1. Overview of Escalation Framework

Acute cardiotoxic overdoses require a systematic, mechanism-driven approach. Therapy begins with foundational resuscitation, escalates to targeted antidotes, and incorporates advanced hemodynamic support based on severity and response. This framework emphasizes synergy between agents, such as using high-dose insulin to enhance myocardial glucose uptake while norepinephrine restores perfusion pressure.

Mechanism-Matched Sequence

1. Initial Resuscitation (e.g., IV fluids, atropine)
2. Agent-Specific Antidote (e.g., Calcium, Glucagon, Bicarbonate)
3. High-Dose Insulin Euglycemic Therapy (HDI)
4. Intravenous Lipid Emulsion (ILE)
5. Adjunctive Vasopressors and Chronotropes
6. Mechanical Circulatory Support (e.g., ECMO, IABP)

2. Calcium Salts for CCB Toxicity

The primary strategy for calcium-channel blocker (CCB) overdose is to competitively overcome L-type channel blockade by increasing the extracellular calcium gradient.

Mechanism & Indication

By elevating serum ionized calcium, this mass-action effect helps restore myocardial contractility and peripheral vascular tone. It is indicated for refractory hypotension following initial fluid resuscitation and atropine.

Agent Selection & Dosing

• Calcium Chloride (CaCl₂): Provides threefold more elemental calcium than gluconate. Bolus: 10–20 mg/kg (typically 1–2 g in adults) IV over 5–10 minutes. Requires central line administration due to its vesicant properties.
• Calcium Gluconate: Safer for peripheral administration. Requires a larger volume for an equivalent calcium dose.
• Infusion: Follow bolus with a continuous infusion of 0.5–1 mg/kg/min (CaCl₂), titrated to maintain an ionized calcium level of 1.2–1.4 mmol/L.

Monitoring & Contraindications

Monitor ionized calcium every 30-60 minutes during titration, along with continuous ECG and invasive blood pressure. Calcium is contraindicated in digitalis toxicity due to the risk of precipitating irreversible hypercontraction (“stone heart”).

3. Glucagon for β-Blocker Overdose

Glucagon serves as a key antidote for β-blocker (BB) toxicity by bypassing the blocked β-receptors to stimulate cardiac activity.

Mechanism & Indication

Glucagon directly activates adenylate cyclase, increasing intracellular cyclic AMP (cAMP). This leads to a subsequent rise in intracellular calcium, exerting positive inotropic and chronotropic effects independent of β-receptors. It is indicated for symptomatic bradycardia and hypotension unresponsive to atropine.

Dosing & Administration

• Bolus: 3–10 mg IV over 1–2 minutes.
• Infusion: 2–5 mg/hr, titrated to heart rate and blood pressure response.

Adverse Effects & Monitoring

The most common side effect is nausea and vomiting; consider prophylactic antiemetics (e.g., ondansetron). Glucagon can also cause initial hyperglycemia followed by hypoglycemia as glycogen stores are depleted. Monitor glucose hourly. Tachyphylaxis (waning effect) is common after 30-60 minutes.

4. High-Dose Insulin Euglycemic Therapy (HDI)

HDI is a cornerstone therapy for refractory shock in both BB and CCB overdose. It improves cardiac function by optimizing myocardial energy metabolism.

Mechanism & Indication

In a stressed state, the heart shifts from fatty acid to glucose metabolism. High-dose insulin promotes this shift by upregulating GLUT4 transporters, increasing glucose uptake. This enhances ATP production, improves intracellular calcium handling, and boosts inotropy. It is indicated for refractory shock (SBP < 90 mmHg) or bradycardia after initial antidotes have failed.

Dosing & Euglycemic Support

• Bolus: 1 unit/kg of regular insulin IV.
• Infusion: Start at 0.5–1 unit/kg/hr. Increase by 0.5 U/kg/hr every 15–30 minutes as needed. Doses up to 10–22 U/kg/hr may be required.
• Dextrose: Concurrently administer dextrose (e.g., D10W at 0.5 g/kg/hr) to maintain euglycemia (blood glucose >100 mg/dL).

Monitoring & Adverse Effects

The primary risks are hypoglycemia and hypokalemia. Monitor blood glucose every 15 minutes during titration, then hourly. Monitor serum potassium hourly and aggressively replace to maintain K⁺ >3.5 mEq/L, as insulin drives potassium into cells.

5. Sodium Bicarbonate for TCA Toxicity

Sodium bicarbonate is the first-line antidote for the cardiotoxic effects of tricyclic antidepressants (TCAs), which are primarily caused by fast sodium channel blockade.

