstarch. In the early hours of treatment, she required extreme inotropic support (2.6 ?g kg^-1 min^-1 adrenaline, 10 ?g kg^-1 min^-1 dopamine and 1 ?g kg^-1 min^-1 milrinone). She was hyperglycemic (14.3 – 21.9 mmol l^-1) and acidotic (SBE –9 to –12 mmol l^-1). A Swan-Ganz catheter was introduced to reveal that her CO was 15.4 l min^-1, CI 9.28 l m^-2 min^-1, and SVR - 218 dyn s cm^-5. Dopamine was replaced with 1.5 ?g kg^-1 min^-1 noradrenaline, which resulted in stabilization of cardiovascular function and stepwise reduction of the adrenaline infusion. Mechanical ventilation was discontinued after 54 hours and inotropic support was discontinued after another 7 hours. She was transferred to a low-dependency area after 96 hours.
Discussion. Severe poisoning with calcium channel blockers is difficult to treat. Verapamil, if not overdosed, acts mainly on the myocardium. Administered in excessive doses, it blocks the sinus node, depresses atrioventricular conduction, and dilates peripheral vessels. First-line pharmacological treatment comprises vasoactive drugs and calcium. Several reports suggest that phosphodiesterase inhibitors and insulin are beneficial. In the reported case, the main problem was the low PVR, requiring large doses of noradrenaline, and hyperglycemia.

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