Mechanism & Indication

Bicarbonate works via two mechanisms: it increases serum pH, which favors the non-ionized (less active) form of the TCA, and it increases the extracellular sodium concentration, which helps overcome the competitive channel blockade. It is indicated for a QRS duration >100 ms, hypotension, or ventricular arrhythmias.

Dosing & Monitoring

• Bolus: 1–2 mEq/kg IV over 2–5 minutes. Repeat every 3–5 minutes until QRS duration narrows (<100 ms) or serum pH reaches 7.50–7.55.
• Infusion: If boluses are repeatedly required, an infusion (e.g., 150 mEq in 1 L D5W at 250 mL/hr) can be used to maintain alkalemia.
• Monitoring: Check arterial blood gases and ECG (QRS width) frequently during titration. Monitor for hypokalemia and hypernatremia.

6. Intravenous Lipid Emulsion (ILE) Therapy

ILE is a rescue therapy for refractory cardiovascular collapse caused by lipophilic drug overdoses, including BBs, CCBs, and TCAs.

Mechanism & Indication

The primary proposed mechanism is the “lipid sink” theory, where the emulsion creates an expanded lipid phase in the plasma, sequestering the lipophilic drug away from its site of action. Other proposed benefits include direct cardiotonic effects and improved myocardial energy from fatty acid metabolism. It is indicated for refractory shock or cardiac arrest after first-line antidotes have failed.

Dosing & Monitoring

• Bolus: 1.5 mL/kg of 20% ILE over 1 minute.
• Infusion: 0.25 mL/kg/min for 30–60 minutes.
• Repeat: One additional bolus may be given if there is no initial response.
• Monitoring: Check triglycerides at baseline and every 4–6 hours. Watch for pancreatitis, ARDS, and interference with lab assays (lipemia).

7. Adjunctive Hemodynamic Support

When targeted antidotes are insufficient to restore perfusion, vasopressors and chronotropes are used to support blood pressure and heart rate.

8. Dosing Adjustments in Organ Dysfunction

Organ failure significantly alters drug pharmacokinetics and requires careful dose modification.

Renal Impairment

• Calcium: In severe renal impairment (CrCl < 20 mL/min), halve the initial infusion rate and monitor ionized calcium more frequently (e.g., every 20-30 minutes).
• Glucagon: Reduce infusion rate by approximately 20% if CrCl < 30 mL/min.
• Renal Replacement Therapy (RRT): Both insulin and glucagon are removed by dialysis. Monitor glucose and potassium very closely (e.g., q15 min) immediately post-dialysis.

Hepatic Failure

• Lipophilic Drugs: Hepatic failure can increase the free fraction of highly protein-bound drugs, potentially worsening toxicity.
• High-Dose Insulin: Start HDI at the lower end of the dosing range (0.5 U/kg/hr) and titrate more slowly, as insulin clearance is reduced.

9. Administration Routes and Devices

Safe administration is critical for these high-risk therapies.

• Central Venous Catheter: Essential for administering calcium chloride, high-concentration vasopressors, and high-dose insulin to prevent extravasation and allow for rapid dilution.
• Arterial Line: Strongly recommended for continuous, beat-to-beat blood pressure monitoring, which is crucial for titrating vasopressors and inotropes.
• Infusion Pumps: All continuous infusions must be administered via calibrated infusion pumps. Use smart pumps with drug libraries and dose-error reduction software when available.
• Line Compatibility: Be mindful of compatibility issues. Intravenous lipid emulsion, in particular, should not be co-infused with most other medications. Flush lines thoroughly between incompatible drugs.

10. Monitoring, Toxicity Surveillance, and Pharmacoeconomics

A comprehensive monitoring plan is essential to guide therapy and mitigate adverse effects.

Key Monitoring Parameters

• Hemodynamics: Invasive blood pressure, heart rate, urine output, and serial POCUS or formal echocardiography to assess cardiac function.
• Laboratory: Frequent monitoring of glucose, electrolytes (especially K⁺), ionized Ca²⁺, triglycerides (with ILE), and arterial blood gases (with bicarbonate).

Pharmacoeconomics

While some therapies like ILE have a high acquisition cost, their use may be offset by reducing the need for more resource-intensive interventions like ECMO. Core therapies like insulin, dextrose, and bicarbonate are generally low-cost, but the intensive monitoring they require contributes significantly to overall ICU resource utilization.

11. Integrated Clinical Decision Algorithm

This algorithm provides a tiered, stepwise framework for managing severe cardiotoxic overdoses, escalating from initial supportive care to advanced rescue therapies.